EAU Guidelines on Sexual and Reproductive Health: A Summary of the 2026 Recommendations for Measurement and Biochemical Confirmation of Hypogonadism

Despite the consensus that diagnosis of male hypogonadism requires both biochemical and clinical criteria, important uncertainties remain regarding preanalytical conditions, assay selection, and the role of free testosterone (T) and sex hormone-binding globulin (SHBG) measurements. To address these issues, this study provides a summary of the European Association of Urology Guidelines on Sexual and Reproductive Health (SRH) recommendations for the measurement of total T and biochemical diagnosis of male hypogonadism.

For the 2026 guidelines on SRH, new and relevant evidence was identified, collated, and appraised via a structured assessment of the literature. Database searches included MEDLINE, EMBASE, and the Cochrane Library. Recommendations within the guidelines were developed by the panel to prioritize clinically important care decisions. The strength of each recommendation was determined according to a balance between the desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including the certainty of estimates), and the nature and variability of patient values and preferences.

Key recommendations emphasize the importance of measuring total T in a fasting state and in the morning (7:00-10:00 AM). Immunoassays remain clinically acceptable for total T measurement when liquid chromatography-tandem mass spectrometry is unavailable. A T level of ≤12 nmol/l continues to be the recommended threshold for diagnosing symptomatic male hypogonadism in clinical practice. Emerging evidence supports broader use of SHBG to prevent misdiagnosis of male hypogonadism. Calculated free T, derived from total T, SHBG, and albumin levels, should be considered in conditions known to affect circulating SHBG levels.

Accurate biochemical confirmation of male hypogonadism requires standardized sampling procedures and validated assays. Total T remains the cornerstone of diagnosis; however, SHBG and calculated free T are essential in men with altered binding protein levels. Recent data, although based on limited evidence, support the use of calculated free T even in healthy individuals and not just in patients with conditions associated with potential alterations in SHBG levels.

This paper explains how testosterone (T) should be measured to diagnose low T (male hypogonadism). Testing should be done in the morning and after fasting. In some cases, additional measurements such as SHBG and calculated free T may help improve diagnostic accuracy, although current evidence supporting their use is limited.