Male hypogonadism, also known as testosterone deficiency, is a failure of the testes to produce the male sex hormone testosterone, sperm, or both.
It can be due to a testicular disorder or the result of a disease process involving the hypothalamus and pituitary gland.
Hypogonadism can affect many organ functions and it can have a negative impact on quality of life.
The signs and symptoms depend on when it starts, how severe the deficiency is, and whether or not there is a decrease in the major functions of the testes.
A lack of testosterone can cause a wide range of symptoms.
These depend on:
- the age of onset
- the degree of testosterone deficiency
- how long the loss has been occurring
Adolescents and young adults who have not yet completed puberty appear younger than their chronological age.
They may also have small genitalia, a lack of facial hair, failure of the voice to deepen, and difficulty gaining muscle mass, even with exercise.
Puberty-onset hypogonadism can lead to:
- impaired sexual development
- decreased testicular size
- enlarged breasts
Symptoms of adult-onset hypogonadism include:
- erectile dysfunction
- low sperm count
- depressed mood
- decreased libido
- sleep disturbances
- decreased muscle mass and strength
- loss of body hair (pubic, axillary, facial)
- osteoporosis and decreased bone mineral density
- increased body fat
- breast discomfort and enlargement
- hot flashes
- poor concentration and decreased energy
Hypogonadism in a male refers to a decrease in either or both of the two major functions of the testes: sperm production and testosterone production.
This can happen for a number of reasons.
In primary hypogonadism, the testicles do not respond to hormone stimulation. This can be due to a congenital disorder such as Klinefelter’s syndrome, or acquired as a result of radiation treatment, chemotherapy, mumps, tumors or trauma to the testes.
In secondary hypogonadism, a disease state interferes with either the hypothalamus or pituitary gland, the main glands that release hormones to stimulate the testes to produce testosterone.
Situations that can cause secondary hypogonadism include:
- systemic illness
- medication side effects
- liver cirrhosis
- toxins (alcohol and heavy metals)
- morbid obesity.
Andropause is sometimes used to describe decreased testosterone due to the normal aging process. Testosterone levels in males increase until the age of 17 years. Then, starting at approximately 40 years of age, testosterone levels begin to decline at 1.2-2 percent per year.
Risk factors for hypogonadism include type 2 diabetes, obesity, renal failure, HIV, hypertension, chronic obstructive pulmonary disease (COPD) and taking glucocorticoid (steroids), opioid or antipsychotic medication therapy.
Testosterone replacement therapy (TRT) is the recommended treatment for male hypogonadism.
It is normally given as a topical gel, transdermal patch, or by injection. Oral forms of testosterone are not used due to the high risk of side effects, such as upset stomach.
TRT can eliminate many, if not all, of the signs and symptoms of male hypogonadism.
- increased libido
- mood improvement
- increased bone mineral density
- overall improved quality of life
However, there are a few risks associated with it.
It may lead to worsening of benign prostatic hyperplasia (BPH), acceleration of pre-existing prostate cancer, and worsening of both sleep apnea and congestive heart failure. TRT should not be started without first attending to these conditions.
All males who are using TRT require ongoing medical evaluation to determine adequate response to treatment. This will include regular blood tests and periodic digital rectal exams.
TRT is contraindicated in men with erythrocytosis, a condition involving a high volume percentage of red blood cells in the blood.
The response to TRT is individualized, and testosterone levels are not an indicator of who will respond to TRT and who will not. It is also worth noting that while it can relieve symptoms of hypogonadism, TRT does not restore fertility.
Hypogonadism can also affect females. In women with hypogonadism, the ovaries produce low levels of female sex hormones. This affects the functioning of the ovaries and the reproductive system.
Symptoms include delayed puberty and a lack of menstruation or irregular menstruation. Breasts may not develop fully and height may be affected. This may be due to a genetic problem, an autoimmune condition, or a range of environmental factors.
After puberty, a wide range of factors can lead to hypogonadism, including tumors, eating disorders, genetic problems, and surgery, such as a hysterectomy.
Symptoms will include hot flashes, mood changes, changes in energy levels, and discontinued menstruation.
Some lifestyle changes can help boost testosterone levels.
- losing weight
- managing stress
- getting adequate sleep
- avoiding alcohol
- giving up smoking.
The measures can help maintain normal testosterone levels.
If an individual is at risk of or may have hypogonadism, a doctor will take a thorough medical history taken and carry out a physical examination, including blood tests.
Two key blood tests must be carried out to confirm the presence of hypogonadism:
- serum total
- free testosterone
The normal range of these blood tests has some variability, but a reading of between 300 and 1,000 nanograms per deciliter (ng/dL) is considered normal. Levels will be below the normal range in a person with hypogonadism.
For accuracy, the blood test should be drawn between the hours of 7.00 and 11.00 in the morning on at least two occasions. Additional testing may be necessary to confirm a diagnosis of hypogonadism.
Awareness of male hypogonadism is growing, but many adult men with the condition remain undiagnosed and untreated. This may negatively influence both their quality of life in men and their life span.
Any male who thinks he may have low testosterone levels should seek medical advice, as treatment can reverse most of the symptoms and risks of male hypogonadism.
However, before starting treatment with TRT, all men should discuss the risks and benefits with their health care provider.