‘What should I do with a 60‐year old man with a slightly low serum total testosterone concentration and normal levels of serum gonadotrophins’?

Summary The fundamental question in assessing an older man with a slightly low total testosterone and normal gonadotrophin levels is to determine whether or not he has clinical hypogonadism. Hypogonadism is defined as a clinical syndrome complex, which comprises both symptoms as well as biochemical testosterone deficiency. As symptoms are nonspecific and there are no clear cut‐off values for testosterone levels this invariably leads to a clinical dilemma. International guidelines have been published which provide recommendations to aid the clinician in making a diagnosis. Late‐onset hypogonadism, the preferred terminology for age‐related hypogonadism, can only be made once other causes have been excluded. Evidence shows that low testosterone levels are associated with several common male conditions including erectile dysfunction, osteoporosis and diabetes. Short‐term studies have shown benefits of testosterone replacement therapy (TRT) on body composition, bone metabolism, insulin resistance, sexual function and quality of life. Recommendations give clear advice on safety monitoring, specifically in relation to prostate health. If a diagnosis of hypogonadism is made with borderline testosterone levels then a 3‐month trial of TRT can be considered. The diagnosis of hypogonadism associated with borderline testosterone levels and the decision to treat should only be made by an experienced clinician.