Department of Endocrinology, Ghent University Hospital, Ghent, Belgium.
Rev Endocr Metab Disord. 2022 Dec;23(6):1139-1150. doi: 10.1007/s11154-022-09763-4. Epub 2022 Nov 10.
To make the diagnosis of hypogonadism in an ageing man, in absence of rare organic cause often referred to as functional or late onset hypogonadism (LOH), he should present with a clinical syndrome suggestive of androgen deficiency and have consistently low serum testosterone (T) levels. This does not differ from the diagnosis of any other form of hypogonadism. Particular to LOH diagnostic are uncertainties surrounding this entity: signs and symptoms of androgen deficiency (including sexual symptoms) are nonspecific in older men; clinical significance of only moderately low T levels is uncertain; comorbidity plays a substantial role with potential for reversibility; the place of T therapy in these men is debatable. This context demands for a pragmatic, but appropriately conservative approach to diagnosis. Evaluation should be stepwise with clinical evaluation, if suggestive for androgen deficiency, followed by measurement of a fasting morning serum T, if unequivocally low to be confirmed in a separate morning sample by a second low T or, if initial T borderline low or in presence of factors known to affect SHBG, by a low calculated free T level. All other (free) T results make hypogonadism an unlikely cause of the patient's symptoms. In the absence of consensus cut-off levels for total and free T in the published clinical guidelines for diagnosis of hypogonadism, it seems appropriate in the context of LOH to use stringent criteria indicating a convincingly low serum T. The approach to the diagnosis of LOH is not fundamentally different from that of other forms of hypogonadism but should put extra weight on prioritizing the shunning of overdiagnosis above the risk of underdiagnosis.
要诊断老年男性的性腺功能减退症，如果没有罕见的器质性原因，通常称为功能性或迟发性性腺功能减退症（LOH），他应该表现出具有雄激素缺乏症的临床综合征，并且血清睾丸激素（T）水平持续降低。这与任何其他形式的性腺功能减退症的诊断并无不同。LOH 诊断的特殊性在于围绕该病症的不确定性：雄激素缺乏症的体征和症状（包括性功能障碍）在老年男性中不具有特异性；仅中度低 T 水平的临床意义尚不确定；合并症起着重要作用，且具有潜在的可逆转性；这些男性中 T 治疗的地位存在争议。这种情况下，需要采取务实但适当保守的诊断方法。评估应逐步进行，首先进行临床评估，如果提示存在雄激素缺乏症，然后测量空腹早晨血清 T，如果明确降低，则在另一早晨样本中通过第二次低 T 或如果初始 T 值边缘降低或存在已知影响 SHBG 的因素，则通过低计算游离 T 水平来确认。所有其他（游离）T 结果都使性腺功能减退症不太可能是患者症状的原因。在缺乏发表的性腺功能减退症诊断临床指南中总 T 和游离 T 的共识截止值的情况下，在 LOH 的情况下，使用表明血清 T 明显降低的严格标准似乎是合适的。LOH 的诊断方法与其他形式的性腺功能减退症并无根本不同，但应更加重视避免过度诊断的风险高于诊断不足的风险。
