Hypogonadism in general practice: complexity is not a reason to look away.
When primary care withdraws, commerce moves in.
Direct-to-consumer telehealth services now offer testosterone replacement therapy with minimal clinical assessment, while many general practitioners remain reluctant to engage with hypogonadism at all — caught between diagnostic scepticism when the clinical presentation is non-specific, suspicion of patient motive, and insufficient confidence in their own clinical authority over the condition.
This ambivalence is not benign. When general practice withdraws from a clinical problem, the vacuum is filled — by commercial models that treat testosterone as a product rather than a therapy, and by specialist referral pathways that are neither necessary nor scalable for most presentations. The result is a growing cohort of men whose symptoms are either commodified or dismissed.
Why GPs hesitate
Stigma, countertransference, and the fear of peer opinion.
The barriers to GP engagement with hypogonadism are well-documented but poorly examined. Stigma plays a role: testosterone carries cultural associations with performance enhancement, masculinity, and vanity that make some clinicians uncomfortable.1 Countertransference is rarely named but frequently present — a clinician's own discomfort with the intersection of hormones, sexuality, and masculinity can shape the consultation before a single question is asked.
Fear of peer opinion compounds this further. A clinician who prescribes testosterone risks being seen — by colleagues, by pharmacists, by the broader profession — as credulous or commercially influenced, and this shared stigma functions as its own form of countertransference, shaping clinical decisions before the evidence has been weighed.2
Beyond stigma, there is a genuine knowledge gap. Many GPs lack confidence in distinguishing primary from secondary hypogonadism, interpreting equivocal biochemistry, or navigating the nuance of constitutional symptoms — fatigue, low mood, reduced libido, cognitive dulling — that overlap with depression, sleep disorders, and metabolic disease.3 This diagnostic complexity is real, but it is not unique. General practitioners routinely assess patients with undifferentiated fatigue, persistent cough, treatment-resistant depression, or unexplained weight change. In those contexts, complexity invites investigation, not avoidance.
What is missing
Not more guidelines, but more clinical engagement.
What is often missing is not more guidelines but more clinical engagement. A careful sexual and constitutional history — taken without embarrassment and without assumption — remains the most powerful diagnostic instrument available.4 This includes understanding confounding contributors: obstructive sleep apnoea, haemochromatosis, chronic opioid use, medications such as long-term antiepileptics and corticosteroids, the metabolic syndrome itself, and a subtler history of testicular atrophy that will not be volunteered unless asked about directly.5,6
It also means recognising that many men presenting for assessment have already been wrestling with their symptoms for years before overcoming the shame of seeking help. Men under-engage with primary care; by the time they present, they have often already optimised their lifestyle in good faith. The constitutional symptoms of hypogonadism are not volitional, and men seeking enhancement already source illicit testosterone without GP involvement. The reflexive instruction to exercise more, lose weight, and eat better — offered without inquiry into what the patient has already attempted — risks being both clinically inadequate and relationally dismissive.
Equally, the meaning a man attaches to his symptoms deserves exploration. Fatigue is not merely a biomarker deficit; it carries implications for identity, competence, and intimate relationships.7 General practice, with its longitudinal relational model, is uniquely positioned to hold this complexity — far more so than a direct-to-consumer telehealth consultation or a specialist appointment that begins after the most important clinical thinking has already occurred, or not, in primary care.
A clear position
Not uncritical prescribing — but not abdication either.
This is not an argument for uncritical prescribing. Testosterone replacement carries real risks — erythrocytosis, fertility suppression, and cardiovascular considerations that the TRAVERSE trial has only partially resolved — requiring informed discussion and ongoing monitoring.8,9 Rather, hypogonadism belongs within the clinical repertoire of general practice, assessed with the same rigour and curiosity applied to any complex, undifferentiated presentation.
To cede this ground is to fail patients in multiple ways: dismissing a potential diagnosis without understanding the varying diagnostic cut-offs for testosterone across age and clinical context; avoiding scope creep by reflexively referring to a specialist who will often send the patient back to primary care; or reluctantly ordering investigations but not meaningfully interpreting the results. Each of these is a disservice.
There was a time when every migraine was referred to neurology, every low mood to psychiatry. General practice reclaimed those conditions not by simplifying them but by developing the confidence to hold their complexity. Hypogonadism warrants the same reclamation.10
The patients are already presenting. The question is whether general practice will meet them with clinical depth, or continue to look away.