Testosterone therapy often prescribed without guideline-based testing

Clinical Takeaway: Before starting testosterone, confirm guideline-concordant testing, including two low morning testosterone levels, gonadotropin evaluation when appropriate, and screening for contraindications and safety risks.

Testosterone use has risen sharply despite stable hypogonadism diagnosis rates, raising concern that some men may be exposed to avoidable risks without clear biochemical evidence of androgen deficiency.

Only a small proportion of men prescribed testosterone therapy at a large academic health system had documentation consistent with endocrine guideline recommendations, according to a retrospective study being presented at ENDO 2026, the Endocrine Society’s annual meeting.

Researchers reviewed charts from 200 adult male patients at Michigan Medicine who had a hypogonadism diagnosis and received an initial testosterone prescription between January 2020 and January 2025. The mean age at prescribing was 52.5 years, with a range of 18 to 87 years. Most patients were White (85%), non-Hispanic (95%), married (66%), and sexually active (67%).

Evaluation was most often prompted by fatigue (63%), erectile dysfunction (62%), decreased libido (54%), or patient request (25%). Common comorbidities included obesity (63%; mean BMI, 33.0), hypertension (52%), depression (40%), diabetes (28%), and arthritis (28%).

Only 12% of men had two low morning testosterone levels, LH and/or FSH testing, and no contraindications to testosterone therapy documented before treatment. Safety monitoring was also incomplete: 62% had PSA testing and 77% had a complete blood count in the year before the first prescription. Notably, 55% had documented obstructive sleep apnea, 4% had prostate cancer, and 1.5% had PSA levels greater than 4 ng/mL before testosterone initiation.

Prescriptions were most often written in primary care (45%), followed by urology (35.5%) and endocrinology (18%). Topical testosterone was the most common formulation, used in 68.5% of prescriptions.

“Our study findings highlight opportunities to improve patient care and reduce inappropriate testosterone prescribing,” said senior author Maria Papaleontiou, MD, of the University of Michigan. She said the findings could support quality-improvement efforts and clinical decision support tools to promote more consistent, guideline-concordant prescribing.

Source: Sinha S, et al. Endocrine Society Annual Meeting, Abstract SUN-141. June 13, 2026. Discordance Between Clinical Guideline Recommendations and Testosterone Prescribing in a Real-World Setting