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Testosterone deficiency: a common, unrecognized syndrome

Abstract

Testosterone deficiency syndrome (TDS) refers to the clinical signs and symptoms that result from an abnormally low testosterone level. Men with 'classic' hypogonadism can have unequivocally low testosterone levels and typical symptoms and signs. By contrast, the age-related decline of testosterone levels can be responsible for ambiguous clinical pictures, which can potentially be misinterpreted as part of the aging process or depression. Nevertheless, this decline can have detrimental effects on quality of life and on the function of multiple organ systems. TDS is underdiagnosed—its overall prevalence varies from 6% to 9.5% in community-dwelling men aged 40–70 years, and rises to 15–30% in diabetic or obese men—and undertreated; less than 10% of men with TDS receive treatment. This Review highlights potential pitfalls in the diagnosis of both clinical and biochemical components of TDS.

Key Points

  • Symptoms and signs of testosterone deficiency syndrome (TDS) should be present simultaneously with a consistent, abnormally low, testosterone level for the diagnosis of TDS to be made

  • The clinical picture is usually typical in young men whereas it is usually less clear-cut in older men, because of their slow decline in testosterone levels

  • Men with sexual dysfunction, low physical activity, abdominal obesity, loss of muscle mass and strength, diabetes or metabolic syndrome should be screened for TDS

  • Low testosterone levels must be demonstrated in at least in two morning serum samples taken at an interval of 1–2 weeks, with measurement of serum follicle-stimulating hormone and luteinizing hormone levels to distinguish between primary (testicular) and secondary (hypothalamic–pituitary) hypogonadism

  • The overall prevalence of TDS varies from 6% to 9.5% in community-dwelling men aged 40–70 years, and rises to 15–30% in diabetic or obese men with or without metabolic syndrome

  • Comorbid diseases and drug interactions must be excluded before considering a diagnosis of TDS

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Figure 1: Simplified algorithm for the endocrine evaluation of men with symptoms or signs that could be related to testosterone deficiency.
Figure 2: Algorithm used to determine the need for testosterone-replacement therapy in symptomatic men.

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Correspondence to Jacques L Tostain.

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JL Tostain declared that he has acted as a consultant and received speaker's honoraria from Pierre Fabre Medicament.

F Blanc declared no competing interests.

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Tostain, J., Blanc, F. Testosterone deficiency: a common, unrecognized syndrome. Nat Rev Urol 5, 388–396 (2008). https://doi.org/10.1038/ncpuro1167

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