Table of Contents
What is male hypogonadism?
Male hypogonadism means the testicles do not produce enough of the male sex hormone testosterone. When levels are low, men might have decreased sex drive, less muscle mass, erectile dysfunction, and fatigue.
Hypogonadism has a negative effect on organ function and quality of life. Testosterone is responsible for male reproductive and sexual functions. It affects puberty, fertility, muscle mass, body composition, bone strength, fat metabolism, sex drive, mood and mental processes (Fig. 1).
Testosterone is an androgen. Production of androgens decreases slightly with age. Low levels are more common in men who are obese and have multiple health conditions.
Hypogonadism in childhood
Hypogonadism can develop at any age but affects young children, adolescent boys, and men differently. It has little impact on young children and may well go away over time. In contrast, low hormone levels at puberty can affect a boy’s sexual development.
Adolescent boys with hypogonadism typically have undeveloped muscles and genitals, a high-pitched voice, and little or no body hair. Breasts may form, and arms and legs may become out of proportion to a small torso as they continue to grow.
In most cases, a delay in development is normal and will correct itself, although the wait may be emotionally and socially difficult.
Check for hypogonadism if a boy:
- Shows symptoms of hypogonadism
- Has male family members who had hypogonadism
- Has hormone levels that decrease
- Has had injuries, infections, or medical treatments that can affect hormone levels
Living with hypogonadism
For most adults with hypogonadism, the condition is lifelong and treatment is ongoing. The goal is to improve quality of life, sense of well-being, sexual function, and muscle and bone strength. Hormone replacement combined with weight loss, a healthy diet, stopping smoking, and increasing exercise can help.
Symptoms of hypogonadism
Hypogonadism can occur at any age. The symptoms will be different depending on your age when it develops.
Common symptoms in adult men include:
- Hot flushes
- Low sex drive
- Erectile dysfunction
- Mood changes
- Difficulty concentrating
- Problems sleeping
- Loss of muscle mass
- Decreased bone density
- Enlarged breasts
- Loss of body hair
Older men with low hormone levels may have low sexual desire and activity, erectile dysfunction, and hot flushes. In men with normal testosterone levels, these symptoms can be caused by other conditions.
Diagnosis of hypogonadism
Male hypogonadism is diagnosed based on:
- Long-term discomfort from symptoms
- Low testosterone levels in the blood measured at least two separate times
Your doctor might refer you to a hormone specialist (endocrinologist) if hypogonadism is suspected.
Various symptoms that you may have are presented below.
Physical and clinical symptoms suggestive of low testosterone:
- Small testes
- Male infertility
- Little body hair
- Gynaecomastia – enlarged breast tissue in men
- Decrease in body mass and muscle strength
- Central obesity
- Metabolic syndrome (having three of the five following conditions: central obesity, high blood pressure, high blood sugar, high blood triglycerides, and low blood high-density lipoprotein (HDL)
- Type 2 diabetes
- Osteoporosis (small bone density)
- Mild anaemia
Sexual symptoms suggestive of low testosterone:
- Reduced sexual desire and sexual activity
- Erectile dysfunction
- Fewer and smaller early morning erections
Perception symptoms suggestive of low testosterone:
- Hot flushes
- Changes in mood, fatigue and anger
- Sleep disturbances
- Smaller perception function
A physical exam will look at your body hair, male pattern hair loss, body mass index, the waist-hip ratio, muscle mass, presence of gynaecomastia, testicular size, examination of the penis and digital rectal examination of the prostate. Your doctor will make sure they are consistent with your age. Your doctor might also take a medical history to assess your general health.
For an adult patient, the doctor could also ask about your sexual life.
If you have symptoms of hypogonadism, your doctor will take blood to test your testosterone level. Blood should be drawn in the morning before breakfast. This test should be done at least two separate times.
To distinguish between primary and secondary forms of hypogonadism, a doctor may check the hormone level. This should also be measured in the morning, at two occasions.
If both tests confirm you have low testosterone, further testing can determine whether the cause is testicular (primary hypogonadism) or pituitary (secondary type).
|Tests to determine type of hypogonadism|
|Additional blood tests||Other conditions can cause the same symptoms as hypogonadism. Bloods tests will also assess levels of:
|Imaging||MRI or CT scan may be used to check for tumours in the pituitary gland|
|Genetic testing||Some types of hypogonadism are caused by problems in the way the genes developed. These tests can check for genetic causes of low hormone levels.|
Treatment of hypogonadism
Losing weight, adjusting your diet, stopping smoking, and increasing exercise can improve your quality of life with hypogonadism. These changes can also help increase muscle strength and improve diabetes control and sexuality.
Hormone replacement therapy is the main treatment for both types of hypogonadism. Tumours found in the pituitary gland may require surgery, medication, radiation, or replacement of other hormones.
Main indications for testosterone treatment:
- Delayed puberty
- Klinefelter syndrome with hypogonadism
- Sexual dysfunction and low testosterone, not responding to medication or proper medical treatment
- Osteoporosis in hypogonadism
- Adult men with low testosterone and consistent multiple symptoms of hypogonadism following unsuccessful treatment of obesity and other medical conditions
- Under-active pituitary gland (hypopituitarism)
Contra-indications against testosterone treatment:
- Advanced or metastatic prostate cancer
- Men with active desire to have children
- High level of haematocrit > 54%
- Severe cardiac failure (New York Heart Association IV)
Hormone replacement therapy
The goal of hormone replacement is to improve quality of life, sense of well-being, sexual function, muscle strength, and bone mineral density.
Replacement of the hormone testosterone aims to restore levels in men diagnosed with low testosterone caused by problems in the testicles (primary hypogonadism).
Pituitary hormones may be replaced if low levels are caused by a problem in the pituitary gland (secondary hypogonadism). These hormones can stimulate genital development in boys. They can increase sperm production and restore fertility in men.
Risks of testosterone treatment
In addition to side effects, hormone replacement carries some risks related to natural changes in hormone levels. Testosterone replacement can cause both cancerous and non-cancerous prostate tumours, enlarged breasts, infertility, and blood clots in the veins.
Do not use testosterone replacement therapy if you have:
- Heart problems
- Prostate cancer
- An enlarged prostate that causes problems urinating
- Male breast cancer
- A high red blood cell count
- Severe sleep apnoea
- Infertility but might want to have children
Types of testosterone replacement therapy
Different types of testosterone replacement are absorbed into the body differently and have different side effects.
Consider starting therapy with a type that can be stopped easily (short-acting treatment) if side effects are a problem.
Not all types of testosterone replacement therapy are available. Work with your doctor to choose the right type of testosterone replacement therapy for you.
|Taken by mouth||
|Injected into the buttock or arm||
|Applied to the skin||
Regular medical monitoring is recommended during treatment. Your doctor will schedule visits with you to assess whether treatment is working, address possible side effects, and check treatment safety. Your testosterone will be tested over time to help determine the right dosage for therapy. Follow-up may include blood tests, examination of your prostate and your heart, and bone density scans.
With treatment, your symptoms will go away gradually. For example, your sex drive might improve first, then your mood might improve, and then erectile function might return.
General information about male hypogonadism
Testosterone is produced mainly in the testicles and also by the adrenal glands. Women have testosterone, but in much smaller amounts than men.
In the brain, the hypothalamus and pituitary gland help the testicles produce testosterone. They produce hormones that prompt action in the testicles. In response, the testicles produce sperm and testosterone.
|What does testosterone do?|
|Brain||Affects sex drive, mood, and mental processes (cognition)|
|Skin||Affects male pattern body and facial hair, balding, and oil production|
|Larynx||Deepens voice and prompts formation of Adam’s apple|
|Organ||Stimulates production of erythropoietin, which causes red blood cells to form|
|Male sexual organs||Affect penile and prostate growth and function and production of sperm|
|Muscle||Increases strength and muscle mass|
|Liver||Affects production of proteins|
|Fat||Decreases fat mass|
|Bone marrow||Stimulates production of stem cells|
|Bone||Accelerates growth, increases bone strength, and maintains bone density|
Types and causes of hypogonadism
Primary hypogonadism is caused by a problem in the testicles. Secondary hypogonadism is caused by a problem in glands that tell the testicles to make testosterone.
Common causes of hypogonadism
|Male hypogonadism of testicular origin (primary)||Male hypogonadism of hypolothamic – pituitary origin (secondary)|
|* Decreased testosterone varies greatly among men. Almost a third of men older than age 75 have low testosterone.|
|Male hypogonadism due to mixed dysfunction of hypothalamus / pituitary and testes (adult onset)||Male hypogonadism due to defects of androgen target organs|
Hypogonadism and fertility
Hypogonadism can reduce sperm production and cause infertility. Men who want to have children should not use testosterone replacement, but other treatment may be available.
Men with hypogonadism caused by pituitary problems (secondary type) can potentially be treated with a hormone called human chorionic gonadotrophin, or hCG. This hormone stimulates production testosterone in the testicles. It is combined with treatment to increase production of sperm. This therapy can be used only for a limited time and should be guided by a competent specialist.
Men with hypogonadism caused by problems in the testicles (primary type) who have fertility problems need evaluation of the testicles and may require assisted reproductive technology. This technology can help couples who have not been able to conceive a child.