Icsm Treat Symptomatic Low Tt

---
name: icsm-treat-symptomatic-low-tt
description: Recommends initiating testosterone therapy in symptomatic men with total testosterone less than 12 nmol/L (350 ng/dL). Triggers when patients present with low libido, erectile dysfunction, fatigue, or decreased vigor and have confirmed low T levels.
---

# Treat symptomatic men with low testosterone

## STEP 1 — Gather Information
Collect symptom history (low libido, erectile dysfunction, fatigue, diminished physical vigor, depressed mood, sleep disturbances) and obtain morning total testosterone (between 07:00-11:00 fasting) using a reliable assay on at least two separate occasions; exclude acute illness; assess hematocrit, PSA, and perform DRE to rule out prostate abnormalities before therapy.

## STEP 2 — Rule In / Rule Out
Rule in if the patient reports at least one hypogonadal symptom AND has total testosterone <12 nmol/L (350 ng/dL) on two separate morning samples; rule out if testosterone ≥12 nmol/L or the patient is asymptomatic.

## STEP 3 — Classify or Stratify
Classify as a candidate for testosterone therapy if symptomatic and biochemically hypogonadal, then screen for contraindications: desire for fertility, baseline hematocrit ≥54%, known prostate cancer, or untreated severe lower urinary tract symptoms.

## STEP 4 — Decide
If candidate and no contraindications, initiate testosterone therapy using shared decision‑making to select formulation (gel, injectable, etc.) and target correction of serum total testosterone to the mid‑normal reference range (approximately 12‑25 nmol/L).

## Clinical Guardrails / Mimics / Pitfalls
Do not treat eugonadal men; avoid monotherapy for moderate/severe erectile dysfunction without PDE5 inhibitor; monitor hematocrit (hold if ≥54%); PSA and DRE per prostate cancer screening guidelines; testosterone therapy is contraindicated in men seeking fertility.

## Concrete Clinical Example
A 48‑year‑old man presents with low libido, erectile dysfunction, and fatigue; morning total testosterone is 10.5 nmol/L on two occasions, hematocrit 48%, PSA 1.2 ng/mL, DRE benign; after discussing risks/benefits, transdermal gel is started aiming for mid‑normal testosterone.

**Source:** Box2 Recommendation 2, International Consultation on Sexual Medicine (ICSM) 2024, 2025, https://doi.org/10.1093/sxmrev/qeaf036

> **TODO:** consider adding scripts/calc.py for the icsm-treat-symptomatic-low-tt calculator