Research

Perform digital rectal examination (DRE) in all men before initiating testosterone therapy to exclude prostate abnormalities or support suspicion of hypogonadism when prostate volume is reduced. Triggered when a clinician considers starting testosterone and questions whether a prostate exam is needed first or whether to check the prostate before prescribing TTh.

This skill suggests testosterone therapy may be considered after radical prostatectomy when postoperative PSA is undetectable and pathology reveals negative surgical margins, negative seminal vesicles, and negative lymph nodes. It is triggered when a clinician encounters a post‑prostatectomy patient with symptomatic low testosterone and questions whether it is safe to initiate testosterone therapy or if the cancer is sufficiently cleared.

This skill guides clinicians to consider testosterone therapy after definitive radiation or brachytherapy for prostate cancer when the patient shows a good post-treatment response (e.g., stable low PSA) and remains low-risk. It is triggered when a patient with persistent hypogonadism symptoms and low testosterone levels is being followed post-radiotherapy and the clinician questions the safety of initiating testosterone therapy.

Contraindicates testosterone therapy in men with metastatic prostate cancer because of insufficient safety data and risk of rapid progression. Triggers when a patient has metastatic disease and low testosterone and the clinician wonders "can I use testosterone here?" or "is testosterone therapy appropriate in metastatic PCa?"

This skill advises against initiating testosterone therapy in eugonadal men with normal serum testosterone and no symptoms of deficiency. It is triggered when a clinician questions whether to prescribe testosterone for a patient with normal labs and no hypogonadal symptoms, such as asking 'should I give testosterone to someone with normal T?' or 'is treatment appropriate for eugonadal men?'

This skill advises against initiating testosterone therapy in men who express a desire for future fathering, as exogenous testosterone suppresses spermatogenesis and can lead to infertility. It is triggered when a patient reports wanting children and the clinician contemplates prescribing testosterone, raising the question of whether testosterone therapy is safe for future fertility or should be avoided.

Testosterone monotherapy is not an effective treatment for clinical depressive disorders in hypogonadal men and should not be used for that purpose. Consider this when a patient presents with depressive mood and low testosterone, questioning whether testosterone will improve depression or if depression should be treated separately.

Advises against testosterone therapy in men with biochemical recurrence after prostate cancer treatment due to very limited data and potential risk of progression. Consider when a patient has a rising PSA after definitive therapy and the clinician evaluates testosterone for hypogonadism, questioning whether TTh is safe in BCR.

Advises adjusting testosterone dose based on serum levels and clinical response: reduce dose if total testosterone consistently exceeds the normal range, escalate if hypogonadal symptoms persist despite sub-mid-normal levels. Triggered when a clinician reviews a patient's testosterone result and symptoms and wonders, "Do I need to change the dose or is the current dose appropriate?"

Recommends reviewing serum testosterone levels every 6 months during ongoing therapy to monitor for excessive use and signs of androgen excess such as hirsutism or acne. It is indicated when a clinician manages a woman receiving long-term testosterone therapy and needs to evaluate for adverse effects or consider dose adjustment.

The guideline recommends against routinely measuring testosterone in women for diagnostic purposes due to the lack of a reliable correlation between symptoms and testosterone levels. This recommendation is triggered when a clinician orders a testosterone test to assess fatigue, low libido, or mood symptoms without evidence of underlying endocrine pathology.

Recommends measuring testosterone levels at baseline and after 3–6 weeks of initial treatment to assess for patient overuse or excessive dosing. Triggered when initiating testosterone therapy in women with hypoactive sexual desire disorder (HSDD) to verify levels remain within physiological range and avoid supratherapeutic dosing.

For women of color with facial hirsutism seeking photoepilation, suggest long‑wavelength laser (Nd:YAG or diode) with skin cooling and warn about paradoxical hypertrichosis, especially in Mediterranean or Middle Eastern backgrounds. Consider electrolysis or topical eflornithine when PH risk is high.

Measures serum total and/or free testosterone in women with an abnormal Ferriman–Gallwey hirsutism score to evaluate for hyperandrogenemia. Triggered when a clinician wonders whether to check androgen levels because the patient's hirsutism score exceeds the population cutoff.

Orders early morning 17‑hydroxyprogesterone to screen for nonclassic congenital adrenal hyperplasia due to 21‑hydroxylase deficiency in hyperandrogenemic women with amenorrhea or infrequent menses. Triggered by menstrual irregularity with hirsutism and a clinical request to rule out adrenal hyperplasia.

In patients with known hyperandrogenemia undergoing hair removal (laser, photoepilation, or electrolysis), add pharmacologic therapy to minimize hair regrowth. Trigger phrases include "known hyperandrogenemia," "post-laser hair regrowth," and "persistent hirsutism after hair removal."

The clinician orders early morning serum total and free testosterone when total testosterone is normal but the patient presents with moderate to severe hirsutism or mild hirsutism accompanied by signs of hyperandrogenism such as menstrual irregularity or lack of response to therapy. This is indicated when a clinician questions whether to check free testosterone in a patient with normal total testosterone but worsening hirsutism and irregular periods.

Measure early morning serum DHEAS to screen for adrenal hyperandrogenism in women with hirsutism and normal total/free testosterone but clinical signs of androgen excess. Consider testing when there is suspicion of nonclassic congenital adrenal hyperplasia or adrenal tumor, especially in patients with high-risk ethnicity, family history, or progressive hirsutism despite normal ovarian androgen levels.

Perform dexamethasone suppression testing to evaluate functional adrenal androgen excess in women with hirsutism. Trigger phrases include “moderate/severe hirsutism with normal total testosterone,” “clinical evidence of hyperandrogenic disorder despite normal androgens,” or “progression of hirsutism despite therapy.”

Consider oral contraceptive‑antiandrogen combination therapy for severe hirsutism causing emotional distress or after inadequate response to OC monotherapy. Avoid using this combination as first‑line treatment; reserve for patients with severe distress or prior OC failure.

The skill recommends against testing for elevated androgen levels in eumenorrheic women with only unwanted local hair growth and no abnormal hirsutism score. Trigger phrases include statements like, “She only has stray facial hair but regular periods; do we need androgen labs?”

Assess urinary corticoid metabolites by mass spectrometry to exclude apparent cortisone reductase deficiency. Indicated when a woman presents with moderate/severe hirsutism or mild hirsutism accompanied by clinical evidence of a hyperandrogenic endocrine disorder such as menstrual disturbance, progression despite therapy, or signs of virilization.

Image the adrenal glands with CT and the ovaries with transvaginal ultrasound when biochemical evaluation suggests an androgen‑secreting tumor, such as markedly elevated DHEAS or testosterone, rapid progression of hirsutism, or virilization. Trigger phrases include “sudden‑onset hirsutism,” “virilization (clitoromegaly, deepening voice),” “DHEAS > 700 µg/dL,” “testosterone in male range,” or “progressive hirsutism despite therapy.”

Suggests adding electrolysis or laser/photoepilation after pharmacologic therapy when the patient desires additional cosmetic improvement beyond medication alone. Triggered by clinician statements such as "She’s improved on the pill but wants smoother skin; should we add laser?"