Managing testosterone deficiency in men – UK guidance

A panel of UK specialists convened by the British Society of Sexual Medicine has published a new guideline on the management of testosterone deficiency in men (J Sex Med 2017;14:1504-1523).

The guideline aims to help UK practitioners effectively diagnose and manage primary and age-related testosterone deficiency, with 25 recommendations covering screening, diagnosis, initiating testosterone therapy, the benefits and risks of therapy and follow-up.

Testosterone should be considered for men with sexual dysfunction (erectile dysfunction, loss of spontaneous erections, low sexual desire), all men with type 2 diabetes or who are obese (BMI >30 kg/m2 or waist circumference >102 cm) and men at risk from the adverse effects of long-term treatment with opioids, antipsychotics, or anti-epileptic drugs. The risk of cardiovascular disease should be assessed before and during treatment and management should be optimised before initiating testosterone. Localised low-risk prostate cancer is not a contraindication to treatment.

The guideline recommends that a trial of testosterone therapy should last at least 6 months. It points out that maximal impact on sexual function and metabolic control is often not evident until after 12 months, but the authors acknowledge there is no evidence of benefit on body composition, bone mineralisation or metabolic syndrome after six months.

The guidelines recommend that testosterone therapy combined with a phosphodiesterase 5 inhibitor such as sildenafil should be considered if either approach is ineffective on its own, especially in men with multiple risk factors. A systematic review of six randomised trials in a total of 587 men with type 2 diabetes has concluded that testosterone therapy ‘may moderately improve sexual desire and erectile function’ but there is little evidence of long-term safety. The review, written by specialists in the UK and Saudi Arabia who did not contribute to the guideline, concludes that testosterone therapy ‘could be considered for men with type 2 diabetes when potential risks and benefits of therapy are carefully considered and other therapeutic options are unsuitable’.

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