Diagnosis of Hypogonadism in Men
April 2013
Volume 4, Issue 2

Reference ranges of testosterone in men generated using liquid chromatography tandem mass spectrometry in a community-based sample of healthy nonobese young men in the Framingham Heart Study and applied to three geographically distinct cohorts

J Clin Endocrinol Metab. 2011;96(8):2430-9

Introduction:  In making a diagnosis of androgen deficiency, reference ranges are key; they aid in dividing testosterone levels into low or normal.  Therefore, the researchers established total testosterone (TT) and free testosterone (FT) reference ranges; they did this by using a community-based sample of men.

Methods:  This study used the Framingham Heart Study (FHS) Generation 3; 456 healthy, non-obese men ages 19-40 were included.  Using liquid chromatography tandem mass spectrometry, TT was measured.  FT was calculated.

TT and FT results below the 2.5th percentile of the reference sample were considered low (TT < 348 ng/dL; FT < 70.0 pg/mL).

Three categories of conditions are associated with low testosterone levels:  physical dysfunction, sexual symptoms, and diabetes.  The association between these categories and low TT and FT was examined in the FHS broad sample (combination of Generations 2 and 3), the European Male Aging Study (EMAS), and the Osteoporotic Fractures in Men Study (MrOS).

Results:  In the FHS Generation 3 reference sample, the following results were reported:

  • TT
    • Mean:  723.8 (221.1) ng/dL
    • Median (quartile):  698.7 (296.5) ng/dL
    • 2.5th percentile value: 348.3 ng/dL
  • FT
    • Mean:  141.8 (45.0) pg/mL
    • Median (quartile):  134.0 (60.0) pg/mL
    • 2.5th percentile value:  70.0 pg/mL

In the 3 cohorts, subjects who had low TT and FT were, when compared to those with normal levels, were more likely to have difficulty climbing stairs, a slow walking speed, or frailty and diabetes.  Also in all 3 cohorts, men with low TT and FT were more likely to experience at least one of these:  sexual symptoms (EMAS only), physical dysfunction, or diabetes.

Men in EMAS who had low TT and FT were more likely to experience sexual symptoms than men with normal levels.

Conclusion:  This study created reference ranges from a healthy, young (age 19-40 years) community-based sample, and it gives a basis for identifying testosterone levels as normal or low.  It was seen that, using these criteria, men with low TT or FT were more likely to experience sexual symptoms, physical dysfunction, and diabetes. 

Commentary

This article is important because it is essential to have valid reference ranges for both total testosterone (TT) and free testosterone (FT) in order to accurately make the diagnosis of androgen deficiency.

In this study, a community-based sample of young, healthy, non-obese men from the Framingham Heart Study had their TT measured via liquid chromatography tandem mass spectrometry. This is considered the optimum method for measuring TT. SHBG levels were determined by immunoflurometric assay. FT was calculated using SHBG and the mass action equation. These levels were correlated with symptoms and used to identify appropriate reference ranges. Values below the proposed reference ranges were associated with increased sexual symptoms, physical dysfunction, and diabetes.

The identification of these ranges represents an important step in defining the androgen deficiency syndrome in men. The rationale for using a reference range for young, normal men is that symptoms in young and older men with low T levels for young men often are corrected by testosterone replacement.

Interventional studies with testosterone therapy in symptomatic patients identified as androgen deficient by these reference ranges are necessary to evaluate outcomes.

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