Testosterone prescribing has increased 3-fold in the United States over the past two decades — driven partly by legitimate recognition of hypogonadism as an under-diagnosed condition, and partly by direct-to-consumer marketing and telehealth prescribing of testosterone for non-specific complaints of fatigue, low libido, and cognitive fog in men with testosterone levels in the low-normal range. The 2025 AUA/Endocrine Society guidelines attempt to clarify appropriate use in this complex landscape.
Diagnosis of Hypogonadism
Classical hypogonadism requires both: (1) consistently low morning testosterone (total testosterone < 300 ng/dL on two separate morning samples, with laboratory-specific thresholds) AND (2) symptoms attributable to testosterone deficiency (decreased libido, erectile dysfunction, decreased spontaneous erections, decreased energy, depressed mood, decreased concentration, hot flashes, gynecomastia, decreased beard/body hair, reduced muscle mass). Low testosterone without symptoms should not be treated routinely — testosterone levels decline 1–2% per year after age 30, making "low" levels common in older men without clear clinical disease. Workup should include LH/FSH (to classify primary vs secondary hypogonadism), prolactin, thyroid function, and evaluation for reversible causes (obesity, medications, chronic illness, sleep apnea).
The TRAVERSE Trial: Cardiovascular Safety Resolved
The 2023 TRAVERSE trial (n=5,246, mean age 57, established or high-risk CVD, baseline testosterone 150–300 ng/dL) provided the definitive cardiovascular safety data: TRT was non-inferior to placebo for MACE (HR 1.07, 95% CI 0.94–1.21). However, TRT increased rates of atrial fibrillation (3.5% vs 2.4%), acute kidney injury, and pulmonary embolism — signals requiring monitoring. This trial resolves the prior FDA black box cardiovascular concern for appropriate candidates but highlights the importance of continued monitoring. Treatment options include topical gels (most common — good dosing flexibility but transfer risk to partners/children), injections (testosterone cypionate/enanthate, cost-effective but creates peak-trough cycling), transdermal patches, and pellets. For facilities managing TRT patients, our diagnostic equipment section and laboratory supplies section support hormone monitoring protocols.
