British Society for Sexual Medicine recommendations for UK practice with levels of evidence and grades of recommendation
| . | LoE . | Grade . |
|---|---|---|
| Recommendations—screening | ||
| Screen for TD in adult men with consistent and multiple signs of TD | 3 | C |
| Screen all men presenting with ED, loss of spontaneous erections, or low sexual desire | 1 | A |
| Screen for TD in all men with type 2 diabetes, BMI > 30 kg/m2, or waist circumference > 102 cm | 2 | A |
| Screen for TD in all men on long-term opiate, antipsychotic, or anticonvulsant medication | 2 | B |
| Recommendations—diagnosis | ||
| Restrict diagnosis of TD to men with persistent symptoms suggesting TD and confirmed low T level | 3 | C |
| Measure fasting T levels in the morning before 11 am, acknowledging that, in normal life, non-fasting levels could be up to 30% lower | 2 | A |
| Repeat TT assessment on ≥2 occasions by a reliable method; in addition, measure free T in men with levels close to lower normal range (8–12 nmol/L) or those with suspected or known abnormal SHBG level | 1 | A |
| Measure LH serum levels to differentiate primary from secondary TD | 2 | A |
| Base decisions on therapy on published action levels rather than laboratory reference ranges | 4 | B |
| Recommendations—initiating T therapy | ||
| Perform cardiovascular, prostate, breast, and hematologic assessments before start of treatment | 1a | A |
| Offer T therapy to symptomatic men with TD syndrome for treated localized low-risk prostate cancer (Gleason score < 8, stages 1–2, preoperative PSA level < 10 ng/mL, and not starting before 1 y of follow-up) and without evidence of active disease (based on measurable PSA level, DRE result, and evidence of metastatic disease) | 3 | B |
| Assess cardiovascular risk factors before commencing T therapy and optimize secondary prevention in men with established disease | 1a | A |
| Recommendations—benefits and risks of T therapy | ||
| Beyond 6 mo there is evidence of benefit for T therapy in body composition, bone mineralization, and features of metabolic syndrome. | 3 | A |
| T therapy improves sexual desire, erectile function, and sexual satisfaction | 1 | A |
| Decreases in BMI and waist size and improved glycemic control and lipid profile are observed in hypogonadal men receiving T therapy | 2 | A |
| Trials of T therapy should be ≥6 mo and maximal benefit is often seen beyond 12 mo | 2 | A |
| Fully inform the patient about expected benefits and side effects of therapy and facilitate a joint decision by an informed patient and physician | 3 | A |
| Fully discuss the adverse effect of T therapy and its future reversibility on future fertility for each patient and his partner and offer alternative treatment as necessary | 1b | B |
| In patients with adult-onset TD, when TRT is prescribed, offer weight-loss and lifestyle advice as standard management | 2 | A |
| In severely symptomatic patients with TT levels < 8 nmol/L, lifestyle and dietary advice alone is unlikely to produce meaningful clinical improvement within a relevant clinical period | 2 | B |
| Recommendations—follow-up | ||
| Assess response to therapy at 3, 6, and 12 mo and every 12 mo thereafter | 4 | C |
| Aim for a target TT level of 15–30 nmol/L to achieve optimal response | 4 | C |
| Monitor hematocrit before treatment, at 3–6 mo, 12 mo, and every 12 mo thereafter; decrease dosage, or switch preparation, if hematocrit is >0.54; if hematocrit remains high, consider stopping and reintroduce at a lower dose | 4 | C |
| Assess prostate health by PSA and DRE before commencing TRT followed by PSA at 3–6 mo, 12 mo, and every 12 mo thereafter | 4 | C |
| Assess cardiovascular risk before TRT is initiated and monitor cardiovascular risk factors throughout therapy | 1b | A |
| . | LoE . | Grade . |
|---|---|---|
| Recommendations—screening | ||
| Screen for TD in adult men with consistent and multiple signs of TD | 3 | C |
| Screen all men presenting with ED, loss of spontaneous erections, or low sexual desire | 1 | A |
| Screen for TD in all men with type 2 diabetes, BMI > 30 kg/m2, or waist circumference > 102 cm | 2 | A |
| Screen for TD in all men on long-term opiate, antipsychotic, or anticonvulsant medication | 2 | B |
| Recommendations—diagnosis | ||
| Restrict diagnosis of TD to men with persistent symptoms suggesting TD and confirmed low T level | 3 | C |
| Measure fasting T levels in the morning before 11 am, acknowledging that, in normal life, non-fasting levels could be up to 30% lower | 2 | A |
| Repeat TT assessment on ≥2 occasions by a reliable method; in addition, measure free T in men with levels close to lower normal range (8–12 nmol/L) or those with suspected or known abnormal SHBG level | 1 | A |
| Measure LH serum levels to differentiate primary from secondary TD | 2 | A |
| Base decisions on therapy on published action levels rather than laboratory reference ranges | 4 | B |
| Recommendations—initiating T therapy | ||
| Perform cardiovascular, prostate, breast, and hematologic assessments before start of treatment | 1a | A |
| Offer T therapy to symptomatic men with TD syndrome for treated localized low-risk prostate cancer (Gleason score < 8, stages 1–2, preoperative PSA level < 10 ng/mL, and not starting before 1 y of follow-up) and without evidence of active disease (based on measurable PSA level, DRE result, and evidence of metastatic disease) | 3 | B |
| Assess cardiovascular risk factors before commencing T therapy and optimize secondary prevention in men with established disease | 1a | A |
| Recommendations—benefits and risks of T therapy | ||
| Beyond 6 mo there is evidence of benefit for T therapy in body composition, bone mineralization, and features of metabolic syndrome. | 3 | A |
| T therapy improves sexual desire, erectile function, and sexual satisfaction | 1 | A |
| Decreases in BMI and waist size and improved glycemic control and lipid profile are observed in hypogonadal men receiving T therapy | 2 | A |
| Trials of T therapy should be ≥6 mo and maximal benefit is often seen beyond 12 mo | 2 | A |
| Fully inform the patient about expected benefits and side effects of therapy and facilitate a joint decision by an informed patient and physician | 3 | A |
| Fully discuss the adverse effect of T therapy and its future reversibility on future fertility for each patient and his partner and offer alternative treatment as necessary | 1b | B |
| In patients with adult-onset TD, when TRT is prescribed, offer weight-loss and lifestyle advice as standard management | 2 | A |
| In severely symptomatic patients with TT levels < 8 nmol/L, lifestyle and dietary advice alone is unlikely to produce meaningful clinical improvement within a relevant clinical period | 2 | B |
| Recommendations—follow-up | ||
| Assess response to therapy at 3, 6, and 12 mo and every 12 mo thereafter | 4 | C |
| Aim for a target TT level of 15–30 nmol/L to achieve optimal response | 4 | C |
| Monitor hematocrit before treatment, at 3–6 mo, 12 mo, and every 12 mo thereafter; decrease dosage, or switch preparation, if hematocrit is >0.54; if hematocrit remains high, consider stopping and reintroduce at a lower dose | 4 | C |
| Assess prostate health by PSA and DRE before commencing TRT followed by PSA at 3–6 mo, 12 mo, and every 12 mo thereafter | 4 | C |
| Assess cardiovascular risk before TRT is initiated and monitor cardiovascular risk factors throughout therapy | 1b | A |
BMI = body mass index; DRE = digital rectal examination; ED = erectile dysfunction; LH = luteinizing hormone; LoE = level of evidence; PSA = prostate-specific antigen; T = testosterone; TD = testosterone deficiency; TRT = testosterone replacement therapy; TT = total testosterone.
British Society for Sexual Medicine recommendations for UK practice with levels of evidence and grades of recommendation
| . | LoE . | Grade . |
|---|---|---|
| Recommendations—screening | ||
| Screen for TD in adult men with consistent and multiple signs of TD | 3 | C |
| Screen all men presenting with ED, loss of spontaneous erections, or low sexual desire | 1 | A |
| Screen for TD in all men with type 2 diabetes, BMI > 30 kg/m2, or waist circumference > 102 cm | 2 | A |
| Screen for TD in all men on long-term opiate, antipsychotic, or anticonvulsant medication | 2 | B |
| Recommendations—diagnosis | ||
| Restrict diagnosis of TD to men with persistent symptoms suggesting TD and confirmed low T level | 3 | C |
| Measure fasting T levels in the morning before 11 am, acknowledging that, in normal life, non-fasting levels could be up to 30% lower | 2 | A |
| Repeat TT assessment on ≥2 occasions by a reliable method; in addition, measure free T in men with levels close to lower normal range (8–12 nmol/L) or those with suspected or known abnormal SHBG level | 1 | A |
| Measure LH serum levels to differentiate primary from secondary TD | 2 | A |
| Base decisions on therapy on published action levels rather than laboratory reference ranges | 4 | B |
| Recommendations—initiating T therapy | ||
| Perform cardiovascular, prostate, breast, and hematologic assessments before start of treatment | 1a | A |
| Offer T therapy to symptomatic men with TD syndrome for treated localized low-risk prostate cancer (Gleason score < 8, stages 1–2, preoperative PSA level < 10 ng/mL, and not starting before 1 y of follow-up) and without evidence of active disease (based on measurable PSA level, DRE result, and evidence of metastatic disease) | 3 | B |
| Assess cardiovascular risk factors before commencing T therapy and optimize secondary prevention in men with established disease | 1a | A |
| Recommendations—benefits and risks of T therapy | ||
| Beyond 6 mo there is evidence of benefit for T therapy in body composition, bone mineralization, and features of metabolic syndrome. | 3 | A |
| T therapy improves sexual desire, erectile function, and sexual satisfaction | 1 | A |
| Decreases in BMI and waist size and improved glycemic control and lipid profile are observed in hypogonadal men receiving T therapy | 2 | A |
| Trials of T therapy should be ≥6 mo and maximal benefit is often seen beyond 12 mo | 2 | A |
| Fully inform the patient about expected benefits and side effects of therapy and facilitate a joint decision by an informed patient and physician | 3 | A |
| Fully discuss the adverse effect of T therapy and its future reversibility on future fertility for each patient and his partner and offer alternative treatment as necessary | 1b | B |
| In patients with adult-onset TD, when TRT is prescribed, offer weight-loss and lifestyle advice as standard management | 2 | A |
| In severely symptomatic patients with TT levels < 8 nmol/L, lifestyle and dietary advice alone is unlikely to produce meaningful clinical improvement within a relevant clinical period | 2 | B |
| Recommendations—follow-up | ||
| Assess response to therapy at 3, 6, and 12 mo and every 12 mo thereafter | 4 | C |
| Aim for a target TT level of 15–30 nmol/L to achieve optimal response | 4 | C |
| Monitor hematocrit before treatment, at 3–6 mo, 12 mo, and every 12 mo thereafter; decrease dosage, or switch preparation, if hematocrit is >0.54; if hematocrit remains high, consider stopping and reintroduce at a lower dose | 4 | C |
| Assess prostate health by PSA and DRE before commencing TRT followed by PSA at 3–6 mo, 12 mo, and every 12 mo thereafter | 4 | C |
| Assess cardiovascular risk before TRT is initiated and monitor cardiovascular risk factors throughout therapy | 1b | A |
| . | LoE . | Grade . |
|---|---|---|
| Recommendations—screening | ||
| Screen for TD in adult men with consistent and multiple signs of TD | 3 | C |
| Screen all men presenting with ED, loss of spontaneous erections, or low sexual desire | 1 | A |
| Screen for TD in all men with type 2 diabetes, BMI > 30 kg/m2, or waist circumference > 102 cm | 2 | A |
| Screen for TD in all men on long-term opiate, antipsychotic, or anticonvulsant medication | 2 | B |
| Recommendations—diagnosis | ||
| Restrict diagnosis of TD to men with persistent symptoms suggesting TD and confirmed low T level | 3 | C |
| Measure fasting T levels in the morning before 11 am, acknowledging that, in normal life, non-fasting levels could be up to 30% lower | 2 | A |
| Repeat TT assessment on ≥2 occasions by a reliable method; in addition, measure free T in men with levels close to lower normal range (8–12 nmol/L) or those with suspected or known abnormal SHBG level | 1 | A |
| Measure LH serum levels to differentiate primary from secondary TD | 2 | A |
| Base decisions on therapy on published action levels rather than laboratory reference ranges | 4 | B |
| Recommendations—initiating T therapy | ||
| Perform cardiovascular, prostate, breast, and hematologic assessments before start of treatment | 1a | A |
| Offer T therapy to symptomatic men with TD syndrome for treated localized low-risk prostate cancer (Gleason score < 8, stages 1–2, preoperative PSA level < 10 ng/mL, and not starting before 1 y of follow-up) and without evidence of active disease (based on measurable PSA level, DRE result, and evidence of metastatic disease) | 3 | B |
| Assess cardiovascular risk factors before commencing T therapy and optimize secondary prevention in men with established disease | 1a | A |
| Recommendations—benefits and risks of T therapy | ||
| Beyond 6 mo there is evidence of benefit for T therapy in body composition, bone mineralization, and features of metabolic syndrome. | 3 | A |
| T therapy improves sexual desire, erectile function, and sexual satisfaction | 1 | A |
| Decreases in BMI and waist size and improved glycemic control and lipid profile are observed in hypogonadal men receiving T therapy | 2 | A |
| Trials of T therapy should be ≥6 mo and maximal benefit is often seen beyond 12 mo | 2 | A |
| Fully inform the patient about expected benefits and side effects of therapy and facilitate a joint decision by an informed patient and physician | 3 | A |
| Fully discuss the adverse effect of T therapy and its future reversibility on future fertility for each patient and his partner and offer alternative treatment as necessary | 1b | B |
| In patients with adult-onset TD, when TRT is prescribed, offer weight-loss and lifestyle advice as standard management | 2 | A |
| In severely symptomatic patients with TT levels < 8 nmol/L, lifestyle and dietary advice alone is unlikely to produce meaningful clinical improvement within a relevant clinical period | 2 | B |
| Recommendations—follow-up | ||
| Assess response to therapy at 3, 6, and 12 mo and every 12 mo thereafter | 4 | C |
| Aim for a target TT level of 15–30 nmol/L to achieve optimal response | 4 | C |
| Monitor hematocrit before treatment, at 3–6 mo, 12 mo, and every 12 mo thereafter; decrease dosage, or switch preparation, if hematocrit is >0.54; if hematocrit remains high, consider stopping and reintroduce at a lower dose | 4 | C |
| Assess prostate health by PSA and DRE before commencing TRT followed by PSA at 3–6 mo, 12 mo, and every 12 mo thereafter | 4 | C |
| Assess cardiovascular risk before TRT is initiated and monitor cardiovascular risk factors throughout therapy | 1b | A |
BMI = body mass index; DRE = digital rectal examination; ED = erectile dysfunction; LH = luteinizing hormone; LoE = level of evidence; PSA = prostate-specific antigen; T = testosterone; TD = testosterone deficiency; TRT = testosterone replacement therapy; TT = total testosterone.
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