On behalf of the American Association of Clinical Endocrinology (AACE), we appreciate the opportunity to provide our perspective on the recently authorized testosterone screening program for U.S. service members over age 30. AACE supports efforts to protect the health and readiness of our military personnel; however, testosterone screening, evaluation, and treatment should be evidence-based, clinically appropriate, and consistent with established clinical guidelines.

The Secretary of War has authorized a screening program for US troops above the age of 30 to have their testosterone routinely checked as part of annual health screenings. The rationale seems to be to ensure men have the right testosterone levels to operate at their "absolute best." Troops with low testosterone levels will be offered voluntary hormone replacement therapy. AACE feels strongly that the men and women, who sacrifice so much in service to our country, receive the highest-quality healthcare, grounded in the best available medical evidence and established standards of care. AACE recognizes that maintaining the health and readiness of our military is of paramount importance. However, we also believe appropriate evaluation and treatment for testosterone deficiency should be reserved for men with symptoms and signs suggestive of hypogonadism and performed in accordance with established clinical guidelines.

Currently the Endocrine Society guidelines recommend diagnosing hypogonadism in men with symptoms and signsof testosterone deficiency and unequivocally low morning serum total testosterone and/or free testosterone concentrations using an accurate and reliable assay.¹ The diagnosis should be confirmed by repeat morning measurement rather than based on a single testosterone level. Normal ranges in a healthy male are variable and there are no defined optimal levels for performance.^2-3

Our primary concern with mandatory annual screening is that it may lead to hasty misdiagnoses and unnecessary treatments that may carry lifelong risks. Total testosterone, while a marker of health, could indicate an underlying health condition rather than testosterone deficiency itself. It is also important to note that total testosterone levels can be transiently low due to various factors such as illness, sleep disturbances, stress, obesity, medications, and alcohol consumption. For this reason, a low testosterone level should be confirmed with repeat testing rather than used in isolation to establish a diagnosis. If low testosterone is confirmed, an appropriate clinical evaluation should then be performed to identify the underlying etiology, including potentially reversible or clinically significant causes, before initiating testosterone therapy. This evaluation should involve a clinician with expertise in the diagnosis and management of testosterone disorders, such as an endocrinologist.

There are consequences associated with treating individuals without symptoms. Exogenous testosterone stimulates red blood cell production; if not monitored appropriately, this can significantly increase blood viscosity, raising the risk of hypertension, deep vein thrombosis (DVT), and heart attack. Additionally, exogenous testosterone, especially at supraphysiological doses, can adversely affect cholesterol levels and lead to adverse vascular and cardiac changes.

Some of the excess circulating testosterone is converted into estradiol. Elevated estrogen levels relative to androgen signaling frequently cause swelling or pain in glandular breast tissue (leading to gynecomastia). Higher androgen exposure also causes dermatologic side effects including accelerating male pattern baldness in individuals genetically predisposed to it and leading to oily skin and acne. Excessive and/or fluctuating androgen levels can cause heightened aggression, mood instability, anxiety, and sleep disturbances (or worsening of underlying sleep apnea).

The TRAVERSE Study revealed an increased risk of heart rhythm disturbance called atrial fibrillation (3.5% compared to 2.4%) and acute kidney injury (AKI) (2.3% compared to 1.5%).⁴ Moreover, testosterone use can lead to a decrease in sperm count and testicular atrophy, potentially contributing to infertility, which is a significant concern for a young population. Additionally, there is a potential risk of dependence due to the increased confidence and physical changes that may accompany testosterone use. After stopping external testosterone, full recovery of the body's natural axis can take months to years, and in some cases, endogenous testosterone production or sperm counts never fully return to their baseline levels.

Some service members suffer traumatic brain injury and checking pituitary function as well as testosterone could be appropriate in this population as well as men with symptoms and signs of testosterone deficiency. This would be important to help localize if true hypogonadism is a central problem (i.e. in the pituitary) or, if it is a primary testicular issue. Well-established clinical guidelines already provide recommendations for the appropriate evaluation of testosterone deficiency and pituitary function following traumatic brain injury. ^5-6

Consideration of the availability of knowledgeable clinicians to work-up low testosterone and the cost and burden of long-term treatment and monitoring needs to be had. A study published in 2015 showed that only a small proportion of 111,000 veterans who received a testosterone prescription from the VA between 2009 and 2012 underwent appropriate testing, and some received the therapy despite important contraindications.⁷ These findings highlight the importance of appropriate diagnostic evaluation before initiating therapy. In a recent study of nearly 359,000 men prescribed testosterone, more than one-third had no documented evidence of hypogonadism, and these men experienced a significantly higher risk of major cardiovascular events over the subsequent 10 years than men treated for documented hypogonadism.⁸

Before initiating testosterone therapy, service members should undergo a thorough informed consent process that includes discussion of the potential benefits, risks, and long-term implications of treatment. Importantly, reproductive goals and the desire for current or future fertility should be specifically addressed, as exogenous testosterone can suppress spermatogenesis and adversely affect fertility. Management should also take a holistic approach to the service member’s health, including assessment and optimization of sleep, nutrition, physical activity, weight, medications, and other underlying health conditions that may contribute to low testosterone levels or affect overall health and performance. Testosterone therapy, when indicated, should be one component of a comprehensive approach to optimizing the health and well-being of the service member.

We strongly urge an evidence-based, symptom and risk-directed approach rather than a screening program. Physicians prescribing testosterone should follow guidelines and recommendations on testosterone therapy as mandated by expert bodies. We share the goal of ensuring that our service members are healthy and able to perform at their best while also ensuring that testing and treatment are appropriate, evidence-based, and consistent with established standards of care. We encourage the Department of War to work with the American Association of Clinical Endocrinology (AACE) and other experts in this field as this program is developed and implemented. AACE and its members would welcome the opportunity to provide our expertise and collaborate with the Department to help ensure that our service members receive the highest standard of care.

EXECUTIVE SUMMARY:

The American Association of Clinical Endocrinology (AACE) appreciates the Department of War commitment to optimizing the health and readiness of our nation's service members. Current evidence does not support routine population screening for testosterone deficiency in asymptomatic men. Because testosterone deficiency is a clinical diagnosis requiring compatible symptoms, biochemical confirmation, and evaluation for underlying causes, AACE recommends a symptom- and risk-directed approach rather than universal screening.

Key Recommendations:

• Testosterone deficiency is a clinical diagnosis. Diagnosis should be based on compatible symptoms and signs together with confirmed, unequivocally low testosterone concentrations—not a single laboratory value.
• Routine screening may result in overdiagnosis and overtreatment. Testosterone levels may be transiently reduced by illness, sleep disturbance, stress, obesity, medications, alcohol use, and other reversible conditions.
• Low testosterone should be confirmed and evaluated before treatment. Repeat testing and evaluation for reversible or underlying causes, including pituitary disease when appropriate—should occur before initiating testosterone therapy.
• Testosterone therapy carries important risks and requires ongoing monitoring. Potential adverse effects include erythrocytosis with increased thromboembolic risk, atrial fibrillation, infertility, testicular atrophy, gynecomastia, mood changes, and the need for long-term laboratory monitoring. Excess testosterone can be converted to estrogen.
• Many active-duty service members are younger than participants in the major testosterone trials. The long-term risks and benefits of testosterone therapy in this younger population remain less well established.
• AACE recommends a symptom- and risk-directed approach rather than universal screening. We welcome the opportunity to work collaboratively with the Department of War to ensure service members receive evidence-based evaluation and the highest standard of endocrine care.

Sincerely,

Dace Trence, MD, MACE
President, American Association of Clinical Endocrinology (AACE)

Contributors

• Jenna Sarvaideo, DO
• Anna L. Goldman, MD

References

1. 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. doi:10.1210/jc.2018-00229
2. Sonksen et al. Why do Endocrine Profiles in Elite Athletes Differ between Sports? Clinical Diabetes and Endocrinology (2018) 4:3
3. Handelsman et al. Serum Androgen Profile of Elite Athletes. J Clin Endocrinol Metab. 2026,00,1-7
4. Lincoff AM, Bhasin S, Flevaris P, et al. Cardiovascular Safety of Testosterone-Replacement Therapy. N Engl J Med. 2023;389(2):107-117. doi:10.1056/NEJMoa2215025
5. Tritos et al. American Assoc of Clinical Endocrinologists and American College of Endocrinology Disease State Clinical Review: A Neuroendocrine Approach to Patients with Traumatic Brain Injury. Endocrine Practice. 2015 Jul; 21(7):823-31
6. Kelestimer et al. Approach to the Patient With Traumatic Brain Injury-Induced Pituitary Dysfunction. J Clin Endocrinol Metab. 2026 May 19;111(6): e1695-e1707.
7. Jasuja et al. Ascertainment of Testosterone Prescribing Practices in the VA. Med Care. 2015 Sep; 53(9): 746-52. 
8. Kerniss et al. Off-Label Testosterone Therapy is Associated With Higher Long Term Cardiovascular Risk in Men. eBioMedicine. 2026; 130: 106373