Marcus

Marcus, 32, an office worker, comes in asking to be referred to endocrinology for testosterone replacement therapy. He has done his own research and arranged a private testosterone test, which came back low. He hands you the result: total testosterone 8.9 nmol/L (reference range 11.0 to 30.0 nmol/L). He is convinced this explains how he has been feeling and wants a referral to start treatment. On talking to him, he describes low libido, difficulty maintaining erections, low mood, tiredness, and feeling "flat" for the last couple of months. He has read that low testosterone causes all of this. Looking at his notes, you see he was started on sertraline 50mg by a colleague ten weeks ago for low mood and anxiety. He is otherwise well, on no other medications, does not smoke, drinks moderately, and has a normal BMI. His private test was a single sample taken at 4pm.

You have a limited-length appointment. Rank the following as an opening move, the option that best sets up a plan Marcus will genuinely engage with, given how much you still don't know.

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1
Acknowledge his research and how he has been feeling, explain that a single afternoon testosterone level is not diagnostic, and arrange a proper repeat (early morning, fasting, with LH, FSH, prolactin, and other relevant bloods) before deciding anything, while exploring how his symptoms relate to his recent sertraline and low mood.
2
Refer him to endocrinology for TRT assessment as he requests, given the low result and his symptoms.
3
Stop the sertraline, since it is likely causing his sexual dysfunction, and review him in a month.
4
Explain that his symptoms are almost certainly caused by the sertraline and his depression, reassure him his testosterone is a red herring, and make no further changes.
5
Tell him his testosterone is low and start a trial of testosterone replacement in primary care to see if his symptoms improve.