This checklist organizes a cause-first conversation after a low testosterone result. It is not a diagnostic score; checking an item does not prove it caused the result.
Confirm the biochemical finding
- Reason documented: why testosterone was ordered.
- Symptoms described: compatible symptoms or signs are described, not inferred from a questionnaire total.
- Two samples: at least two separate samples under clinician-accepted conditions.
- Context available: collection time, fasting, sleep schedule, illness, units, interval, and laboratory.
- Illness considered: a result drawn during acute illness was interpreted cautiously.
- SHBG context: total testosterone read with SHBG when SHBG may be abnormal.
- Free testosterone: used only for a defined question, with its method known.
- Clinician's verdict: deficiency confirmed, borderline, or needs better measurement.
Locate the signaling pattern
- LH considered to separate a testicular pattern from a pituitary one.
- FSH considered when fertility or testicular function matters.
- Prolactin or other pituitary testing obtained when the pattern or symptoms support it.
- Pattern named: primary, secondary, mixed, functional, exposure-related, or unresolved.
- On-treatment values: a normal level while using prescription testosterone is not mistaken for normal function.
- Outside records requested when treatment began elsewhere.
Review medications and exposures
Bring an accurate list, including nonprescription products and prior exposures. The purpose is to find contributors, never to stop a necessary medicine without supervision.
- Opioids, current or prior
- Glucocorticoids or other medicines that affect reproductive signaling
- Cancer treatment, pelvic or testicular radiation, or chemotherapy
- Anabolic steroids, prohormones, research chemicals, or performance products
- Prior or current prescription testosterone, including another clinic's
- Supplements marketed for testosterone, estrogen control, recovery, or bodybuilding
- Medicines linked to sexual, mood, sleep, weight, or energy symptoms
- Alcohol, cannabis, nicotine, and other relevant substances
Examine sleep and breathing
- Sleep duration: sleep opportunity and actual sleep are described.
- Apnea signs: snoring, witnessed pauses, gasping, morning headache, waking to urinate, or severe sleepiness.
- Existing treatment: known sleep apnea therapy and its effectiveness.
- Other causes: insomnia, shift work, caregiving, and work demands separated.
Review weight, nutrition, and metabolic health
- Weight and waist changes described over time without blame.
- Metabolic contributors: diabetes, insulin resistance, thyroid, liver, and others considered.
- Energy balance: severe calorie restriction, undernutrition, overtraining, or rapid weight change discussed.
- SHBG versus signaling: altered SHBG distinguished from reduced gonadal signaling.
- Not dismissed: weight-related suppression has not been used to rule out organic disease.
Review illness and general health
- Acute events: recent fever, hospitalization, surgery, trauma, or severe inflammation.
- Chronic disease: kidney, liver, lung, heart, neurologic, infectious, or inflammatory.
- Fatigue causes: anemia, thyroid disease, depression, and medication effects considered.
- Cardiovascular risk assessed when erectile dysfunction or exertional symptoms are present.
- Urgent symptoms are not being delayed for a testosterone workup.
Check pituitary and neurologic clues
- Headache, new or progressive
- Vision: new visual-field change, double vision, or unexplained visual loss
- Nipple discharge or marked prolactin abnormality
- Other pituitary hormone symptoms
- History: pituitary disease, head trauma, brain radiation, infiltrative disease, or surgery
- Imaging threshold: a severe secondary pattern that meets the clinician's threshold for imaging
Check testicular and developmental clues
- Development: undescended testis, unusual puberty, infertility, or known genetic condition
- Injury or treatment: testicular injury, torsion, infection, surgery, chemotherapy, or radiation
- Examination: change in testicular size, consistency, or a new scrotal finding
- Follow-up: ultrasound or specialist evaluation for an unresolved finding
- Emergency: sudden severe scrotal pain treated as urgent, not as a hormone question
Build the final cause statement
Write down the confirmed biochemical finding, the clinical findings supporting its relevance, the localized pattern and most likely cause, dangerous or structural causes addressed, reversible factors being treated or observed, evaluation still required, and the date the statement will be reconsidered.
Common questions
If I check several items on this list, does that mean I have found the cause of my low testosterone?
No. The checklist is not a diagnostic score, and checking an item does not prove that it caused the result. It organizes a cause-first conversation so that the finding is confirmed, the signaling pattern is located, and medications, sleep, weight, illness, and pituitary and testicular clues are all reviewed before a cause statement is written.
Should I stop a medication on this list that might be lowering my testosterone?
Not on your own. The purpose of the medication review is to find contributors, never to stop a necessary medicine without supervision. Bring an accurate list, including nonprescription products and prior exposures, and let the clinician decide what, if anything, should change.