EMAS position statement: Testosterone replacement therapy in older men.

Late-onset hypogonadism is associated with metabolic syndrome, reduced bone mineral density, and increased cardiovascular morbidity and mortality risk.

• Late-onset hypogonadism is characterized by low testosterone concentrations associated with clinical symptoms in the absence of organic disease in ageing men.
• TRT reverses most of these conditions in young hypogonadal men, but the risk/benefit ratio of TRT in older men is described as 'debatable'.
• This position statement updates the 2015 EMAS statement on TRT in older men with new research.

TRT may be offered to older men with severe hypogonadism and erectile dysfunction to improve sexual desire, erectile, and orgasmic function.

• The recommendation specifically applies to men with both confirmed severe hypogonadism and erectile dysfunction.
• Benefits include improvement of sexual desire, erectile function, and orgasmic function.
• TRT should only be offered after explaining the uncertainties regarding the long-term safety of this treatment.

TRT should be considered in hypogonadal men with severe insulin resistance or pre-diabetes mellitus.

• The recommendation is specifically for men with severe insulin resistance or pre-diabetes mellitus, not all metabolic conditions.
• This represents one of the specific clinical indications for TRT in older men identified in the position statement.
• The statement does not specify TRT as a first-line treatment for these conditions.

TRT may be considered in combination with proven treatment strategies for osteoporosis in hypogonadal older men.

• TRT for osteoporosis is recommended only in combination with proven treatment strategies, not as monotherapy.
• Bone density and/or quality should be assessed as part of monitoring in older men on TRT.
• This represents a conditional rather than a strong recommendation.

TRT may be considered for selected patients with persistent mild depressive symptoms and/or low self-perceived quality of life when combined with standard medical care.

• The recommendation applies to 'selected patients' only, indicating a limited and individualized indication.
• TRT for depressive symptoms must be combined with standard medical care for each condition.
• The recommendation is for 'mild' depressive symptoms that are 'persistent', not severe or acute depression.

TRT is contraindicated in hypogonadal men actively seeking fertility treatment.

• This is listed as a clear contraindication, distinct from relative contraindications.
• The contraindication is specifically for men 'actively seeking fertility treatment'.
• No exceptions or qualifications are noted for this contraindication.

TRT should not be routinely used in older men to improve exercise capacity/physical function or to improve or prevent cognitive decline, due to lack of data.

• The recommendation against routine use is specifically cited as being 'due to a lack of data'.
• This applies to both exercise capacity/physical function and cognitive function outcomes.
• The statement explicitly recommends against TRT for prevention of cognitive decline.

TRT must be avoided in older frail men with known breast cancer or untreated prostate cancer, in men who had myocardial infarction or stroke within the last four months, and in those with severe or decompensated heart failure.

• The time threshold for recent cardiovascular events is specifically defined as 'within the last four months' for myocardial infarction or stroke.
• Breast cancer and untreated prostate cancer are absolute contraindications.
• Severe or decompensated heart failure is also listed as a contraindication.
• The quality of evidence regarding patients with previous prostate cancer or cardiovascular disease is described as 'too low to draw definitive conclusions'.

Short-acting transdermal preparations should be preferred for TRT initiation in older men, with injectable forms considered subsequently.

• The preference for transdermal preparations at initiation is specific to older men.
• Injectable forms are not excluded but are positioned as a subsequent rather than first-line option.
• The rationale for preferring short-acting transdermal preparations at initiation is not explicitly stated in the abstract but is implied to relate to safety monitoring flexibility.

Older men on TRT should be monitored at 3, 6, and 12 months after initiation and at least yearly thereafter, with evaluation including total testosterone, haematocrit, PSA, and bone density.

• Monitoring schedule: 3, 6, and 12 months after initiation, then at least yearly, or more frequently if indicated.
• Required measurements include total testosterone, haematocrit, and prostate-specific antigen (PSA) concentrations.
• Assessment of bone density and/or quality is also included in monitoring recommendations.
• Clinical response assessment is also part of the monitoring protocol.

Duration of TRT treatment should not be arbitrarily limited, and treatment should continue as long as the man feels benefits outweigh risks, with withdrawal considered when hypogonadism is reversed.

• The statement explicitly states that 'any limits on duration of use are arbitrary'.
• Decisions must be made on an individual basis.
• Withdrawal should be considered when hypogonadism is reversed after resolution of an underlying disorder.
• Patient perception of benefit versus risk is explicitly incorporated into the treatment continuation decision.

Obese and overweight hypogonadal men should be encouraged to undergo lifestyle modifications including exercise and weight loss to increase endogenous testosterone.

• Lifestyle modification is recommended as a strategy to increase endogenous testosterone.
• This applies specifically to obese and overweight patients.
• The recommended modifications include both exercise and weight loss.
• This suggests lifestyle modification as an alternative or adjunct to TRT in this population.