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CHICAGO — Only a small proportion of men prescribed testosterone therapy received recommended diagnostic testing for androgen deficiency, and many received testosterone therapy despite contraindications, a single-center study showed.

“Testosterone prescriptions have quadrupled in the last three decades in the United States, despite stable rates of hypogonadism diagnoses, a pattern consistent with overuse and potentially inappropriate prescribing,” lead author Maria Papaleontiou, MD, associate professor in the Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, told Medscape Medical News.

The study results suggest a need to increase use of guidelines to ensure safe testosterone prescribing, Papaleontiou said. “Improving guideline-concordant testosterone prescribing has clear public health relevance because testosterone therapy is increasingly utilized for common, nonspecific symptoms, and initiation without appropriate diagnostic evaluation may expose patients to avoidable risks without providing clinical benefit,” she added.

The findings were presented at ENDO 2026: The Endocrine Society Annual Meeting.

Guidelines Seldom Followed

The investigators conducted a retrospective chart review of 200 men who had a recorded diagnosis of hypogonadism and had received a testosterone prescription between January 2020 and January 2025. The records were analyzed for symptoms of hypogonadism, laboratory diagnostic evaluation prior to index testosterone prescription, and relative and absolute contraindications to testosterone therapy.

Adherence to the Endocrine Society guidelines for hypogonadism workup was defined as conducting two separate morning testosterone tests and additional pituitary hormone testing (luteinizing hormone [LH] and follicle-stimulating hormone [FSH]) to distinguish between primary and secondary hypogonadism in men found to have the condition. Contraindications to testosterone prescriptions included elevated prostate specific antigen (PSA), defined as > 4.0 ng/mL; a history of prostate or breast cancer; elevated hematocrit (> 50%); and obstructive sleep apnea.

Age at first testosterone prescription ranged from 18 to 87 years (mean 52.5). Most were White (85%), non-Hispanic (95%), married (66%) and sexually active (67%). Overall, 46% reported alcohol use and 60% were nonsmokers. Reasons for evaluation for hypogonadism included fatigue (63%), erectile dysfunction (62%), decreased libido (54%), and patient request (25%). Comorbidities included obesity (63%, mean BMI 33), hypertension (52%), depression (40%), diabetes (28%), and arthritis (28%).

While all participants had at least one testosterone level measured, just 12% of men who received testosterone had two low morning testosterone levels (total testosterone < 300 ng/dL, free testosterone < 70 pg/mL, or low bioavailable testosterone, between 5 AM and 10 AM), had LH and/or FSH measured, and no contraindications to testosterone therapy.

Nearly two thirds (62%) of patients had a PSA test and 77% had a complete blood count measured in the year prior to the testosterone prescription. Looking at contraindications, 55% of patients had documented obstructive sleep apnea, 4% had prostate cancer, and 1.5% had an elevated PSA prior to the index testosterone prescription.

The medical specialties of the testosterone prescribers were 45% primary care, 35.5% urology, 18% endocrinology, and 1.5% by other specialties. Topical formulations were the most common (68.5%).

Patient characteristics significantly associated with an appropriate diagnostic evaluation included having two or more comorbidities vs fewer than two (odds ratio [OR], 0.25; P = .02) and an endocrinologist as the prescriber compared to primary care doctor (OR, 12.05; P < .01) or urologist vs primary care physician (OR, 5.62; P = .04).

Although testosterone can benefit men with true hypogonadism, inappropriate prescribing carries many risks, including worsening hypertension and sleep apnea, Papaleontiou told Medscape Medical News. It can also shut down the body’s natural testosterone production, leading to low sperm production and infertility, she added.

“There is also concern about misuse or abuse, especially when testosterone is used without a clear medical need or at higher-than-prescribed doses,” Papaleontiou said.

Sign of the Times

The finding that 25% of testosterone prescriptions were initiated following patient requests is probably partly attributable to direct-to-consumer advertising, Papaleontiou noted.

“Testosterone-related content on social platforms has significantly increased over the last several years. Testosterone has been coined as the ‘fountain of youth’ to optimize performance through enhancing muscle and improving energy levels in social media, and direct-to-consumer advertising, coupled with dedicated ‘low T’ clinics, availability of patient-friendly testosterone gels and patches, and ambiguity in guidelines about treatment of age-related decline in testosterone levels, probably all drive the trend of increased patient requests for testosterone,” Papaleontiou said.

Asked to comment, session moderator Channa Jayasena, MD, PhD, professor of reproductive endocrinology and andrology at Imperial College London in the United Kingdom, also expressed concern about overprescribing.

“This is a problem of our time in that there's a worldwide explosion of prescribing, often from private providers and increasingly from very corporate entities with reduced clinician involvement,” he told Medscape Medical News. “Even in an orthodox, traditional setting, there are examples of things not being done as they should.”

Widespread overprescription could have broad consequences, Jayasena said. “I think it's more important than ever to actually ensure that we're giving testosterone to the right people, because if we don't, it makes a lot of clinicians nervous about giving testosterone to anyone. So, by overprescribing, what we see is actually underprescribing, because people are afraid of it,” he explained.

Jayasena pointed out that there is debate in the medical community about what constitutes low testosterone and who should be selected for treatment. “Where men have potentially reversible causes of testosterone, should you be sending them for GLP-1s or lifestyle or straight for testosterone?” he said. The study shows that “there's a lot of variation in practice, which means that some men are being overtreated, but I also think that some men are being undertreated.”

Papaleontiou said the study results highlight opportunities to improve patient care and reduce inappropriate prescribing.

“Long-term, these findings can lead to quality improvement efforts and clinical decision supports that promote consistent, guideline-concordant testosterone prescribing,” she said.

Papaleontiou and Jayasena reported no relevant financial relationships. 

Miriam E. Tucker is a freelance journalist based in the Washington, DC area. She is a regular contributor to Medscape, with other work appearing in the Washington Post, NPR’s Shots blog, and Diatribe. She is on X (formerly Twitter) @MiriamETucker and BlueSky @miriametucker.bsky.social