European Urology

Letters to the Editor published online

Guidelines for late-onset hypogonadism (LOH) are considered to be an important contribution for evidence-based clinical routine and, therefore, are highly welcomed, particularly as this is still a field of considerable controversy. However, after reading the recently published guidelines [1], two major questions remain.

First, when low testosterone levels are significantly linked to specific symptoms, why did we fail to provide valuable instruments to quantify this syndrome? As stated in the current guidelines, “Questionnaires such as AMS [Aging Male Symptom Score] and ADAM [Androgen Deficiency in Aging Men] are not recommended … because of low specificity.” These questionnaires address almost all aspects of symptoms considered to be related to LOH, so one can also conclude that LOH is simple not associated with these symptoms.

Second, in guidelines on treatment of LOH citing level of evidence (Table 1), one would expect a clear statement about the level of evidence for treating LOH. In the introduction, the authors state that “key questions of the effects of testosterone on patient-reported outcomes and functional benefits that may retard physical or mental frailty of the elderly or improve the quality of life are not yet available.”

In fact, after carefully reviewing the literature, wouldn’t a level 1, grade A recommendation not to substitute testosterone in men with low androgen levels be indicated? At least two recent large controlled trials concluded negatively on the role of testosterone supplementation. A US 2-yr trial concluded that “neither DHEA nor low-dose testosterone replacement has physiologically relevant effects on body composition, physical performance … or quality of life” [2]. A recent European 6-mo trial came to the conclusion that “testosterone supplementation … did not affect functional status or cognition but increased lean body mass and had mixed metabolic effects” [3].

Although these questions are formulated to be rather provocative, we would like to thank the authors of these guidelines for their comprehensive work. The guidelines provide an important basis for our daily work with aging men who are affected by low testosterone levels.
Conflicts of interest: The authors have nothing to disclose.