What clinical steps should be taken to evaluate low testosterone or erectile dysfunction before using OTC supplements?
Executive summary
A safe, evidence-based evaluation for suspected low testosterone or erectile dysfunction (ED) requires a structured clinical assessment, targeted laboratory testing with proper timing and assay awareness, and exclusion of reversible medical, psychological, and medication-related causes before considering testosterone therapy or any over‑the‑counter (OTC) supplement [1] [2]. Major specialty guidelines emphasize repeating morning total testosterone on validated assays, measuring gonadotropins to classify primary versus secondary hypogonadism, and prioritizing lifestyle modification and standard ED treatments (including phosphodiesterase‑5 inhibitors) over empiric testosterone for isolated ED [2] [3] [4].
1. Take a focused medical, sexual and psychosocial history first
Guidelines agree that the first clinical step is a thorough history exploring libido, nocturnal/early‑morning erections, mood, physical function, chronic disease (diabetes, obesity, cardiovascular disease), medications including finasteride, substance use, and psychosocial contributors to sexual dysfunction because many symptoms are non‑specific and may reflect depression, chronic stress, or comorbid illness rather than true androgen deficiency [1] [5] [6].
2. Perform a focused physical examination to look for signs of hypogonadism and comorbidity
A directed exam should search for testicular atrophy, gynecomastia, body composition changes, and features suggesting syndromic causes of secondary hypogonadism; this step helps identify men who need more urgent endocrine or pituitary workup [7] [6].
3. Measure testosterone correctly: timing, repetition and assay quality matter
Initial biochemical evaluation requires a morning, fasting total testosterone measured on a reliable assay and repeated to confirm a low value because circadian variation and transient illness can give misleading single readings; guidelines stress using validated reference ranges and repeating measurements before labeling a man hypogonadal [2] [7] [1].
4. Add targeted hormonal tests to classify the problem
Measure LH and FSH to distinguish primary (testicular) from secondary (hypothalamic‑pituitary) hypogonadism; in men with low LH/FSH consider further testing including serum prolactin, thyroid function, and iron studies when indicated to detect pituitary adenoma or other endocrine disorders (and stop biotin for 72 hours before gonadotropin testing because of assay interference) [7] [8] [2].
5. Evaluate erectile dysfunction as a separate—but overlapping—diagnosis
ED is multifactorial; clinicians should use validated tools (IIEF) and assess vascular, neurologic, medication and psychosocial causes while recognizing that normal testosterone is not required for erections and that testosterone therapy does not consistently restore erectile function when used alone [9] [4] [8].
6. Prioritize reversible causes, lifestyle change and evidence‑based ED treatments before hormonal therapy
International guidelines recommend addressing obesity, diabetes, sleep disorders, and other comorbidities and using first‑line ED treatments such as PDE5 inhibitors rather than defaulting to testosterone for age‑related declines; testosterone may help men with confirmed hypogonadism and symptoms but is not a guaranteed fix for ED and is often not recommended as monotherapy solely to improve erections [3] [4] [2].
7. Reserve imaging and specialist referral for red flags or secondary hypogonadism
Pituitary MRI and referral to endocrinology or urology are warranted when secondary hypogonadism is suspected (low gonadotropins with low T), when prolactin or other tests are abnormal, or when exam/history suggest organic disease; the prevalence of clinically significant pituitary lesions in older men is low, so imaging should be individualized [7] [2].
8. Discuss risks, monitoring and the limits of evidence before any therapy — and be cautious about OTC supplements
If testosterone therapy is contemplated for confirmed hypogonadism, clinicians should discuss cardiovascular and prostate risks and implement baseline and follow‑up monitoring per guidelines; multiple reviews show modest or inconsistent benefit of testosterone on erectile function and urge shared decision‑making [1] [2] [4]. The provided sources do not supply systematic evidence for OTC “testosterone boosters” or herbal supplements; therefore claims of safety or efficacy for such products cannot be endorsed on the basis of these guideline documents [1] [10].