• Adam C Millar, Lau Adrian N C ANC Department of Medicine (Millar, Tomlinson, Detsky, Lipscombe) and Institute of Health Policy, Management and Evaluation (Tomlinson, Detsky, Lipscombe),, George Tomlinson, Alan Kraguljac, David L Simel, Allan S Detsky, and Lorraine L Lipscombe.
• Department of Medicine (Millar, Tomlinson, Detsky, Lipscombe) and Institute of Health Policy, Management and Evaluation (Tomlinson, Detsky, Lipscombe), University of Toronto, Toronto, Ont.; Department of Medicine (Millar, Lau, Tomlinson, Kraguljac, Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Durham Veterans Affairs Medical Center (Simel), Durham, NC; Department of Medicine (Simel), Duke University, Durham, NC; Department of Medicine (Lipscombe), Women's College Research Institute of Women's College Hospital, Toronto, Ont.
• CMAJ. 2016 Sep 20; 188 (13): E321-E330.

BackgroundPhysicians diagnose and treat suspected hypogonadism in older men by extrapolating from the defined clinical entity of hypogonadism found in younger men. We conducted a systematic review to estimate the accuracy of clinical symptoms and signs for predicting low testosterone among aging men.MethodsWe searched the MEDLINE and Embase databases (January 1966 to July 2014) for studies that compared clinical features with a measurement of serum testosterone in men. Three of the authors independently reviewed articles for inclusion, assessed quality and extracted data.ResultsAmong 6053 articles identified, 40 met the inclusion criteria. The prevalence of low testosterone ranged between 2% and 77%. Threshold testosterone levels used for reference standards also varied substantially. The summary likelihood ratio associated with decreased libido was 1.6 (95% confidence interval [CI] 1.3-1.9), and the likelihood ratio for absence of this finding was 0.72 (95% CI 0.58-0.85). The likelihood ratio associated with the presence of erectile dysfunction was 1.5 (95% CI 1.3-1.8) and with absence of erectile dysfunction was 0.83 (95% CI 0.76-0.91). Of the multiple-item instruments, the ANDROTEST showed both the most favourable positive likelihood ratio (range 1.9-2.2) and the most favourable negative likelihood ratio (range 0.37-0.49).InterpretationWe found weak correlation between signs, symptoms and testosterone levels, uncertainty about what threshold testosterone levels should be considered low for aging men and wide variation in estimated prevalence of the condition. It is therefore difficult to extrapolate the method of diagnosing pathologic hypogonadism in younger men to clinical decisions regarding age-related testosterone decline in aging men.© 2016 Canadian Medical Association or its licensors.

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