GPAtlas🧭 When to suspect
Testosterone deficiency (the term the British Society for Sexual Medicine now prefers to “hypogonadism”) is a clinical and biochemical diagnosis: it requires consistent symptoms together with two low early-morning testosterone levels. A number on its own is never the diagnosis, and asymptomatic men without an associated condition should not be screened.
The three commonest symptoms are erectile dysfunction, reduced libido and loss of early-morning erections – and it is worth asking about morning erections even in a man who is not currently sexually active, as their absence is a useful pointer. Beyond sexual symptoms, deficiency often hides behind fatigue, low mood and a cluster of metabolic problems, so a low testosterone is frequently functional (driven by obesity, type 2 diabetes or chronic illness) rather than true gonadal failure.
The key primary-care skills are to test the right men in the right way, to separate primary from secondary deficiency, and to exclude prostate cancer and protect fertility before any thought of treatment.
| Symptoms that should prompt a test | Conditions & medications that should prompt a test |
|---|---|
|
• Erectile dysfunction, low libido, loss of morning erections (the classic triad) |
• Type 2 diabetes, obesity or metabolic syndrome (a low result is often functional/non-gonadal) |
|
• Fatigue, reduced vigour, low mood, irritability, poor concentration |
• Osteoporosis or a low-trauma fracture; unexplained anaemia |
|
• Gynaecomastia, hot flushes or sweats |
• Pituitary or hypothalamic disease; HIV with weight loss; chronic kidney disease, COPD |
|
• Reduced muscle mass/strength; increased central fat; reduced shaving frequency |
• Long-term opioids, oral glucocorticoids, antipsychotics; anabolic-steroid use (past or present) |
|
• Headache or visual disturbance (think pituitary – see Red Flags) |
• Undescended testes, mumps orchitis, testicular trauma/surgery, prior chemo- or radiotherapy; Klinefelter’s |
Source: BSSM 2023 · Society for Endocrinology
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