Testosterone levels: clinical debate

Modern lifestyle factors such as obesity, poor diet, exposure to environmental toxins, chronic stress, poor sleep and reduced physical activity are contributing to a global decline in testosterone levels.

In the UK, low testosterone – also known as male hypogonadism – is defined as a clinical and biochemical syndrome, with symptoms including low libido, erectile dysfunction, fatigue, depression, increased body fat, loss of muscle mass and cognitive decline, alongside reduced serum testosterone levels.

UK guidance considers total testosterone levels below 12nmol/L as low or borderline, and levels below 8nmol/L as diagnostic of deficiency. Some clinicians advocate for age-specific thresholds, recognising that younger men naturally have higher levels.

Testosterone therapy is recommended for men with confirmed hypogonadism, but there is ongoing debate about whether current thresholds are too rigid, potentially missing symptomatic men, versus concerns about overdiagnosis and unnecessary long-term treatment.

Testosterone replacement therapy (TRT) can offer benefits such as improved mood, energy, libido and muscle mass, but it also carries risks including increased haematocrit, cardiovascular strain and stimulation of prostate tissue.

Monitoring involves regular checks of testosterone, PSA and haematocrit, with treatment reviewed at three, six and 12 months.

Shared care models are increasingly being used, with specialists initiating therapy, and GPs or pharmacists supporting ongoing management.

Weight reduction, lifestyle modification and effective management of comorbidities can increase testosterone and reduce the associated risks for diabetes and cardiovascular diseases.

Community pharmacists can play a key role in counselling patients so that these factors can be optimised, as well as checking adherence to monitoring protocols and safe prescribing practices.