title: Commentary: Who is a candidate for testosterone therapy? A synthesis of international expert opinions.
abstract: BACKGROUND
  Despite increasing use of testosterone therapy (TTh) for men with testosterone deficiency (TD), there remains uncertainty determining who is a candidate for treatment.
  
  
  OBJECTIVE
  The aim if this study was to report the opinions of international experts on TTh, as initially presented at the meeting of the World Meeting on Sexual Medicine in Chicago, United States in August 2012.
  
  
  METHODS
  Expert responses to questions regarding the diagnosis of TD based on their own clinical and research experience.
  
  
  RESULTS
  All experts emphasized the primacy of symptoms for the diagnosis of TD. Total testosterone (T) thresholds used to identify TD ranged from 350 ng/dL to 400 ng/dL (12-14 nmol/L); however, experts emphasized the diagnostic limitations of this test. Free T was obtained by all, with some valuing this test more than total T for clinical decision making. Only one expert routinely used a screening questionnaire. None used age-adjusted values. Bioavailable T and the free androgen index were not used. Luteinizing hormone (LH) and sex hormone-binding globulin levels were routinely obtained at evaluation. Additional supportive evidence for TD diagnosis included small testicular volume, high androgen receptor CAG repeats, elevated LH, and presence of diabetes or metabolic syndrome. Two T tests were generally obtained but not always required. Some experts did not require morning testing in men 50 years and older. All monitored prostate-specific antigen and hematocrit after initiation of TTh. All but one expert would consider a trial of TTh to a symptomatic man with total T within the normal range. Recent studies suggesting increased cardiovascular risk with T therapy were not found to be credible.
  
  
  CONCLUSIONS
  Determining who is a candidate for TTh requires clinical assessment based on symptoms and signs, with confirmatory laboratory evaluation. These expert opinions differed from some published guidelines by the emphasis on symptoms as paramount, recognition of the limitations of total T as a diagnostic test, and the potential utility of a therapeutic trial in symptomatic cases with normal total T concentrations.
authors.affiliation: Men's Health Boston, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
authors.forename: Abraham
authors.initials: A
authors.lastname: Morgentaler
authors.forename: Mohit
authors.initials: M
authors.lastname: Khera
authors.forename: Mario
authors.initials: M
authors.lastname: Maggi
authors.forename: Michael
authors.initials: M
authors.lastname: Zitzmann
mesh_terms: D000328:Adult; D002318:Cardiovascular Diseases / Q000150:complications; D048909:Diabetes Complications / Q000150:complications; D020249:Hormone Replacement Therapy; D006801:Humans; D007986:Luteinizing Hormone / Q000378:metabolism; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D017430:Prostate-Specific Antigen / Q000378:metabolism; D012307:Risk Factors; D012738:Sex Hormone-Binding Globulin / Q000378:metabolism; D013739:Testosterone / Q000172:deficiency / Q000627:therapeutic use*; D014481:United States
chemical_list: D012738:Sex Hormone-Binding Globulin; D013739:Testosterone; D007986:Luteinizing Hormone; D017430:Prostate-Specific Antigen
keywords: Diagnosis; Evaluation; Hypogonadism; Monitoring; Testosterone; Treatment