Course 03 · Men's health

Testosterone Deficiency in Men

Diagnosis, treatment, monitoring, and fertility considerations.

Most testosterone prescribing education comes from clinics, compounding pharmacies, and social media. This course teaches the diagnosis and the prescribing decisions from the primary literature and the current Endocrine Society and AUA guidance — and then tells you what to do when the patient is already on therapy and something isn't right.

Start at Part I Clinical toolkit Provider reference
Estimated contact hours
6.00
Pharmacology hours
4.75
Parts
8
Format
Written · self-paced

Development status: In development — pilot testing scheduled. Contact hours shown are the author's pre-submission estimate. This activity has not yet been submitted to the American Association of Nurse Practitioners® and may not be described as accredited, approved, or approval-pending until an approval letter is issued.

Introduction

Educational Need

Testosterone prescribing has grown substantially over the past two decades, and a large share of that prescribing now happens outside of endocrinology and urology — in primary care, in men's health clinics, and in direct-to-consumer telehealth. Nurse practitioners are increasingly the clinicians men see first with fatigue, low libido, and a printout from an online lab panel.

The educational problem is not a lack of information; it is that most of the available information is commercial. Protocols circulate from compounding pharmacies, supplement vendors, gym communities, and social media, and they frequently recommend supraphysiologic targets, routine aromatase inhibition, and diagnostic shortcuts that are not supported by any professional society. Meanwhile the diagnostic standard itself — repeat early-morning fasting testing, SHBG and calculated free testosterone where indicated, and classification with LH and FSH — is often skipped entirely.

The consequences are concrete. Men receive lifelong therapy for reversible conditions such as untreated obstructive sleep apnea, obesity, and opioid-induced androgen deficiency. Men of reproductive age are started on therapy without ever being asked about fertility, and later present with azoospermia. Erythrocytosis goes unmonitored. And the cardiovascular conversation, which changed meaningfully with the publication of the TRAVERSE trial and subsequent FDA labeling revisions, is frequently conducted on the basis of a decade-old headline.

This activity addresses that gap with a practical, evidence-anchored clinical framework: confirm the diagnosis correctly, look for what is reversible, ask about fertility before the first dose, select the formulation deliberately, monitor what actually matters, and troubleshoot therapy without reflexively escalating the dose.

Learning objectives

Upon completion of this activity, participants should be able to:

  1. Differentiate the clinical presentations of testosterone deficiency from the many conditions that mimic it, including obstructive sleep apnea, depression, thyroid disease, anemia, and medication effect.
  2. Apply correct testosterone testing methodology — early-morning fasting sampling, confirmatory repeat testing, and appropriate use of SHBG and calculated free testosterone.
  3. Distinguish primary from secondary hypogonadism using LH and FSH, and determine when prolactin, iron studies, or pituitary imaging are indicated.
  4. Identify and address reversible contributors to low testosterone before initiating therapy, including obesity, opioids, glucocorticoids, and untreated sleep apnea. (pharmacology)
  5. Select an appropriate testosterone formulation and starting dose based on the patient's fertility goals, hematocrit, adherence profile, and preference. (pharmacology)
  6. Construct a guideline-based monitoring plan including testosterone level timing by formulation, hematocrit, PSA, and symptom reassessment. (pharmacology)
  7. Manage erythrocytosis, elevated estradiol, gynecomastia, acne, and other adverse effects of testosterone therapy without reflexively discontinuing treatment. (pharmacology)
  8. Counsel men on the fertility consequences of exogenous testosterone and describe evidence-supported fertility-preserving strategies. (pharmacology)
  9. Interpret the current cardiovascular and prostate safety evidence, including the TRAVERSE trial, and counsel patients accurately about risk. (pharmacology)
  10. Determine when to discontinue therapy, when to refer to urology or endocrinology, and how to document shared decision-making for an off-label or long-term therapy. (pharmacology)

Target audience

Nurse practitioners in primary care, family medicine, internal medicine, urology, and telehealth who evaluate and manage adult men with symptoms of testosterone deficiency.

Format and access

Online · Enduring self-study · 100% written and interactive (no recorded sessions). 12-month access from enrollment. There are no recorded audio or video sessions; all content is written and interactive.

Curriculum

8 Parts, ordered the way a testosterone visit actually unfolds.

6 of 8 Parts carry pharmacology content. Each Part opens with measurable objectives, closes on a clinical vignette with the reasoning worked through, and includes self-assessment items keyed to those objectives.

  1. Part
    I

    The HPG Axis, Androgen Physiology, and What 'Low T' Actually Means

    How the hypothalamic-pituitary-gonadal axis regulates testosterone, why levels are diurnal and pulsatile, what SHBG does to the number you see on the report, and why age-related decline is not the same disease as pathologic hypogonadism.

    45 minOpen Part
  2. Part
    II

    Symptoms, Differential Diagnosis, and Correct Testing Methodology

    Which symptoms are actually specific, the conditions that mimic testosterone deficiency, how to draw and repeat the test correctly, and how to classify primary versus secondary hypogonadism with LH, FSH, and prolactin.

    55 minOpen Part
  3. Part
    III

    Reversible Causes, Contraindications, and the Fertility Branch Point

    Pharmacology

    The contributors worth correcting before writing a prescription, the absolute and relative contraindications, the fertility conversation that must happen first, and how to document shared decision-making for a long-term therapy.

    40 minOpen Part
  4. Part
    IV

    Formulation Selection, Starting Doses, and Titration

    Pharmacology

    Every available formulation compared on pharmacokinetics, dosing, erythrocytosis risk, transference risk, cost, and adherence — plus concrete starting doses, how to time the confirmatory level for each route, and how to titrate.

    65 minOpen Part
  5. Part
    V

    Monitoring: Hematocrit, PSA, Estradiol, and the Follow-Up Rhythm

    Pharmacology

    A concrete monitoring calendar, the hematocrit thresholds that trigger action, how to approach PSA changes on therapy, when estradiol is worth measuring, and what does not need routine monitoring.

    45 minOpen Part
  6. Part
    VI

    Troubleshooting: Non-Response, Adverse Effects, and Difficult Conversations

    Pharmacology

    The scenarios that actually fill your inbox — 'it stopped working,' acne, gynecomastia, mood changes, testicular atrophy, injection site problems, hair loss, and the patient who is buying testosterone online.

    55 minOpen Part
  7. Part
    VII

    Cardiovascular Safety, Prostate Safety, and Counseling Accurately

    Pharmacology

    What TRAVERSE actually showed and did not show, the atrial fibrillation and pulmonary embolism signals, current FDA labeling, the venous thromboembolism question, bone and body composition outcomes, and what to say to a patient who read a headline.

    40 minOpen Part
  8. Part
    VIII

    Fertility, Discontinuation, Referral, and Long-Term Planning

    Pharmacology

    Fertility preservation before and during therapy, restarting the axis after testosterone or anabolic steroid exposure, how to discontinue safely, and clear referral triggers for urology, endocrinology, and reproductive medicine.

    40 minOpen Part
Earning credit

Four steps to the certificate.

Read every Part, pass the final examination at 80% or higher, complete the activity evaluation, then print your certificate. The pre-test is optional and is not scored for credit.

  1. Optional
    Pre-test

    Ten items that show you which Parts to read most closely.

  2. Step 1
    Learning objectives

    Course-level and Part-level measurable objectives, with pharmacology items flagged.

  3. Step 2
    Final examination

    Single-best-answer items from every Part. 80% to pass; unlimited retakes.

  4. Step 3
    Activity evaluation

    Objective achievement, faculty expertise, commercial bias, and practice change.

  5. Step 4
    Certificate of completion

    Released after a passing examination and a submitted evaluation.

Evidence base

Anchored to the primary sources.

Verified August 2026. Every Part closes on its own numbered reference list — see the full course reference list or the guidelines & evidence watch for currency notes and the pending reviews, trials, and regulatory actions we are tracking.

  • AUA 2018 / 2024

    Evaluation and Management of Testosterone Deficiency: AUA Guideline (Mulhall JP, Trost LW, Brannigan RE, et al.) — published 2018, reviewed and validity confirmed 2024.

  • Endocrine Society 2018

    Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline (Bhasin S, et al., J Clin Endocrinol Metab. 2018;103(5):1715–1744).

  • Endocrine Society 2026 statement

    Endocrine Society. Statement on Testosterone Replacement Therapy (July 2026) — reaffirms symptom-plus-confirmed-low-level diagnosis at any age, discourages the terms 'age-related', 'late-onset', and 'functional' hypogonadism, and states there is insufficient evidence for population-level screening of asymptomatic men.

  • TRAVERSE 2023

    Lincoff AM, Bhasin S, Flevaris P, et al. Cardiovascular Safety of Testosterone-Replacement Therapy. N Engl J Med. 2023;389(2):107–117. Noninferior for MACE in 5,246 men with, or at high risk of, cardiovascular disease; excess atrial fibrillation, acute kidney injury, and pulmonary embolism observed.

  • TRAVERSE fracture substudy 2024

    Snyder PJ, Bhasin S, Cunningham GR, et al. Testosterone Treatment and Fractures in Men with Hypogonadism. N Engl J Med. 2024;390(3):203–211. Clinical fracture incidence was higher, not lower, with testosterone — bone density gains did not translate into fracture reduction.

  • FDA 2025 labeling

    FDA class-wide labeling change for all testosterone products (February 2025): the boxed-context cardiovascular warning language was revised in light of TRAVERSE, a warning regarding blood-pressure increases was added, and the indication remains limited to classical hypogonadism due to established disease.

  • T4DM 2021

    Wittert G, Bracken K, Robledo KP, et al. Testosterone treatment to prevent or revert type 2 diabetes in men enrolled in a lifestyle programme (T4DM). Lancet Diabetes Endocrinol. 2021;9(1):32–45.

  • TTrials

    Snyder PJ, et al. The Testosterone Trials — a coordinated set of seven placebo-controlled trials in 790 men aged 65+ addressing sexual function, physical function, vitality, cognition, anemia, bone, and coronary plaque.

EverLucent Vault integration

The CE teaches the reasoning. Vault runs the workflow.

This course is designed so its decision logic transfers directly into a Vault men's health protocol module — the same eligibility gates, formulation logic, monitoring cadence, and referral triggers, executed as workflow rather than taught as content.

  • Eligibility checklist

    Confirmatory testing, reversible contributors, contraindications, and fertility intent as a structured gate before any prescription.

  • Formulation selector

    Fertility intent, hematocrit, household exposure, adherence, and cost drive a recommended formulation and starting dose.

  • Monitoring scheduler

    Auto-generates the baseline / 3 mo / 6 mo / 12 mo lab and visit cadence with formulation-specific level timing.

  • Erythrocytosis pathway

    Hematocrit-triggered actions with contributor checklist and escalation to phlebotomy or formulation change.

  • Fertility branch

    Routes men with reproductive intent away from testosterone monotherapy and into semen analysis and specialist referral.

  • Documentation blocks

    Shared decision-making language, off-label disclosures, and monitoring plan text ready to paste into the chart.