Late-onset hypogonadism in men over 40 – how to use the updated EAU 2025 guidelines and new findings on the cardiovascular safety of testosterone therapy

Overview

Late-onset hypogonadism is a clinical syndrome defined by androgen-deficiency symptoms and persistently low testosterone; it affects roughly two to eight percent of European men aged 40–79 years and becomes more prevalent with advancing age, obesity and cardiometabolic comorbidities.

The 2025 update of the European Association of Urology (EAU) guidelines sets a unified biochemical threshold of total testosterone below 12 nmol/L confirmed by two morning samples and emphasises baseline assessment of luteinizing hormone (LH), follicle-stimulating hormone (FSH), blood pressure and haematocrit before therapy. The large multicentre TRAVERSE trial showed that transdermal testosterone replacement does not increase major adverse cardiovascular events, yet revealed a mild rise in systolic blood pressure, a finding reflected in the latest US Food and Drug Administration (FDA) labelling changes.

Building on this evidence, we propose a four-step algorithm encompassing precise diagnosis, judicious initiation of treatment, integrated management of cardiometabolic risk factors and personalised fertility preservation. Such an approach permits effective and safe management of symptomatic late-onset hypogonadism while mitigating long-term risks.

Keywords:

late-onset hypogonadism, testosterone replacement therapy, EAU guidelines 2025, TRAVERSE trial, cardiovascular safety