ORF09-03 - Discordance between Clinical Guideline Recommendations and Testosterone Prescribing in a Real-World Setting

Context: Discordant with existing endocrine guidelines, prior studies have shown that men without biochemical evidence of androgen deficiency receive testosterone. Indeed, testosterone prescriptions quadrupled in the last three decades in the U.S., despite stable rates of male hypogonadism diagnoses. Inappropriate testosterone prescribing may be associated with risks, such as hypertension, erythrocytosis, infertility and concern for abuse.

Objective: To understand testosterone prescribing practices and evaluate patient characteristics associated with receipt of testosterone prescription at a single institution.

Methods: We conducted a retrospective chart review of a random sample of 200 male patients aged 18 years who had at least one outpatient primary care visit at Michigan Medicine in the past year, had a diagnosis of hypogonadism by ICD-9 or 10, and received an initial testosterone prescription during the study period (1/2020-1/2025). Transgender individuals and patients with HIV were excluded. Demographic characteristics, signs and symptoms of hypogonadism, laboratory diagnostic evaluation prior to index testosterone prescription, and relative and absolute contraindications to testosterone therapy were ascertained.

Results: The mean age at index testosterone prescription was 52.5 years (range, 18-87). Majority of men were White (85%), non-Hispanic (95%), married (66%) and sexually active (67%). Overall, 46% reported alcohol use and 60% were non-smokers. Evaluation for hypogonadism was commonly initiated due to fatigue (63%), erectile dysfunction (62%), decreased libido (54%) and patient request (25%). Prevalent comorbidities included obesity (63%, mean BMI 33.0), hypertension (52%), depression (40%), diabetes (28%) and arthritis (28%). Only 12% of men who received testosterone had two low morning testosterone levels (total testosterone < 300ng/dL, free testosterone < 70pg/mL, or low bioavailable testosterone, between 5am and 10am), LH and/or FSH measured, and no contraindications to testosterone therapy. Moreover, 62% of patients had a prostate specific antigen (PSA) and 77% had a complete blood count measured in the year prior to the index testosterone prescription. Overall, 55% of patients had documented obstructive sleep apnea, 4% prostate cancer, and 1.5% PSA >4 ng/mL prior to the index testosterone prescription. A total of 45% of testosterone prescriptions were by primary care, 35.5% by urology, 18% by endocrinology and 1.5% by other specialties, with topical formulations being the most common (68.5%).

Discussion: Only a small proportion of men who received testosterone therapy underwent guideline-concordant diagnostic testing for androgen deficiency and a subset received testosterone therapy despite contraindications. Future studies should evaluate targeted interventions aimed at reducing inappropriate testosterone prescribing.