The Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Association of Urology (AEU) have reached consensus on a series of unified criteria for the diagnosis of male hypogonadism associated with aging, with the aim of avoiding examinations and treatments that do not benefit patients.
Both organizations have set out these recommendations in the new “National Consensus Document on Age-Associated Male Hypogonadism,” presented during the 67th SEEN Congress held recently in Santiago de Compostela (La Coruña). The text aims to clearly distinguish this condition from other clinical conditions and to promote more individualized management of each case.
“One of the main challenges of age-associated male hypogonadism is to differentiate it from changes proper to aging and from other diseases that can present similar symptoms,” the SEEN member of the Working Group on Gonads, Gender Identity and Sexual Differentiation (GIDSEEN) and first author of the report, Dr. Mireia Mora Porta, has said in this regard, adding that, “for this reason, it is essential to establish common diagnostic criteria that make it possible to correctly identify patients.”
The new consensus updates the previous document, published 16 years ago, and incorporates a diagnostic algorithm that combines biochemical confirmation with etiological guidance, including differential diagnosis and exclusion of secondary causes. This is a complex disorder with significant underdiagnosis in older men, characterized by reduced concentrations of testosterone and effects on multiple systems of the body.
Among the clinical manifestations, which are often confused with normal aging or with other frequent comorbidities, on the sexual level there are described reduced morning erections, loss of sexual desire, and erectile dysfunction. In the physical sphere, persistent fatigue, decreased strength, reduced muscle mass, and increased visceral fat are common; likewise, changes in mood, concentration problems, a sense of lack of energy, and associated cardiometabolic disorders are observed.
For this reason, age-associated hypogonadism constitutes a recurring reason for consultation in Primary Care and in the specialties of Endocrinology and Urology. Added to this is the very marked increase in the use of testosterone outside the healthcare setting for aesthetic or sports purposes. However, the document reminds that replacement therapy should not be indicated in men who do not have a well-established clinical and biochemical diagnosis.
Relationship between testosterone deficiency and metabolic pathologies
In this context, the consensus highlights "the close relationship between testosterone deficiency and metabolic diseases," and details that "between 30 and 50 percent of men with type 2 diabetes or metabolic syndrome present hypogonadism, and men with obesity record testosterone concentrations 30 percent lower—an equivalent reduction to almost three decades of aging—exceeding 75 percent prevalence in cases of grade 3 obesity."
In light of these data, the document recommends that, before starting replacement hormone therapy, those reversible factors that may be implicated in testosterone deficiency be addressed. Four main areas are proposed: changes in lifestyle; weight reduction in patients with overweight or obesity; review of the medication that may alter the synthesis or action of testosterone, and special monitoring of the use of opioids, chronic glucocorticoids and anabolic agents.
Likewise, it is proposed to limit requests for testosterone determinations to men with compatible symptomatology and to certain risk groups, such as those who have type 2 diabetes, obesity or metabolic syndrome, osteoporosis, chronic kidney disease, HIV infection with weight loss, moderate or severe chronic obstructive pulmonary disease (COPD), infertility or pituitary disorders.
The text also reviews the cut-off points and the diagnostic algorithm, and defines three decision ranges for total testosterone (TT): "TT > 12 nmol/l (346 ng/dl), which rules out the diagnosis of male hypogonadism; TT < 8 nmol/l (230 ng/dl), which establishes a likely diagnosis and is very suggestive of the disease; and TT between 8 and 12 nmol/l (230-346 ng/dl), which requires the complementary evaluation of calculated free testosterone (TLc)". "In the case of low levels, these must be confirmed with a new determination at least separated from the first by 2-4 weeks," it adds.
Lastly, the consensus is committed to adapting treatment to the characteristics of each patient, taking into account different formulations of testosterone (short- and long-acting injectable preparations, and transdermal gels), with specific schedules and monitoring. In addition, a six-month therapeutic trial with transdermal testosterone gel is proposed, especially in elderly or frail men, since this formulation makes it possible to stop therapy quickly if adverse effects arise.
In any case, "not all symptoms associated with male aging respond to a testosterone deficiency, nor do all patients with low levels of this hormone need treatment," the coordinator of the Andrology Working Group of the AEU and a participant in the preparation of the document, Dr. Josep Torremadé, has explained, while stating that "it is essential to carry out an individualized clinical assessment, identify the possible causes, and address those factors that may be reversible before considering hormone therapy".