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Recent studies demonstrate a high prevalence of hypogonadism in men with metabolic syndrome and type 2 diabetes. Men with low testosterone levels have a higher mortality rate. Diagnosis and treatment with testosterone replacement can lead to improvement in well-being and quality of life. Early studies of testosterone replacement therapy have shown a benefit on glycaemic control, insulin resistance, visceral adiposity and cholesterol. Low testosterone levels are associated with the presence and the degree of atherosclerosis in carotid, coronary and aortic vessels. Furthermore, testosterone replacement therapy in testosterone deficient men with erectile dysfunction converts over half of PDE5 inhibitor non-responders to responders. This review presents the up-to-date evidence in relation to testosterone, and discusses the importance of criteria to make a diagnosis of hypogonadism in diabetic men. Copyright © 2007 John Wiley & Sons.