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.

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.