Do elderly men need treatment for low testosterone levels? This question requires careful clinical assessment rather than a simple yes or no answer. Testosterone naturally declines with age, typically by 1–2% annually after age 30–40, but this gradual reduction differs from pathological hypogonadism. Not all older men with low testosterone require treatment. The decision depends on confirmed biochemical deficiency, troublesome symptoms affecting quality of life, exclusion of other medical causes, and individual risk-benefit assessment. This article examines when treatment may be appropriate, available therapies, potential risks, and alternative management strategies for elderly men with low testosterone.

Understanding Low Testosterone in Older Men

Testosterone levels naturally decline with age in men, typically decreasing by approximately 1–2% per year after the age of 30–40. This gradual reduction is a normal part of the ageing process and differs significantly from the abrupt hormonal changes experienced during female menopause. By the time men reach their 70s and 80s, testosterone levels may be considerably lower than in younger adulthood, yet many older men remain asymptomatic and healthy.

Age-related testosterone decline should be distinguished from hypogonadism, a clinical condition characterised by abnormally low testosterone production due to testicular or pituitary dysfunction. True hypogonadism requires both biochemical evidence (consistently low serum testosterone on morning blood tests) and relevant clinical symptoms. Common symptoms potentially associated with low testosterone include:

• Reduced libido and erectile dysfunction

• Decreased morning erections

• Reduced muscle mass and strength

• Increased body fat, particularly around the abdomen

• Fatigue and reduced energy levels

• Mood changes, including low mood or irritability

• Reduced bone density (osteoporosis)

• Decreased body and facial hair

• Gynaecomastia (breast enlargement)

• Infertility

However, these symptoms are non-specific and frequently occur in older men for reasons unrelated to testosterone levels, such as cardiovascular disease, diabetes, depression, medication side effects, or simply normal ageing. The overlap between symptoms of low testosterone and other age-related conditions makes diagnosis challenging.

According to guidance from the British Society for Sexual Medicine and the Society for Endocrinology, diagnosis requires two separate morning testosterone measurements (taken before 11 am when levels peak) showing results below the normal reference range, combined with consistent clinical symptoms. Samples should be fasting and taken when the patient is well, not during acute illness. A single low reading or symptoms alone are insufficient for diagnosis.

Further investigations should include luteinising hormone (LH) and follicle-stimulating hormone (FSH) to distinguish primary hypogonadism (testicular failure with high LH/FSH) from secondary hypogonadism (pituitary/hypothalamic dysfunction with low/normal LH/FSH). For borderline results (8-12 nmol/L) or when sex hormone-binding globulin (SHBG) may be altered, measuring SHBG and calculating free testosterone is recommended. Prolactin levels should be checked if secondary hypogonadism is suspected.

Red flags warranting urgent specialist referral include visual field defects, severe headaches, significantly elevated prolactin, or signs of pituitary failure. It is essential that healthcare professionals conduct thorough assessment to exclude other medical conditions before attributing symptoms solely to testosterone deficiency.

When Treatment May Be Recommended for Elderly Men

Not all elderly men with low testosterone levels require treatment. The decision to initiate testosterone replacement therapy (TRT) in older men is individualised and based on careful clinical assessment rather than blood test results alone. The Society for Endocrinology and British Society for Sexual Medicine emphasise that treatment should only be considered when there is confirmed biochemical hypogonadism accompanied by troublesome symptoms that significantly impact quality of life.

Treatment may be recommended when:

• Confirmed diagnosis: Two morning testosterone measurements consistently show levels below the normal range (typically <8–12 nmol/L, though reference ranges vary between laboratories)

• Symptomatic presentation: The patient experiences bothersome symptoms such as reduced libido, erectile dysfunction, fatigue, or loss of muscle mass that cannot be explained by other conditions

• Exclusion of contraindications: Thorough assessment confirms no contraindications to testosterone therapy

• Realistic expectations: The patient understands potential benefits and risks, and symptoms are likely testosterone-related rather than due to other comorbidities

Absolute contraindications to testosterone therapy, as stated in UK product licences (SmPCs), include:

• Known or suspected prostate cancer

• Known or suspected male breast cancer

• Severe cardiac, hepatic or renal failure

• High haematocrit (>50%) at baseline

Before initiating treatment, healthcare professionals should investigate and address reversible causes of low testosterone, including:

• Obesity (weight loss can improve testosterone levels)

• Poorly controlled diabetes

• Obstructive sleep apnoea

• Medications that suppress testosterone (e.g., opioids, corticosteroids)

• Excessive alcohol consumption

• Thyroid dysfunction

• Hyperprolactinaemia

• Haemochromatosis

• Chronic illness or malnutrition

In elderly men, particular caution is warranted due to age-related comorbidities. Comprehensive assessment should include cardiovascular risk evaluation, prostate examination, and consideration of polypharmacy. Men with low or normal LH/FSH alongside low testosterone should be referred to an endocrinologist as this suggests secondary hypogonadism requiring specialist investigation.

For men wishing to preserve fertility, standard testosterone therapy is not appropriate as it suppresses spermatogenesis. These patients should be referred to specialists who may consider alternative treatments such as human chorionic gonadotropin (hCG) or selective oestrogen receptor modulators (SERMs).

The decision requires shared decision-making between patient and clinician, weighing individual circumstances against potential benefits and risks.

Testosterone Replacement Therapy: Benefits and Risks

Testosterone replacement therapy aims to restore testosterone levels to the normal physiological range, potentially alleviating symptoms of hypogonadism. Available formulations in the UK include transdermal gels (such as Testogel, Testavan, Tostran) and intramuscular injections (testosterone undecanoate [Nebido] or mixed esters [Sustanon]). Each has different pharmacokinetic profiles, and selection depends on patient preference, tolerability, and clinical factors.

Potential benefits of TRT in appropriately selected elderly men may include:

• Improved libido and sexual function

• Increased muscle mass and strength

• Enhanced bone mineral density (though effect on fracture risk remains uncertain)

• Improved mood and sense of wellbeing

• Reduced body fat

• Increased energy levels

However, evidence for these benefits in elderly men is variable. Whilst some studies demonstrate improvements in sexual function and muscle mass, effects on other outcomes such as cognitive function, cardiovascular health, and overall quality of life remain uncertain. The benefits tend to be most pronounced in men with severely low testosterone levels and clear hypogonadal symptoms.

Risks and adverse effects associated with TRT include:

• Cardiovascular concerns: Evidence regarding cardiovascular safety remains controversial. Some studies suggest potential increased risk of cardiovascular events, particularly in older men with pre-existing heart disease, though data are inconsistent

• Polycythaemia: Testosterone stimulates red blood cell production, potentially causing elevated haematocrit, which increases thrombotic risk

• Prostate effects: TRT may accelerate growth of pre-existing prostate cancer, though there is no conclusive evidence it causes prostate cancer

• Sleep apnoea: Testosterone may worsen obstructive sleep apnoea

• Skin reactions: Topical preparations can cause local irritation or transfer to partners/children

• Fluid retention and oedema: May worsen heart failure or hypertension

• Acne and oily skin: Due to androgenic effects

• Gynaecomastia: Paradoxical breast enlargement in some men

• Injection-site reactions: With intramuscular preparations

• Pulmonary oil microembolism (POME): A rare but serious risk with testosterone undecanoate injections

• Venous thromboembolism: Particularly in those with thrombophilia

• Testicular atrophy and reduced fertility: Exogenous testosterone suppresses natural production

Monitoring requirements are essential. UK specialist guidance recommends:

• Testosterone levels, full blood count (haematocrit): baseline, 3-6 months, then annually

• Prostate-specific antigen (PSA) and digital rectal examination: baseline and according to Prostate Cancer Risk Management Programme guidance

• Blood pressure and cardiovascular risk assessment: periodically

• Symptom response: 3-6 months

Treatment should be adjusted or discontinued if haematocrit exceeds 54%, if PSA rises significantly (referral per NICE NG12 criteria), or if there is no symptomatic improvement after an adequate trial period (typically 3–6 months).

Patients should be advised to report any suspected side effects via the MHRA Yellow Card scheme.

Alternative Approaches to Managing Low Testosterone

Before considering testosterone replacement therapy, or as complementary strategies, several lifestyle and medical interventions can help optimise testosterone levels naturally and address symptoms attributed to low testosterone.

Lifestyle modifications form the cornerstone of initial management:

• Weight management: Obesity is strongly associated with low testosterone. Weight loss through caloric restriction and increased physical activity can significantly improve testosterone levels in overweight men

• Exercise: Regular resistance training and moderate-intensity aerobic exercise have been shown to support healthy testosterone levels and improve muscle mass, strength, and metabolic health

• Sleep optimisation: Adequate sleep (7–9 hours) is crucial for testosterone production. Addressing sleep disorders, particularly obstructive sleep apnoea, may improve levels

• Stress reduction: Chronic psychological stress elevates cortisol, which can suppress testosterone production

• Nutritional adequacy: Ensuring a balanced diet; treat confirmed deficiencies of zinc or vitamin D if present, though routine supplementation without deficiency is not recommended

• Alcohol moderation: Excessive alcohol consumption suppresses testosterone production

Medical management of comorbidities is equally important. Optimising control of diabetes, treating depression, thyroid dysfunction, and reviewing medications that may suppress testosterone (such as opioids or corticosteroids) can improve both testosterone levels and symptoms.

Addressing specific symptoms may not require testosterone therapy:

• Erectile dysfunction: Phosphodiesterase-5 inhibitors (e.g., sildenafil, tadalafil) are first-line treatment and effective regardless of testosterone status. Note these are contraindicated in men taking nitrates and require cardiovascular assessment

• Osteoporosis: Bisphosphonates, calcium, and vitamin D supplementation are established treatments

• Depression and fatigue: Psychological support, antidepressants, or treatment of underlying medical conditions may be more appropriate

For men with hypogonadotropic hypogonadism who wish to maintain fertility, specialist referral for consideration of human chorionic gonadotropin (hCG) or selective oestrogen receptor modulators (SERMs) may be appropriate alternatives to standard testosterone therapy.

For men with borderline testosterone levels or mild symptoms, a trial period of lifestyle modification (typically 3–6 months) is often recommended before considering pharmacological intervention. This approach addresses reversible factors and may obviate the need for long-term testosterone therapy. Regular monitoring with repeat testosterone measurements can assess response to these interventions.

Making an Informed Decision About Treatment

The decision regarding testosterone treatment in elderly men should be individualised, evidence-based, and collaborative, involving thorough discussion between patient and healthcare professional. Given the complexity of diagnosis, uncertain long-term safety data in older populations, and availability of alternative approaches, informed decision-making is paramount.

Key considerations when contemplating treatment include:

• Symptom severity and impact: Are symptoms significantly affecting quality of life, relationships, or daily functioning? Would potential benefits justify treatment risks?

• Realistic expectations: Testosterone therapy is not a panacea for ageing. It will not reverse all age-related changes, improve cognitive decline, or guarantee increased vitality

• Cardiovascular risk profile: Men with established cardiovascular disease, previous myocardial infarction, or stroke require particularly careful risk-benefit assessment

• Commitment to monitoring: TRT requires ongoing medical supervision with regular blood tests and clinical review

• Alternative explanations: Have other potential causes of symptoms been adequately investigated and addressed?

Questions to discuss with your GP or endocrinologist:

• What are my actual testosterone levels, and how do they compare to the normal range?

• Could my symptoms be caused by other medical conditions?

• What are the realistic benefits I might expect from treatment?

• What are the specific risks given my age and medical history?

• What monitoring will be required, and how often?

• What happens if I choose not to have treatment?

When to seek specialist referral:

• Endocrinology referral is appropriate for men with low testosterone and low/normal LH/FSH (suggesting secondary hypogonadism), raised prolactin, or symptoms of pituitary dysfunction

• Urology referral is indicated for abnormal digital rectal examination or raised age-specific PSA according to NICE NG12 and the Prostate Cancer Risk Management Programme guidance

When to seek medical advice: Men experiencing symptoms potentially related to low testosterone should consult their GP for proper assessment rather than self-diagnosing or seeking unregulated treatment. Non-prescribed testosterone, anabolic steroids, or unregulated 'testosterone boosters' should be avoided due to safety concerns. Private clinics offering testosterone therapy without thorough evaluation should be approached with caution, as inappropriate treatment carries risks.

Ultimately, many elderly men with low testosterone levels do not require treatment, particularly if asymptomatic or if symptoms can be managed through lifestyle modification and treatment of comorbidities. For those with confirmed hypogonadism and troublesome symptoms, testosterone therapy may offer benefits, but requires careful patient selection, realistic expectations, and ongoing medical supervision to ensure safety and efficacy. Treatment should be discontinued if there is no benefit after 3-6 months of adequate therapy.

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