Justin Houman: 4 Checks Before Anyone Starts Testosterone
Justin Houman, Men’s Health Urologist at Tower Urology at Cedars-Sinai Medical Center, shared on LinkedIn:
“For colleagues who see men asking to start testosterone.
The AUA guideline (2018, reaffirmed 2024) asks for two early-morning total testosterone measurements on separate occasions, alongside consistent symptoms, before making the diagnosis.
The reference range of 300 to 1,000 is wide, and men feel well at different points in it, so a single low-normal value doesn’t settle the question either way.
What I add to the workup: free testosterone and SHBG, since a man with a total of 800 or 900 can still have a low free testosterone when SHBG is high; LH and FSH, to separate testicular from pituitary causes and direct the next tests; and a scrotal exam, because men with varicoceles tend to have lower testosterone levels, and repair can raise them on average.
Two questions come before any prescription.
- Does he want children? Standard TRT reduces sperm production within months and can drop it to zero in some men, so fertility comes first.
- Does he snore or gasp for air at night? Sleep apnea can present like low T, and in some situations TRT makes it worse.
Happy to see these patients in Los Angeles.”
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