we chose to investigate whether or not any hypogonadal

symptoms predicted serum TT levels of

400 ng/dL in our

present population. Our present

ﬁ

ndings support our clinical

experience that many men with serum TT levels between 300

and 400 ng/dL can still present with hypogonadal symptoms.

Other investigators have shown an association between

‘

energy

’

and TT levels. In an age-matched cohort of young

hypogonadal and euogonadal males, hypogonadal men

reported greater fatigue (10 vs 7,

0.03) compared with

their eugonadal counterparts [17]. A double-blind placebo

control study has shown that hypogonadal males treated

with TST report less fatigue (

0.03) [18]. Furthermore,

in patients with obstructive sleep apnoea, which is

commonly associated with fatigue, Bercea et al. [19] found

in a case-control study that serum TT levels were the only

independent predictors of physical fatigue (

0.98,

0.033) and reduced activity (

0.97,

0.002).

Young men are less likely to have organic factors

contributing to ED [20], and our present data suggests that

the sexual symptoms often seen in elderly hypogonadal

men are less important in diagnosing clinical

hypogonadism in younger men.

Our present study has both strengths and limitations. We

minimised heterogeneity by surveying men as they were

seen consecutively and by excluding men who had received

AAS and TST in the previous 6 months. We used the

ADAM questionnaire, which was originally validated in

elderly men and was used to screen for adult-onset

hypogonadism [21]. Despite poor speci

ﬁ

city, ADAM

remains one of the best-validated questionnaires for

studying hypogonadal symptoms. We also recorded a single

morning serum TT level for patients at the visit when they

completed the ADAM questionnaire. While this provided a

good record of the relationship between serum TT levels

and hypogonadal symptoms, multiple evaluations of TT

levels and symptoms could have yielded a more robust

comparison. Our present observations should be

extrapolated to the diagnosis of testosterone de

ﬁ

ciency in

patients with the caveat that a low TT level requires

con

ﬁ

rmation with repeated measurement. Furthermore, the

documentation of low TT levels in symptomatic young

men does not invariably imply that a low TT level is the

only or foremost cause of their physical or psychological

symptoms. A comprehensive general assessment is required

to seek potential alternative explanations. Obviously, these

data do not set the criteria for initiating testosterone

replacement but give valuable guidance to the practicing

physician about what threshold to use and what symptoms

to evaluate in young hypogonadal men.

In summary, among men aged

40 years of age visiting a

Men

’

s Health Clinic,

‘

lack of energy

’

predicted a serum TT

level of

400 ng/dL. As there were no differences in

hypogonadal symptom probability at 300 ng/dL and

presence of the symptoms did not predict a TT level of

300 ng/dL, we think a TT of 300 ng/dL should not be

used to diagnose hypogonadism in young men. We

propose the existence of unique hypogonadal symptoms

that become increasingly prevalent in young men. Rather

than using solitary, prede

ﬁ

ned levels of serum TT (i.e.

300 ng/dL) as thresholds for treatment, we recommend

using a different threshold based on symptomatology. The

notion that common and uniform concentrations of

androgen levels can be applied to describe the increasing

prevalence of testosterone-related symptoms in young men

should be challenged on the basis of the conclusions from

the present study.

Table 2

Univariate and multivariable analysis of hypogonadal symptoms predicting a serum TT level of

400 ng/dL. Only factors that were statistically

signi

ﬁ

cant (

0.05) on univariate analysis were included in the multivariable analysis.

Analysis

Odds ratio

95% CI

Univariate

Age

1.01

0.95

–

1.07

0.807

Do you have decreased libido?

1.18

0.69

–

2.02

0.552

Do you have a lack of energy?

2.56

1.48

–

4.40

0.001

Do you have a decrease in strength or endurance?

1.95

1.12

–

3.40

0.018

Have you noticed a decreased

“

enjoyment in life

”

1.59

0.86

–

2.93

0.136

Are you sad and/or grumpy?

2.06

1.07

–

3.96

0.030

Are your erections less strong?

1.40

0.82

–

2.39

0.221

Has there been a recent deterioration in your work performance?

2.29

1.08

–

4.85

0.030

Are you falling asleep after dinner?

1.45

0.81

–

2.58

0.210

Have you noticed a recent deterioration in your ability to play sports?

2.48

1.24

–

4.95

0.010

Have you lost height?

2.73

0.34

–

21.66

0.343

Multivariable

Do you have a lack of energy?

2.59

1.06

–

6.35

0.037

Do you have a decrease in strength or endurance?

0.64

0.25

–

1.61

0.341

Are you sad and/or grumpy?

1.03

0.42

–

2.52

0.954

Has there been a recent deterioration in your work performance?

0.94

0.37

–

2.38

0.889

Have you noticed a recent deterioration in your ability to play sports?

2.60

0.97

–

6.95

0.057

Bolded signi

ﬁ

cance values indicate P

0.05.

2014 The Authors

BJU International

2014 BJU International

145

Hypogonadal symptoms in young men with TT

400 ng/dL