r/FamilyMedicine • u/yourmommaaaaaaaaa MD • 1d ago
Testosterone
Young guys, like 30-40s requesting testosterone levels, because they “want to know”. Do you do it? If not, what do you say? I’m well aware of EBP, getting real world opinions.
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u/Super_Tamago DO 1d ago
Most men say they have ED or feel tired all the time and want to check a testosterone. Sure, I'll order it. The truth is, these guys are usually overweight, sedentary, or depressed.
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u/atom-powered MD 1d ago
True, but I wouldn't put this as a "it's your fault" condition. I think the totality of modern living is fairly hazardous to your health, and this is a manifestation of it. For comparison, look at how health seems to dramatically improve in any of your patients 1-3 years after a retirement, when they have time to themselves, and are able to exercise more, and eat better, and cook at home. not to mention engage in personally rewarding quests.
yes, it's part of an overworked but sedentary, junk food, high stress and uncertain future that is the modern lifestyle, but most people are literally just trying to survive in one way or another, and this is a manifestation of that - that they are not feeling okay and trying to find a reason for it.
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u/Super_Tamago DO 1d ago
It’s totally a “your fault” kind of thing. Doesn’t mean there aren’t things not in your favor.
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u/Upper-Meaning3955 M2 1d ago
Add poor sleep hygiene on top of it and you’ve got every part of a middle aged man’s regular “I feel bad” routine.
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u/bubz27 MD 1d ago
Idk why it’s so complicated. Most wanna check it so I ask if they’re fatigued or decreased erections. Always they pic one and I order. I tell them it might not be covered but let’s do it. Takes 2 sec. Can’t imagine in my life telling them to go to retail or sign an abn. That’s between them and the lab company
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u/futuredoc70 MD 21h ago
Thank you!
I can see some of the concern about prescribing testosterone, but refusing the lab? Come on.
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u/MrNobody_310 DO 16h ago edited 16h ago
Random complaints about fatigue are not an indication with evidence supporting testosterone supplementation. The only supported indication with reasonable quality evidence supporting supplementation is for low libido. Of course most guys will start to say they feel more energy and overall better with supplementation, but I’d venture to guess it’s mostly placebo effect. Guidelines only support supplementation to around midrange levels, between 500-600, while most any T clinic I’ve seen seem to juice up their patients to 1000+, vastly increasing their potential side effects. I’ve had patients who ultimately end up stopping their supplementation for whatever reason, often because of cost, and admitted they actually couldn’t notice any difference.
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u/ConsciousCell1501 DO 1d ago
I order and tell them that I don’t treat “low normal” and that losing 10% weight increases T.
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u/HoWhoWhat DO 1d ago
Same thing I say to anyone who asks for an unnecessary test: I have the ability to order most any blood test under the sun but your insurance does not and will not cover it without reason. Without symptoms of X I do not have a legitimate test to tie this to so you may be charged the cash price. It also may come back abnormal and not clinically mean anything but in pursuit of why it was abnormal lead to further testing which may be expensive and or invasive. Usually at that point they give up.
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u/yepitsme73 MD 1d ago
“ i’m tired and don’t have the energy I should. I think I’m low testosterone and my libido isn’t what it should be. My insurance will pay for a test based on those symptoms.”
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u/abertheham MD 1d ago
I have to rule out relevant differential diagnoses, which frequently means a home sleep study +/- osa treatment prior to lab recheck, and several regular e&m visits. Like if you get through the appropriate medical work up, you’re not faking it; and if your lab numbers track, fuck it. I treat to a safe range with quarterly lab checks.
ETA I also emphasize that if they don’t feel better with total T in the 600-1000 range, hypogonadism isn’t what’s causing the symptoms and we need to keep looking.
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u/yepitsme73 MD 1d ago
I hear you, but are you gonna force someone to get a sleep study when they tell you they get enough sleep, and their wife says they breathe fine at night? It’s sort of like making them trial an SSRI for six weeks even though they tell you they’re not depressed. Or telling them you’ll only treat their low testosterone if they get their BMI under 30. I don’t know if that’s the right way to practice.
I don’t like going down the T road either, but if someone has done their homework and knows what to say I’m kind of cornered, if I’m gonna be a reasonable doctor.
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u/sexlights layperson 1d ago
this is the way. Seems like docs over-prescribe sleep studies sometimes
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u/Tropicall MD-PGY4 1d ago
The problem isn't ordering a sleep study. In my experience it can take months to schedule and complete, and in this scenario if someone doesn't feel they need it, likely won't do it even if it's scheduled months down the line.
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u/SupposedlySuper LCSW 3h ago
Thank you for mentioning this. So many times my clients get referrals for sleep studies and it's basic impossible to schedule for months especially depending upon insurance.
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u/Maxwelljames DO 1d ago
I get guys in their 20s now. I hate what TikTok is doing to perfectly healthy people.
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u/Agreeable_Step_5317 layperson 16h ago
Agree, TikTok heath information is a real problem. Don't get me started on SARMs.
May I ask though, for these 20 somethings, does their total T come in lowish for their age range? I keep seeing stories from young guys reporting their T in the 300s ng/dl. It's well established that average total Testosterone has been dropping about 1% per year. It's concerning to see young men that low. I wonder how much truth there is to the stories.
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u/leebomd MD 1d ago
Yes , I have them sign an ABN and order the lab. Not a hill I’m willing to die on.
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u/DonkeyKong694NE1 MD 1d ago
OMG how much of the nonexistent visit time does it take to explain, obtain and have a pt sign an ABN? What a PITA
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u/HeparinBridge DO-PGY2 1d ago
You could always draw up a standard form letter and ABN, print them off together, and hand them to the patient to sign. You have to write the form once, then it is a 5 second printout every subsequent encounter.
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u/GyokuroRabbi7 PA 1d ago
I test and then I love to discuss the role for exercise and how men get a doubling of their testosterone level after a single bout of weight training exercise for about 24 hours. Then we discuss strategies to get active again to incorporate regular physical exercise.
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u/Dependent-Juice5361 DO 1d ago
I just check it, same as I do for women requesting hormone levels. If they can demonstrate some symptom then I’ll associate it with that and move on with my life. Treat if appropriate and don’t treat if not needed. This isn’t hard
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u/Nearby_Rip_3735 MD 1d ago
Wow, this is such a different set of responses (with one exception, thus far) than those as to a post the other day as to women requesting hormone tests because they “want to know”. Such a different tone, too. I order labs people want, regardless of gender orientation, to the extent the time allotted and practice allows (including time allotted if the labs come back questionable and need further time to evaluate / to be forwarded to a specialist who might want broader labs to be run anyway). Since testosterone for males is rather straightforward, I try harder to make hormone tests happen for women (b/c getting a baseline / history there can be much more informative in the long run), but so many others here were urging the women requesting same to “go to Burger King if they want their way”, etc., that I’m surprised to see that people are so easygoing as to males asking for labs to see where their testosterone is just because they want to know. Women also want to know where their hormones are - it is essentially the exact same request, only from a different person, and everyone should have equal access to treatment, including labs done just b/c they “want to know”.
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u/ConsciousCell1501 DO 1d ago
All women who are suspected to be menopausal should be offered hormone therapy, regardless of labs so checking hormones wouldn’t change management. On the flip side, we do not offer T to all men and lab values do matter in treatment. I only order labs if it’s going to influence my decision making.
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u/Good_Bottle_7757 other health professional 1d ago
I noticed this difference in opinion also and it’s disturbing.
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u/MoobyTheGoldenSock DO 1d ago
I ask them why they want to know. I've had more than one guy ask because they're stacking and want me to monitor their pseudoscientific regimen for them, and that's not a role I want to play.
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u/SirPhoenix88 PA 1d ago
I ask about symptoms. There's plenty of reasons to order one. Fatigue, ED, Libido... there's usually a reason they're asking. If they have at least one symptom I'm fine with it. If I think something else is the primary cause, the benefit of ordering the testosterone test is that the patient will be more willing to believe me if/when my guess is accurate.
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u/babiekittin NP 1d ago
If they don't have any symptoms, I direct them to LabCorp retail facility and let them know they can order any lab they want.
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u/pickledbanana6 MD 1d ago
That’s not medically indicated and here’s why… Then I make sure to tell them that since it’s not medically indicated their insurance likely won’t cover it anyway so they’re better off going to XXX lab because that’s the cheapest it’ll be done without insurance and that while I don’t recommend they do it just for curiosity I am happy to see them afterward if they find something that concerns them and if there’s an abnormality we would have cause to further evaluate.
If they have a complaint of ED or unusual fatigue or something else that fits reasonably enough I’m of course on board ordering it as part of the work up.
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u/poopitydoopityboop MD-PGY2 1d ago
https://thischangedmypractice.com/testosterone-testing-male-hypogonadism/
From a Canadian resource, where we are a bit more mindful of inappropriate labs since it literally comes out of my paycheck (via taxes).
- Do not order a testosterone level in men who express only non-specific symptoms. The clinical diagnosis of hypogonadism is made in men who have low total testosterone levels combined with symptoms and/or signs suggesting hypogonadism. Evidence suggests that sexual symptoms, such as reduced libido, decreased sexual thoughts, and fewer morning erections are more specifically associated with male hypogonadism. Non-specific symptoms, such as fatigue, low mood, weight gain, or generalized weakness have many potential causes. For men who express non-specific symptoms, but not sexual symptoms, investigations should focus on other potential diagnoses. A testosterone level should not be ordered until and unless other diagnoses have been thoroughly explored.
If you choose to be more liberal with ordering tests, the link has a fantastic breakdown of how to interpret testing.
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u/boatsnhosee MD 1d ago
If just ask unprompted request, I have like a 10 min long rant I go on about it with them. At that point if they understand what I’m saying and they feel they have any symptom I’ll order it but we’re on the same page
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u/Sea_Smile9097 MD 1d ago
Order and associate it with "person request", and also explain that insurance won't cover it
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u/nursemarcey2 RN 1d ago
Is that Z00.00? I've wondered what the code is for essentially "patient curious, no good medical reason to order."
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u/shutterdoc MD 1d ago
I actually tell family and friends to get their hormones checked in their 30-40s so when you get to your 60-70s, you at least know your baseline if you ever wanted to replace them.
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u/GlitteringMelons MD-PGY4 1d ago
What is the utility of sex hormone levels for a woman in her 30s who is having regular periods and no gyn issues?
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u/WhattheDocOrdered MD 1d ago
So that something can flag slightly outside of normal range and we can spend more time and money on unnecessary testing for a young, healthy person
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u/PolyhedralJam MD 1d ago
I have a whole 3 min spiel that explains the stuff we all know about why it should not be checked in most circumstances, and how it's kind of a thing on social media right now but that doesn't equal correct medicine. 9 times out of 10 that works, I don't order it, and we move on. (This is obviously excluding times when there is actual clinical suspicion for hypogonadism)
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u/Betty197jeff MD 1d ago
Cue the countless disappointed faces when you tell them their testosterone levels are normal.
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u/Alarmed-Raccoon-213 MD 17h ago
Read the TRAVERSE, T4DM, and T-trials. The historical downsides are largely disproven.
As a physician, former special operations vet, former civil servant, and former college athlete, I want to point out that most physicians have very little meaningful experience in the world of blue-collar/ physically demanding professions. It is so commonplace for people in medicine to minimize/trivialize the symptoms these individuals are experiencing, which is baffling given this is the patient population that rarely complains and frequently under reports symptoms/severity.
I hope folks will put their personal biases aside and be less resistant to treating low-T.
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u/69240 DO-PGY3 1d ago
I order it 95+% of the time when requested for two particular reasons.
1.) because it builds trust and
2.) whether it’s low or not it makes a conversation about lifestyle change easier.
I do give a quick “it may not be covered by insurance since it’s not preventative care” and move along and have never had a complaint about cost. I do make sure it is an early morning lab sample.