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CPE-006 · synthetic case TESTO-FX-05
Raised prolactin with low testosterone
Prolactin 95 ng/mL.
Purpose: Prolactin 95 ng/mL.
Inputs the engine received
Testosterone and hormones
- Total testosterone, sample 1
- 150 ng/dL
- Total testosterone, sample 2 (separate day)
- 160 ng/dL
- LH
- 1 IU/L
- Prolactin
- 95 ng/mL
Symptoms and findings
- Age
- 41 years
- Low libido
- Yes
What the engine reports
A raised prolactin can suppress testosterone and may reflect a pituitary lesion, medication or another cause. Consider pituitary imaging when it is clearly raised, review prolactin-raising drugs, hypothyroidism and macroprolactinemia, and address the cause before testosterone therapy is weighed.
Detected clinical pattern
Criteria for Testosterone Deficiency Met
Symptoms with low total testosterone on two samples (150 and 160 ng/dL). Secondary pattern. The cause still has to be found.
- Axis: Secondary (hypogonadotropic) pattern
Why this pattern was identified
- Low testosterone on two samples. 150 and 160 ng/dL are both below 300 ng/dL (AUA). With compatible symptoms, the criteria for testosterone deficiency are met.
- Secondary pattern. LH 1 IU/L is not elevated despite low testosterone: the problem is above the testes (hypothalamus or pituitary) or functional.
Recommended next steps
For physician consideration. Urgent review always comes first.
- 1Consider pituitary imaging; review prolactin-raising drugs, hypothyroidism, renal failure and macroprolactinemia.
Differentials, pitfalls and contradicting signals
- Functional suppression (obesity, opioids, illness) and pituitary disease look alike on these values.
Missing information
- SHBG (for calculated free testosterone).
Evidence and rule trace · 4 rules
HG-03Low testosterone confirmed on two samples
Inputs: 150 ng/dL · 160 ng/dL
Biochemically low testosterone on two samples.
HG-06Secondary (hypogonadotropic) pattern
Inputs: LH 1 IU/L (upper limit 9) · total testosterone 150 ng/dL
Pattern of secondary (hypogonadotropic) hypogonadism.
HG-MISS-01Information needed to classify
Inputs: low testosterone · SHBG missing
Type of hypogonadism cannot be classified without gonadotropins and prolactin.
HG-07Hyperprolactinemia with low testosterone
Inputs: prolactin 95 ng/mL (upper limit 20) · low testosterone
Raised prolactin with low testosterone.
Evidence
- EV-ES-TRT-2018 · Bhasin S, Brito JP, Cunningham GR, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018;103(5):1715-1744.
- EV-AUA-2018 · Mulhall JP, Trost LW, Brannigan RE, et al. Evaluation and Management of Testosterone Deficiency: AUA Guideline. J Urol. 2018;200(2):423-432.
- EV-TRAVISON-2017 · Travison TG, Vesper HW, Orwoll E, et al. Harmonized reference ranges for circulating testosterone levels in men of four cohort studies in the United States and Europe. J Clin Endocrinol Metab. 2017;102(4):1161-1173.
- EV-ES-PRL-2011 · Melmed S, Casanueva FF, Hoffman AR, et al. Diagnosis and treatment of hyperprolactinemia: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2011;96(2):273-288.
Physician adjudication required. Clinical decision support for physician review. This output identifies laboratory patterns and cautions. It does not diagnose, find the cause, or recommend starting, stopping or dosing testosterone therapy. Physician adjudication is required.
Change the values
The same engine, starting from this case. Change any value and watch the pattern and the rule trace react.
Against typical adult male reference intervals
Testosterone and hormones
- <264
- 264–299
- 300–350 borderline
- >350
4.3 g/dL is assumed when left empty.
Symptoms and findings
Possible reversible contributors
Testosterone therapy context
More testosterone cases
TESTO-FX-01
Low libido and erectile dysfunction, testosterone never measured
A 48-year-old with sexual symptoms and fatigue.
TESTO-FX-02
One low testosterone
Total testosterone 218 ng/dL on a single morning sample.
TESTO-FX-03
Low on two samples with a primary pattern
Testosterone 205 and 190 with LH 22 and FSH 31.
TESTO-FX-04
Secondary pattern with obesity and diabetes
LH 1.2 and FSH 2.0 with BMI 36.
TESTO-FX-06
Headache, visual field loss and prolactin 310
Possible pituitary mass effect.
TESTO-FX-07
Borderline total testosterone
Total testosterone 320 with SHBG 62 and symptoms.
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