Health guide

Hormonal health

Educational only: This page is for general education—not personal medical advice, diagnosis, or treatment. See a licensed clinician for your situation.

Testosterone

Free testosterone and total testosterone

The Endocrine Society recommends diagnosing hypogonadism only when symptoms and signs of testosterone deficiency are present and serum testosterone is unequivocally and consistently low. The initial test is a fasting morning total testosterone, repeated on a separate morning, with an accurate assay. 1

Most testosterone in blood is bound. Sex hormone–binding globulin is the protein that binds it tightly. Free testosterone is the fraction that is not tightly bound. When total testosterone is near the lower limit of the reference range, or when a condition changes sex hormone–binding globulin, the guideline recommends measuring free testosterone by equilibrium dialysis or calculating it from an accurate formula, not relying on the total level alone. 1 A single “normal” total testosterone, read without that context, is not the whole evaluation.

What low testosterone feels like

Symptoms and signs that prompt the evaluation include reduced sexual desire, reduced spontaneous erections, fatigue, depressed mood, loss of body hair, and reduced muscle, among others the guideline lists as consistent with deficiency. Those findings are nonspecific. Fatigue or trouble concentrating, by themselves, do not establish the diagnosis. 1 The same complaints are discussed as exhaustion and as focus problems. Those pages link here rather than repeating this section.

Low testosterone and a longstanding attention disorder can coexist because both can include low energy and poor concentration. Labs plus a developmental history are how they are separated. The two are not mutually exclusive — having one does not rule out the other.

When therapy is appropriate

The guideline recommends testosterone therapy for men with symptomatic testosterone deficiency, to support secondary sex characteristics and symptoms, after a discussion of benefits, risks, and monitoring, and with the patient in the decision. It recommends against starting therapy when a man is planning fertility in the near term, and in a list of other situations that includes breast or prostate cancer, a concerning prostate exam or PSA, elevated hematocrit, untreated severe obstructive sleep apnea, severe urinary symptoms, uncontrolled heart failure, recent heart attack or stroke, and thrombophilia. 1

It also recommends against routine testosterone for all men 65 and older who merely have a low level. In that age group, therapy is a suggestion only when symptoms suggestive of deficiency and consistently low morning levels are both present, after an explicit discussion of risk and benefit. 1 This page does not say the reader is a candidate.

The exhaustion page and the sleep page point here. A visit is an evaluation, not a promise of a prescription. The guideline says that evaluation includes a general health check for systemic illness, eating disorders, heavy exercise, sleep disorders, and medicines or drugs that suppress testosterone, such as opioids and high-dose glucocorticoids. Obesity is described as a cause that may be reversible. 1

Women: cycle, perimenopause, mood, and focus

Midlife women commonly report changes in memory, attention, and concentration during the menopause transition. The International Menopause Society white paper says these cognitive changes should not be confused with dementia, that dementia in midlife is rare, and that most women who go through menopause will not develop dementia. 2 Hormone therapy is not recommended at any age specifically to treat cognitive complaints or to prevent dementia. 3 Bothersome hot flashes and night sweats are a different indication, with its own risk discussion, and are not covered as a prescribing guide here.

Depression, sleep problems, and vasomotor symptoms in perimenopause are associated with cognitive complaints. 2 They are reasons to ask about sleep and mood, which are also on the sleep page and the mental-health page. They are not a shortcut to a hormone prescription.

ADHD in adults remains the DSM diagnosis described on the mental-health page: a long pattern, several symptoms before age 12, impairment in more than one setting, not better explained by another condition. 4 A change in symptoms around a cycle or around menopause does not create that history, and it does not erase it. In the DSM-5-TR, females are more likely than males to present primarily with inattentive features. 4 That is a reason the history has to be taken carefully. It is not a finding that cycle stage equals the diagnosis. Evidence that month-to-month hormone swings reliably change ADHD symptom scores is not settled guideline territory, and this page does not state that they do.

Sexual health

What a proper visit includes

Erectile dysfunction is a reason for a medical, sexual, and psychosocial history, and for counseling that it is a risk marker for cardiovascular disease and other conditions that may need their own evaluation. 5 Shared risk factors include age, smoking, diabetes, hypertension, abnormal lipids, depression, obesity, and inactivity. 5 The visit is that evaluation. It is not a promise of a prescription.

What sildenafil is, in that visit

Men with erectile dysfunction should be informed about an FDA-approved oral PDE5 inhibitor as a treatment option, including benefits and risks, unless it is contraindicated. 5 Sildenafil is in that class. It must not be combined with nitrate medicines. Current VIAGRA labeling says giving sildenafil to someone who uses organic nitrates or organic nitrites, regularly or from time to time, is contraindicated, because sildenafil was shown to deepen the drop in blood pressure from nitrates. The same label says that after a dose it is unknown when a nitrate, if needed, can be given safely. It notes that blood levels at 24 hours are much lower than at the peak, and that it is still unknown whether a nitrate can be safely given at that point. 6 A person who needs emergency care for chest pain should say that a PDE5 inhibitor was taken, so nitrate treatment can be handled with that fact known. 5

Psychological contributors belong in the history. 5 This page does not give a dose or a statement that a prescription will be written.

References

  1. Bhasin S, et al. Testosterone therapy in men with hypogonadism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2018;103(5):1715–1744. https://academic.oup.com/jcem/article/103/5/1715/4939465
  2. Maki PM, Jaff NG. Brain fog in menopause: a health-care professional’s guide for decision-making and counseling on cognition. International Menopause Society white paper. Climacteric. 2022. https://www.imsociety.org/wp-content/uploads/2022/10/IMS-White-Paper-2022-Brain-fog-in-menopause.pdf
  3. The North American Menopause Society. The 2022 hormone therapy position statement. Menopause. 2022. Hormone therapy is not recommended to treat cognitive function or to prevent dementia. https://menopause.org/wp-content/uploads/professional/nams-2022-hormone-therapy-position-statement.pdf
  4. American Psychiatric Association. DSM-5-TR. 2022. ADHD criteria, including several symptoms before age 12 and exclusion of a better explanation.
  5. Burnett AL, et al. Erectile dysfunction: AUA guideline. J Urol. 2018;200(3):633–641. https://www.auanet.org/guidelines-and-quality/guidelines/erectile-dysfunction-(ed)-guideline
  6. Pfizer. VIAGRA (sildenafil citrate) prescribing information, current label. Contraindication with organic nitrates or nitrites; after a dose, it is unknown when nitrates can be safely administered, including at 24 hours. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c8d046c9-d9e9-4660-8ff1-a6c23b16eb3f