Testosterone Testing - Protocol

Effective Date: September 19, 2018

Recommendations and Topics

Scope

This protocol reviews the appropriate use of serum testosterone testing in men and women aged ≥ 19 years. This document is intended to direct primary care practitioners and to help constrain inappropriate test utilization, particularly as it pertains to “wellness” and “anti-aging” practices. This protocol expands on the guidance provided in the associated BC Guideline.caHormone Testing – Indications and Appropriate Use. Testosterone testing for pediatric and transgender* patients is out of scope of this protocol.

* Note: For information and guidance on testosterone testing for transgender people, refer to Gender-affirming Care for Trans, Two-Spirit, and Gender Diverse Patients in BC: A Primary Care Toolkit, produced by Trans Care BC at the Provincial Health Services Authority.

Key Recommendations

  • Testing for testosterone deficiency is not recommended in asymptomatic men or women.
  • The decision to test must be guided by medical history and clinical examination.
  • Testosterone deficiency in men usually presents with a constellation of symptoms. Erectile dysfunction in isolation is not an indication for testosterone testing.
  • In men, serum total testosterone must be collected in the morning, preferably before 10AM, or within 3 hours of waking, and preferably in a fasting state.
  • Men receiving stable androgen replacement can be tested annually.
  • Testosterone testing is not useful for the investigation of low libido in women.

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Tests

The testosterone tests available in British Columbia are:

  • serum total testosterone
  • calculated bioavailable testosterone (cBAT), which includes the sex hormone binding globulin test (SHBG)

MSP Cost of Tests1

Test Cost
Testosterone – total $15.81
cBAT (includes SHBG) $29.37

Current to January 1st, 2018.

Circulating testosterone exists in three forms: free, weakly bound to albumin, and strongly bound to SHBG. Serum total testosterone measures all three forms. Bioavailable testosterone is the sum of free testosterone and albumin bound testosterone. In BC, all bioavailable and free testosterone results are calculated rather than directly measured. Calculated bioavailable testosterone (cBAT) and calculated free testosterone are derived from the same calculation, which utilizes both the measured total testosterone and measured SHBG concentrations. Although the two parameters may be reported separately, cBAT and calculated free testosterone are functionally and diagnostically equivalent (and therefore redundant) – as such, only cBAT will be referenced in the remainder of the guideline. Reference ranges for serum total testosterone and cBAT are method and age dependent and are determined by each laboratory independently. 

Patients should use the same lab for initial and follow up testosterone tests because reference ranges are lab-dependent,2 meaning that results from different labs may not be comparable. For more information about the different forms of testosterone in plasma and their measurement, refer to BCGuidelines.caHormone Testing Guideline Appendix A: Testosterone Testing and Measurement in BC.

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Testosterone Deficiency in Men

Routine biochemical screening for testosterone deficiency (hypogonadism) in asymptomatic men is not recommended. A decision to test must be guided by the medical history and clinical examination. In the case of isolated, or non-specific symptoms only, a comprehensive general assessment is required to exclude potential alternative explanations3 and to guide further investigations. In the case of follow up of a previously ordered, relatively low, testosterone measurement, in a minimally symptomatic man, refer to Appendix A: Differential Diagnosis of Hypogonadism in Men (PDF, 116KB) and Appendix B: Medications that May Alter Testosterone Levels in Men and Women (PDF, 117KB) for conditions and medications associated with changes in testosterone concentration.

Signs and Symptoms of Testosterone Deficiency in Men

There are many non-specific somatic and psychological symptoms associated with hypogonadism (refer to Table 1 below). Any one finding alone is insufficient grounds to order a testosterone test.

Late-onset (age ≥ 40 years) hypogonadism is most specifically defined by the presence of at least three sexual symptoms (decreased frequency of morning erection, decreased frequency of sexual thoughts, and erectile dysfunction) associated with low testosterone and/or a low cBAT3 Erectile dysfunction in isolation is not an indication for testosterone testing because the prevalence of hypogonadism among patients with erectile dysfunction is low.4

Table 1: Symptoms and signs of testosterone deficiency in men, in order of specificity5, 6

Specific to testosterone deficiency Supportive of testosterone deficiency Not specific to testosterone
deficiency
  • Loss of body (axillary, facial, pubic) hair
  • Very small testes (<6 mL)
  • Breast discomfort, gynecomastia
  • Eunuchoidal body proportions
  • Infertility, low sperm count
  • Height loss, low-trauma fracture, low bone mineral density
  • Hot flushes, sweats
  • Pervasive decrease in sexual desire (libido) and activity
  • Erectile dysfunction
  • Decreased frequency of morning erections or spontaneous erections
  • Fatigue or decreased energy
  • Depression or depressed mood
  • Poor concentration and memory
  • Sleep disturbance, increased sleepiness
  • Anemia
  • Decreased muscle bulk and strength
  • Increased body fat, body mass index (BMI)

Adapted from Bhasin 20106 and Bhasin 20185

Some symptoms of hypogonadism in men ≥ 40 years overlap with normal effects of aging.7 The documentation of low total testosterone in elderly men with non-specific symptoms of hypogonadism does not necessarily imply that low testosterone is the cause.

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Testing for Testosterone Deficiency in Men

Serum total testosterone is the initial test of choice. Specimens must be collected in the morning,8 preferably before 10AM, or within 3 hours of waking, and preferably in a fasting state.5, 9 Testing should occur when the sleep-wake pattern is stable (e.g., not during shift changes or jetlag). Testing of serum total testosterone should be performed when patients are clinically well; do not test during acute illness or hospitalization.

If the total testosterone level is below the lab-specific lower limit of normal (approximately 8 nmol/L in younger men (<30 years), and 6 nmol/L in older men (>50 years)),10–13 and a diagnostic question remains, cBAT (which includes SHBG) can be used to confirm or rule out hypogonadism.

For men, total testosterone levels may be low but the cBAT normal when the SHBG concentration is decreased. Total testosterone levels may be normal but cBAT low when SHBG concentration is increased. Idiopathic elevations in SHBG are well known as are other conditions that are associated with mild to marked changes in the SHBG concentration. Refer to Appendix C: Conditions Associated with Altered SHBG Concentrations in Men and Women (PDF, 117KB).

Note that testosterone is characterized by episodic secretion: 30% of men with mildly hypogonadal serum testosterone levels will have a normal level on retesting.

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Diagnosis in Men

It has been observed that men in BC frequently receive prescriptions for testosterone replacement without first having a serum testosterone test to confirm low levels.14 This practice is not appropriate, as biochemical confirmation of a low for age serum total testosterone (or cBAT) is necessary to confirm the clinical impression of hypogonadism. In the absence of this biochemical confirmation, a re-visitation or verification of the original empiric diagnosis will be very difficult since prolonged androgen therapy will result in suppression of the hypothalamic pituitary gonadal axis for as long as 18 months.

While specific investigation is beyond the scope of this protocol, it is important to establish the etiology of hypogonadism, after biochemical confirmation of the clinical diagnosis, and before initiating testosterone replacement. Refer to Appendix A: Differential Diagnosis of Hypogonadism in Men (PDF, 116KB) and Appendix D: Hypogonadism Investigation Algorithm (PDF, 117KB) for guidance on initial investigation and testing.

Prior to initiating testosterone replacement, the following baseline tests are recommended: hematocrit, prostate-specific antigen (PSA), and digital rectal exam (DRE).7 Other contraindications to testosterone replacement should be considered. These are discussed in detail elsewhere.5, 7

Occasionally the cause of hypogonadism is congenital/pituitary/hypothalamic in nature and if there are pre-existing risk factors (e.g., cranial irradiation, hemochromatosis), referral to endocrinology is recommended. Refer to Appendix D: Hypogonadism Investigation Algorithm (PDF, 117KB) for more information.

Consider referral if uncertain. Indications for referral to specialists are outlined in Table 2 below.

Occasionally it is discovered that a man has a high total testosterone. This can be investigated by ordering SHBG. Note, however, that current MSP billing rules require pathologist approval prior to ordering an SHBG test on a patient with a relatively high total testosterone concentration.

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Monitoring of Testosterone-Replacement Treatment in Men

Monitor men receiving androgen replacement by repeating the hematocrit, PSA test, and DRE at 3 and 6 months after initiation, then annually if stable.7 Some recommend that PSA testing after one year is not necessarily obligatory.5 Men receiving stable androgen replacement can be tested with serum total testosterone testing annually.5, 7

Blood collection timing by route of administration:5

  • Injectable testosterone enanthate or cypionate: measure testosterone midway between injections
  • Transdermal gels/Intranasal: measure 2–8 hours after application
  • Transdermal patches: 3–12 hours after application
  • Oral testosterone undecanoate: 3–5 hours after ingestion with a fat-containing meal

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Testosterone Testing in Prostate Cancer

Total testosterone testing is indicated to confirm adequacy of androgen deprivation therapy (ADT) in men with prostate carcinoma. Only tandem mass spectrometry is sufficiently sensitive to accurately measure the low total testosterone seen in men rendered chemically castrate for treatment of prostate carcinoma.15 In BC, testosterone analysis by tandem mass spectrometry is not routinely available and should be specifically requested on the requisition. Testosterone should be tested 3 months after initiating ADT, and in the event of any increase in PSA levels.

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Testosterone Analysis in Women

Testosterone testing is indicated for investigation of signs and symptoms of hyperandrogenism in women based on medical history and clinical examination. Testosterone testing is not indicated for the investigation of women with low libido.16

The upper limit of normal for testosterone in women is approximately 2-3 nmol/L, or slightly higher depending on menstrual phase and use of oral contraceptive medications.17 In polycystic ovarian syndrome, total testosterone concentrations are within the normal reference interval or slightly higher. Consequently, testosterone concentrations greater than twice the upper limit of normal (i.e., greater than 5 nmol/L) suggest an alternate etiology, such as an androgen-secreting tumour.

Signs and Symptoms of Hyperandrogenism in Women

A range of symptoms and signs from hirsutism to virilisation may occur. The Endocrine Society recommends testing for hyperandrogenism in women with hirsutism that is moderate or severe, of rapid onset, or accompanied by menstrual dysfunction, obesity or clitoromegaly.18 Other indications for referral are outlined at the end of this document.

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Testing for Hyperandrogenism in Women

Serum total testosterone is frequently normal in women with mild clinical hyperandrogenism (due to androgen suppression of SHBG production). cBAT testing (which includes SHBG) has a better diagnostic yield for testosterone excess in women.19 Repeat serum testosterone testing is not indicated if cBAT is normal. Testing of other androgens is dependent on clinical findings and is beyond the scope of this protocol; for more information refer to the BC Guideline.caHormone Testing - Indications and Appropriate Use. For women who have regular menstrual cycles, collection should be performed in the morning on day 4–10.18

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Diagnosis of the Cause of Hyperandrogenism in Women

The diagnosis of testosterone excess is based on medical history and physical findings, followed by investigational tests. The most common cause of hirsutism20 and of excess androgen production in pre-menopausal women18 is polycystic ovary syndrome (PCOS). It is important to rule out non-classic congenital adrenal hyperplasia, which occurs in 1.5–6.8% of women with hyperandrogenism.21 A history of rapid virilization is suggestive of ovarian or adrenal malignancy and such patients should be immediately referred. For more information refer to Appendix B: Conditions Associated with Alterations in SHBG Concentration in Men and Women (PDF, 117KB) and Appendix C: Medications that May alter Testosterone Levels in Men and Women (PDF, 117KB). Complete guidance for the investigation and diagnosis of female hyperandrogenism is beyond the scope of this document. Indications for urgent or non-urgent referral are outlined in Table 2 below.

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Monitoring Response to Treatment in Women

Women receiving treatment for hyperandrogenism: Response to treatment of hyperandrogenism in women is clinical. Therefore, testing serum total testosterone and cBAT in patients treated for hyperandrogenism is not recommended unless a concrete cause has been identified, such as non-classical congenital adrenal hyperplasia or an androgen-secreting tumour.

Women receiving androgen therapy for low libido: Testosterone testing is not useful for monitoring women receiving androgen therapy for low libido unless overuse is suspected or unexpected virilisation has developed.

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Indications for Referral

Table 2: Indications for consideration of referral to an endocrinologist, urologist, or obstetrician/gynaecologist as appropriate. Some indications may require urgent referral; indicated with an asterisk.

Men5–7 Women21, 22

Confirmed or suspected:

  • Hypothalamic/pituitary tumour*
  • Hyperprolactinemia*
  • Hemochromatosis
  • Idiopathic hypogonadotropic hypogonadism
  • Cryptorchidism, anorchia
  • Genetic conditions including Klinefelter syndrome, Kallmann syndrome, myotonic dystrophy
  • Male factor infertility

Confirmed or suspected:

  • Rapid virilisation/rapid hair loss*
  • Symptoms consistent androgen-secreting tumour of adrenal or ovarian origin*
  • Cushing syndrome*
  • Acromegaly*
  • Congenital adrenal hyperplasia (CAH)
  • Polycystic ovary syndrome (PCOS)
  • Gestational hyperandrogenism
  • Ovarian hyperthecosis
  • Exogenous androgen administration

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Resources

Abbreviations

TT total testosterone
cBAT calculated bioavailable testosterone
SHBG sex hormone binding globulin

PSA prostate-specific antigen
DRE digital rectal examination

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Practitioner Resources

  • RACE: Rapid Access to Consultative Expertise Program – www.raceconnect.ca
    A telephone consultation line for select specialty services for physicians, nurse practitioners and medical residents.

    If the relevant specialty area is available through your local RACE line, please contact them first. Contact your local RACE line for the list of available specialty areas. If your local RACE line does not cover the relevant specialty service or there is no local RACE line in your area, or to access Provincial Services, please contact the Vancouver Coastal Health Region/Providence Health Care RACE line.
     
    • Vancouver Coastal Health Region/Providence Health Care: www.raceconnect.ca
      Available Monday to Friday, 8 am to 5 pm
      604 696-2131 (Vancouver area) or 1 877 696-2131 (toll free)
    • Northern RACE: 1 877 605-7223 (toll free)
    • Kootenay Boundary RACE: www.divisionsbc.ca/kb/race 1 844 365-7223 (toll free)
    • Fraser Valley RACE: www.raceapp.ca (download at Apple and Android stores)
    • South Island RACE: www.raceapp.ca (download at Apple and Android stores) or www.divisionsbc.ca/south-island/RACE
    • Note that endocrinology on Vancouver Island is available through the Royal Jubilee Hospital/Victoria General Hospital on call endocrinologist. The on call endocrinologist can be reached through intranet.viha.ca or the Royal Jubilee Hospital switchboard.
  • Pathways: PathwaysBC.ca
    An online resource that allows GPs and nurse practitioners and their office staff to quickly access current and accurate referral information, including wait times and areas of expertise, for specialists and specialty clinics. In addition, Pathways makes available hundreds of patient and physician resources that are categorized and searchable.

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Patient and Caregiver Resources

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Appendices

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References

  1. Schedule of Fees for the Laboratory Services Outpatient - Payment Schedule [Internet]. British Columbia Ministry of Health; 2018 [cited 2018 Mar 29]. Available from:
    https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/laboratory-services/laboratory_services_-_schedule_of_fees_2018-01-01.pdf
  2. Buvat J, Maggi M, Guay A, Torres LO. Testosterone Deficiency in Men: Systematic Review and Standard Operating Procedures for Diagnosis and Treatment. J Sex Med. 2013 Jan;10(1):245–84.
  3. Wu FCW, Tajar A, Beynon JM, Pye SR, Silman AJ, Finn JD, et al. Identification of late-onset hypogonadism in middle-aged and elderly men. N Engl J Med. 2010 Jul 8;363(2):123–35.
  4. Buvat J, Lemaire A. Endocrine screening in 1,022 men with erectile dysfunction: clinical significance and cost-effective strategy. J Urol. 1997 Nov;158(5):1764–7.
  5. Bhasin S, Brito JP, Cunningham GR, Hayes FJ, Hodis HN, Matsumoto AM, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab [Internet]. 2018 Mar 17 [cited 2018 Mar 22]; Available from: https://academic.oup.com/jcem/advance-article/doi/10.1210/jc.2018-00229/4939465
  6. Bhasin S, Cunningham GR, Hayes FJ, Matsumoto AM, Snyder PJ, Swerdloff RS, et al. Testosterone Therapy in Men with Androgen Deficiency Syndromes: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2010 Jun 1;95(6):2536–59.
  7. Morales A, Bebb RA, Manjoo P, Assimakopoulos P, Axler J, Collier C, et al. Diagnosis and management of testosterone deficiency syndrome in men: clinical practice guideline. CMAJ. 2015;187(18):1369–77.
  8. Laurino JP. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. Ann Clin Lab Sci. 2006 Mar 20;36(2):224–224.
  9. Sartorius G, Spasevska S, Idan A, Turner L, Forbes E, Zamojska A, et al. Serum testosterone, dihydrotestosterone and estradiol concentrations in older men self-reporting very good health: the healthy man study. Clin Endocrinol (Oxf). 2012 Nov;77(5):755–63.
  10. Kushnir MM, Blamires T, Rockwood AL, Roberts WL, Yue B, Erdogan E, et al. Liquid Chromatography-Tandem Mass Spectrometry Assay for Androstenedione, Dehydroepiandrosterone, and Testosterone with Pediatric and Adult Reference Intervals. Clin Chem. 2010 Jul 1;56(7):1138–47.
  11. Travison TG, Vesper HW, Orwoll E, Wu F, Kaufman JM, Wang Y, et al. Harmonized Reference Ranges for Circulating Testosterone Levels in Men of Four Cohort Studies in the United States and Europe. J Clin Endocrinol Metab. 2017 Apr 1;102(4):1161–73.
  12. Yeap BB, Alfonso H, Chubb SAP, Handelsman DJ, Hankey GJ, Norman PE, et al. Reference Ranges and Determinants of Testosterone, Dihydrotestosterone, and Estradiol Levels Measured using Liquid Chromatography-Tandem Mass Spectrometry in a Population-Based Cohort of Older Men. J Clin Endocrinol Metab. 2012 Nov;97(11):4030–9.
  13. Kannenberg F, Fobker M, Schulte E, Pierściński G, Kelsch R, Zitzmann M, et al. The Simultaneous measurement of serum testosterone and 5α-dihydrotestosterone by gas chromatography–mass spectrometry (GC–MS). Clin Chim Acta. 2018 Jan;476:15–24.
  14. Locke J, Flannigan R, Etminan M, Tavokoli H, Skeldon S, Hoyda T, et al. Patterns of prescribing and monitoring testosterone replacement therapy among 40,081 users in British Columbia between 1997-2013 (Abstract). J Urol. 2018 Apr;199(4):e590.
  15. Klotz L, Shayegan B, Guillemette C, Collins LL, Gotto G, Guérette D, et al. Testosterone suppression in the treatment of recurrent or metastatic prostate cancer — A Canadian consensus statement. Can Urol Assoc J [Internet]. 2017 Dec 19 [cited 2018 May 8];12(2). Available from: http://cuaj.ca/cuaj/index.php/journal/article/view/5116
  16. Wierman ME, Arlt W, Basson R, Davis SR, Miller KK, Murad MH, et al. Androgen therapy in women: a reappraisal: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2014 Oct;99(10):3489–510.
  17. Eisenhofer G, Peitzsch M, Kaden D, Langton K, Pamporaki C, Masjkur J, et al. Reference intervals for plasma concentrations of adrenal steroids measured by LC-MS/MS: Impact of gender, age, oral contraceptives, body mass index and blood pressure status. Clin Chim Acta. 2017 Jul;470:115–24.
  18. Martin KA, Chang RJ, Ehrmann DA, Ibanez L, Lobo RA, Rosenfield RL, et al. Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2008 Apr 1;93(4):1105–20.
  19. Kronenberg H, Williams RH, editors. Williams textbook of endocrinology. 11th ed. Philadelphia: Saunders/Elsevier; 2008. 1911 p.
  20. van Zuuren EJ, Fedorowicz Z. Interventions for hirsutism excluding laser and photoepilation therapy alone: abridged Cochrane systematic review including GRADE assessments. Br J Dermatol. 2016 Jul;175(1):45–61.
  21. Legro RS, Arslanian SA, Ehrmann DA, Hoeger KM, Murad MH, Pasquali R, et al. Diagnosis and Treatment of Polycystic Ovary Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2013 Dec;98(12):4565–92.
  22. Meek CL, Bravis V, Don A, Kaplan F. Polycystic ovary syndrome and the differential diagnosis of hyperandrogenism. Obstet Gynaecol. 2013 Jul;15(3):171–6.

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This guideline is based on scientific evidence current as of the Effective Date.
The guideline was developed by the Guidelines and Protocols Advisory Committee in collaboration with BC's Agency for Pathology and Laboratory Medicine,  and adopted by the Medical Services Commission.

The Guidelines and Protocols Advisory Committee

The principles of the Guidelines and Protocols Advisory Committee are to:

  • encourage appropriate responses to common medical situations
  • recommend actions that are sufficient and efficient, neither excessive nor deficient
  • permit exceptions when justified by clinical circumstances

Contact Information:
Guidelines and Protocols Advisory Committee
PO Box 9642 STN PROV GOVT
Victoria BC V8W 9P1

Email: hlth.guidelines@gov.bc.ca
Website: www.BCGuidelines.ca

Disclaimer
The Clinical Practice Guidelines (the “Guidelines”) have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problem. We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.