Hypogonadism in Men

Be open with your doctor about your medical history, all prescription and nonprescription drugs you are now taking, sexual problems, and any major changes in your life. Your doctor will take a thorough history of your symptoms and then complete a physical exam, including your body hair, breast tissue, and the size and consistency of the testes and scrotum. 

Your doctor will also use blood tests to see if your total testosterone level is low. The normal range depends on the lab that conducts the test. To get a diagnosis of hypogonadism, you need at least two early morning (7–10 AM) blood tests that reveal low testosterone in addition to signs and symptoms typical of low testosterone. The cause of hypogonadism can be investigated further by your doctor. This might include additional blood tests, and sometimes imaging such as a pituitary MRI. 

Testosterone Facts For Men 

• Low testosterone comes with age — Testosterone or "T" levels naturally decrease by 1% each year after age 30, though don’t severely deplete, even in advanced age 
• T production may be disrupted by disorders of the testicles, pituitary gland, or brain 
• T levels change from hour to hour — highest in the morning; lowest at night 
• T levels can temporarily lower due to too much exercise, poor nutrition, severe illness, and with certain medications 
• Normal T levels in adult men should be between 300–1,000 ng/dL (nanograms per deciliter), depending on age and lab used 
• Testosterone must be measured more than once for accurate assessment 

Male hypogonadism is a combination of low testosterone levels and the presence of any of these symptoms: 

• Drop in sex drive (libido) 
• Erectile dysfunction (ED — inability to get or keep an erection) and loss of spontaneous erections 
• Lowered sperm count and infertility (inability to have children) 
• Breast enlargement or tenderness 
• Reduced energy 
• Reduced muscle mass 
• Shrinkage of testes 
• Increased irritability, inability to concentrate, and depressed mood 
• Hot flashes (when testosterone levels are very low) 

Over time, low testosterone may cause a man to lose body hair, muscle bulk, cause weak bones (osteoporosis), low red blood cells and smaller testes. Signs and symptoms (what you see and feel) vary from person to person. 

There are many causes of hypogonadism. They may involve a problem with the testes or with the signal from the brain that controls testosterone secretion. Low testosterone can result from: 

• Testicular injury (trauma, castration) or infection 
• Radiation or chemotherapy treatment for cancer 
• Some medications, such as opiate painkillers and corticosteroids (e.g., steroid injections) 
• Hormone disorders (pituitary tumors or diseases, high levels of prolactin) 
• Chronic diseases, such as liver and kidney disease, obesity, sleep disorders, type 2 diabetes, and HIV/AIDS 
• A genetic condition (Klinefelter syndrome, hemochromatosis, Kallmann syndrome) 
• Anabolic Steroid use  

Improvement of testosterone levels can improve sexual concerns, bone health, muscle and anemia (low red cells in the blood). Hypogonadism can be treated with the use of doctor-prescribed testosterone replacement therapy. This treatment is safe and can be effective for men who are diagnosed with consistently abnormal low testosterone production and symptoms that are associated with this type of androgen (hormone) deficiency. 

Although testosterone replacement therapy is the primary treatment option,  some conditions that cause hypogonadism, such as obesity, can be reversible without testosterone therapy. These should be addressed before testosterone therapy is contemplated. If testosterone therapy is needed, goals of treatment are to improve symptoms associated with testosterone deficiency and maintain sex characteristics.  

There are many different types of testosterone therapy. Method of treatment depends on the cause of low testosterone, the patient’s preferences, cost, tolerance, and concern about fertility. You should discuss the different options with your physician "your partner in care" to find out which therapy is right for you. 

Injections: Self or doctor administered in a muscle every 1–2 weeks; administered at a clinic every 10 weeks for longer-acting. Side effects: uncomfortable, fluctuating symptoms. 

Gels/Solutions: Applied to upper arm, shoulder, inner thigh, armpit. Side effects: may transfer to others via skin contact — must wait to absorb completely into skin. 

Patches: Adhere to skin every day to back, abdomen, upper arm, thigh; rotate locations to lessen skin reaction. Side effects: skin redness and rashes. 

Buccal Tablets: Sticky pill applied to gums twice a day, absorbs quickly into bloodstream through gums. Side effects: gum irritation. 

Pellets: Implanted under skin surgically every 3–6 months for consistent and long-term dosages. Side effects: pellet coming out through skin, site infection/ bleeding (rare), dose decreasing over time and hypogonadism symptoms possibly returning towards the end of dose period. 

Nasal Gel: Applied by pump into each nostril 3x a day. Side effects: nasal irritation or congestion. 

Sometimes a medication called clomiphene citrate is used to treat hypogonadism, but this is not FDA approved for this indication. A thorough discussion is needed with your doctor. 

You should discuss with your physician how to monitor for prostate cancer and other risks to your prostate. Men with known or suspected prostate or breast cancer should not receive testosterone therapy. You should also talk to your doctor about the risks of testosterone therapy if you have, or are at risk for, heart disease or stroke. In addition, if you are planning fertility, you should not use testosterone therapy. 

You should not receive testosterone therapy if you have: 

• Prostate or breast cancer (or suspected) 
• Enlarged prostate causing difficulty with urination 
• Elevated prostate specific antigen (PSA) levels 
• High number of red blood cells 
• Untreated sleep apnea (obstructed breathing during sleep) 
• Planning to have children 
• Heart attack or stroke within the last 6 months 
• Blood clots 

Possible risks of testosterone treatment include: 

• Decreased sperm production  
• A high red blood cell count 
• Acne 
• An increase in prostate size 
• Sleep apnea—the occasional stopping of breathing during sleep (rarely) 

If you are treated with testosterone, your doctor will need to see you regularly, along with blood tests. Testosterone therapy is only recommended for hypogonadism patients. Boosting testosterone is NOT approved by the US Food and Drug Administration (FDA) to help improve your strength, athletic performance, physical appearance, or to treat or prevent problems associated with aging. Using testosterone for these purposes may be harmful to your health. 

There is no firm scientific evidence that long-term testosterone replacement is associated with either prostate cancer or cardiovascular events. The FDA requires that you are made aware that the possibility of cardiovascular events may exist during treatment. Prostate cells are stimulated by testosterone, so be extra vigilant about cancer screenings. African American men over age 45 — especially those with family history of cancer — are already at risk for prostate cancer. 

• What is the cause of my low testosterone? 
• Is testosterone replacement an option for me? 
• When should I get my testosterone level retested? 
• Should I see an endocrinologist or urologist? 
• Do I have hypogonadism? 
• Is the problem with my testes? 
• Is there anything I can do to improve my testosterone levels without taking testosterone therapy? 
• What are the risks and benefits of testosterone therapy? 
• What are the different types of testosterone therapy? 
• What follow up screenings will I need?