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Changes in the worldwide diagnosis and treatment of testosterone deficiency between 2006 and 2010

Diagnosing and treating testosterone deficiency in different parts of the world: changes between 2006 and 2010. Gooren LJ, Behre HM. The Aging Male 2012;15(1):22-27.

This physician-based survey investigated the diagnosis and treatment of testosterone deficiency (hypogonadism) in various parts of the world in 2010.1 The study, conducted in Germany, Spain, the United Kingdom, Brazil and Saudi Arabia between April and May 2010, involved 353 physicians (229 urologists, 84 endocrinologists and 40 primary care physicians) who were interviewed to address the following issues (1) the reasons to use/not use testosterone in patients who have testosterone deficiency (2) the role of safety and other concerns in the decision to not provide testosterone treatment and (3) to evaluate the actual use of testosterone preparations for the treatment of erectile dysfunction. The results of this survey were compared with a previous survey conducted in Germany, Spain, the United Kingdom, Brazil and South Korea by the same investigators in 2006 to determine if any significant changes in clinical practice have occurred over the last 4 years.2
Key Points1

  • In 2010, the majority of physicians surveyed (82%) would regularly use laboratory measurements of total testosterone to diagnose testosterone deficiency and 17% of the physicians surveyed would measure total testosterone levels sometimes

    • Other laboratory measurements used to diagnose testosterone deficiency were free testosterone (32% regularly, 36% sometimes) and sex hormone binding globulin (29% regularly, 45% sometimes) levels
    • The proportion of physicians who would use laboratory measurements to diagnose testosterone deficiency in 2010 did not differ from 2006
  • Physicians consider the main symptoms of testosterone deficiency to be erectile dysfunction (ED; 53%), lack of libido (53%), fatigue (45%), loss of power (13%), depression (26%), weight gain (16%) and loss of hair/reduced body hair (16%)

    • There was an increased awareness among physicians of depression and weight gain as clinical symptoms of low testosterone
  • Similar to the original survey in 2006, for 70% of the physicians surveyed, the severity of the symptoms experienced was considered a more significant reason to start testosterone treatment than the laboratory value of testosterone

    • This was the case more so in Germany (96%), the United Kingdom (63%) and Brazil (62%) than in Saudi Arabia (36%) and Spain (7%), who relied more on testosterone measurements
  • In 2010, significantly more physicians expressed concern about the adverse effects of testosterone treatment compared with 2006 (78% vs 54%; Figure 1)

    • Many physicians remained concerned about prostate cancer (55% vs 51%)
    • Concerns about cardiovascular disease (17% vs 4%), risk of all types of cancer (10% vs 4%) and polycythemia (9% vs 4%) were also expressed
    • Eleven percent of patients eligible for testosterone therapy did not receive treatment due to these concerns.
  • The patterns of prescribing testosterone for short term or longer term treatment did not change from 2006 to 2010

    • Lifelong treatment with parenteral testosterone undecanoate was intended in 33% of patients, whereas 67% of patients used the treatment for a limited time (10–48 months)
    • Duration of treatment was shorter in patients receiving testosterone gel compared with those receiving testosterone undecanoate injections
  • The proportion of patients diagnosed with ED who have testosterone deficiency ranged from 41% to 64% depending on the country

    • These patients were more likely in 2010 to be treated with phosphodiesterase type 5 (PDE5) inhibitor monotherapy or testosterone + PDE5 inhibitors than in 2006
  • Furthermore, there was great variation between countries with regards to the treatments utilized for ED in patients with testosterone deficiency

    • In Saudi Arabia, Spain and the United Kingdom, the use of testosterone + PDE5 inhibitors is increasing
    • In comparison, in Germany, PDE5 inhibitor monotherapy is utilized more.

What is known

Testosterone deficiency (hypogonadism) is increasingly recognized as a significant health problem in aging men.3-6 Testosterone deficiency can adversely affect sexual function, physical health and psychological health.6 Consequently, the quality of life of men with low testosterone is negatively affected.7 The goal of testosterone replacement therapy in these hypogonadal men is to restore testosterone to normal physiological levels in a safe manner and to alleviate symptoms in turn improving health, well-being and quality of life.8,9 However, the attitudes of physicians to testosterone deficiency, in particular the diagnosis and treatment, remain varied.2 A study conducted in 2006 showed that physicians were concerned about inducing prostate problems, in particular prostate cancer, with testosterone therapy.2 This concern lead to ~35% of patients who were eligible for testosterone therapy not receiving treatment. Furthermore, in patients with ED, 18–29% also had testosterone deficiency; however, this was not often treated.2 This study aimed to update our understanding of the attitudes of physicians to the medical problems related to testosterone deficiency, and our understanding of variations in the diagnosis and treatment of testosterone deficiency in various parts of the world.

What this study adds

This survey showed that, while there have been improvements in knowledge since 2006, education of physicians regarding diagnosing testosterone deficiency, the role of testosterone in ED and on the evidence-based relative safety of testosterone treatment is still required in most parts of the world.

Since 2006, the number of symptoms associated with testosterone deficiency in the perception of physicians has increased. In particular, depression and obesity were regarded as potentially associated with testosterone deficiency. These observations call for a diagnosis of testosterone deficiency that combines not only laboratory diagnoses but also clinical symptoms.

This study highlights that physicians are still concerned about the adverse effects associated with testosterone therapy despite recent guidelines on the appropriate use of testosterone therapy.6,8,10 In particular, while there are new outlooks on the relationship between testosterone therapy and prostate cancer, the authors emphasize that caution should still be used by physicians in their approach to the treatment of testosterone deficiency, particularly in the elderly.

The study also highlighted that the combination of PDE5 inhibitors and testosterone is more widely used now by physicians for the treatment of ED in patients with testosterone deficiency and is associated with a high treatment success rate compared with testosterone monotherapy.
Figure 1: Change in the proportion of physicians concerned about the adverse effects of testosterone therapy


1. Gooren LJ, Behre HM. Diagnosing and treating testosterone deficiency in different parts of the world: changes between 2006 and 2010. The Aging Male 2012;15(1):22-27.
2. Gooren LJ, Behre HM, Saad F, et al. Diagnosing and treating testosterone deficiency in different parts of the world. Results from global market research. The Aging Male 2007;10(4):173-181.
3. Ullah MI, Washington T, Kazi M, et al. Testosterone deficiency as a risk factor for cardiovascular disease. Horm Metab Res 2011;43(3):153-164.
4. Wang C, Jackson G, Jones TH, et al. Low testosterone associated with obesity and the metabolic syndrome contributes to sexual dysfunction and cardiovascular disease risk in men with type 2 diabetes. Diabetes Care 2011;34(7):1669-1675.
5. Bassil N, Morley JE. Late-life onset hypogonadism: a review. Clin Geriatr Med 2010;26(2):197-222.
6. Wang C, Nieschlag E, Swerdloff R, et al. Investigation, treatment, and monitoring of late-onset hypogonadism in males: ISA, ISSAM, EAU, EAA, and ASA recommendations. Eur Urol 2009;55(1):121-130.
7. Maggi M, Schulman C, Quinton R, et al. The burden of testosterone deficiency syndrome in adult men: economic and quality-of-life impact. The Journal of Sexual Medicine 2007;4(4 Pt 1):1056-1069.
8. Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2010;95(6):2536-2559.
9. Buvat J, Maggi M, Gooren L, et al. Endocrine aspects of male sexual dysfunctions. J Sex Med 2010;7(4 Pt 2):1627-1656.
10. Wang C, Nieschlag E, Swerdloff RS, et al. ISA, ISSAM, EAU, EAA and ASA recommendations: investigation, treatment and monitoring of late-onset hypogonadism in males. The Aging Male 2009;12(1):5-12.

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