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Primary Hypogonadism: Symptoms, Causes, and Treatments

Primary Hypogonadism: Symptoms, Causes, and Treatments

By Mike Kocsis | 7 minutes read | Last updated: November 13, 2023
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    Male hypogonadism is a condition in which your body fails to produce sufficient male sex hormone, testosterone, which plays many crucial roles in the body. It can affect men of any age; however, it is more prevalent in middle to old aged men. Data shows that 35% of men older than 45 years have primary hypogonadism.

    There are two main kinds of hypogonadism: primary hypogonadism and central (secondary hypogonadism). In this article, you will learn everything you need to know about primary hypogonadism, including its signs, causes, and treatments.

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    What is primary hypogonadism?

    It occurs when your testes do not produce testosterone even after receiving signals from the brain. It can be either acquired or congenital.


    Symptoms of primary hypogonadism 

    Hypogonadism signs depend on when the problem develops and the degree of testosterone deficiency.

    If it develops during foetal development, the baby may have the following symptoms even when it is genetically male.

    • Underdeveloped male genitals
    • Female genitals
    • Ambiguous genitals (that appear to be neither male nor female)


    If it develops before adolescence, it may delay puberty or normal body growth. You may experience the following symptoms.

    • Low muscle mass
    • Hindered growth of sex organs
    • Development of breast tissue
    • Long arms and legs
    • Delay in the development of secondary sex characteristics (facial hair growth, voice deepening, etc.)


    If you develop it after puberty, you may experience a few changes to your masculine physical traits and reproductive system. Some common symptoms men with primary hypogonadism experience are:

    • Accumulation of body fat
    • Reduced muscle mass
    • Low bone density
    • Low sperm count
    • Low libido
    • Erectile dysfunction (ED)
    • Infertility
    • Tiredness
    • Low energy level
    • Irritability
    • Depression
    • Concentration difficulty
    • Hot flashes


    What causes primary hypogonadism?

    There are numerous causes of primary hypogonadism, including:


    Genetic disorders

    Men can have abnormal genes by birth leading to certain genetic disorders and primary hypogonadism. Enlisted below are some genetic disorders that cause primary hypogonadism.

    Klinefelter syndrome: It is a condition in which men are born with an extra X chromosome, meaning they are XXY, while normal men are XY. X and Y are sex chromosomes that (when combined) determine the gender of a baby. Girls are XX, and boys are XY.

    The extra X chromosome in Klinefelter men influences their intellectual and physical development. They have broader hips, larger breasts, less body/facial hair, smaller testicles, and low testosterone hormone production.


    Autoimmune disorders

    Autoimmune disorders are conditions in which your body’s immune system, whose function is to attack foreign cells/particles, starts attacking the body’s own healthy cells by mistake. There are more than 100 autoimmune disorders in humans. The following autoimmune disorders cause primary hypogonadism.

    Addison’s disease: It occurs when your immune system attacks your adrenal gland’s cells. When 90% of the adrenal gland gets damaged, it becomes unable to produce essential hormones like aldosterone and cortisol. 

    Sometimes, very long-chain fatty acids (VLCFA) accumulate in your adrenal cortex and testes, resulting in low testosterone synthesis.


    Undescended testes

    It is a congenital disorder in which testes do not fall into the scrotum (their permanent place) from the abdomen during foetal development or after a few months of birth. As a result, they fail to perform their function normally, and you experience low testosterone.



    Mumps orchitis: It occurs due to the mumps virus when it attacks men after puberty. Testicles become painful and swollen. They may also get damaged, leading to a reduction in testicular size and testosterone production.



    Testicles are located outside the abdomen; hence, they are more susceptible to injuries. A minor-to-severe testicular injury can cause serious problems, including low or no testosterone formation.


    Certain diseases

    Hypoparathyroidism: It is an endocrine disease that is caused by mutations in several genes. In this disease, parathyroid glands fail to produce enough parathyroid hormone; as a result, your blood calcium level rises. Hypoparathyroidism also influences the ability of testicles to synthesise testosterone.

    Liver and kidney diseases: These diseases increase the risk of primary hypogonadism in men. Data shows that 44% of men with renal failure have testosterone deficiency.


    Chemotherapy or radiotherapy

    Cancer treatments may also reduce the ability of testicles to produce testosterone and sperm, leading to infertility. However, it is a temporary issue, and most men regain their fertility when the treatment ends.

    Doctors often suggest patients preserve their sperm before starting chemotherapy/radiotherapy.



    Reduction in testosterone levels is a normal part of ageing. Data shows that over 30% of men older than 75 years have low testosterone levels.


    Role of testosterone

    In men, testosterone plays many roles in body, cognitive, and sexual development. Its most prominent effects start when you are about to enter puberty. These effects include the deepening of voice, the appearance of body/facial hair, the development of body odour, and acne.

    Testosterone plays the following critical roles in men.

    Sexual functions

    Cognitive development

    • Influences mood and behaviour (may cause aggression and reduce depression)
    • Improves certain cognitive skills (such as spatial orientation)
    • Maintains a feeling of happiness and well-being

    Body development


    How is primary hypogonadism diagnosed?

    Your doctor will first conduct a physical examination to look for visible signs and symptoms. They will then ask you to have a few blood tests, including hormone tests.

    For a testosterone test, your blood sample will be taken early in the morning when it is at its highest concentration. This test will be conducted two to three times on different days. Healthy men have 300 to 1,000 nanograms of testosterone per deciliter (ng/dL). If your level is below 300 ng/dL, you may have testosterone deficiency.

    He may conduct other tests to rule out other causes. Thyroid hormone levels can influence your testosterone levels. For this reason, your doctor will measure their levels.

    Follicle-stimulating hormone and luteinising hormone levels are also checked to determine whether it is primary hypogonadism or secondary. Your doctor may also check your iron levels, as they can also reduce testosterone production.


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    How to treat primary hypogonadism?

    Testosterone replacement therapy (TRT) is the most commonly used treatment for male hypogonadism. It involves the administration of bioidentical testosterone, helping increase blood testosterone levels.

    TRT offers the following benefits.

    There are many testosterone delivery systems. Your doctor will explain the pros and cons of each system to help you choose the one that best suits your particular condition, lifestyle, and budget. 


    Testosterone Administration

    Topical gels: It is applied directly to the skin once a day. Doctors advise their patients to let the gel dry fully before they have a skin-to-skin contact with others to prevent testosterone transfer. Shoulders, upper arms, and abdomen are the most suitable gel application sites.

    Transdermal patches: It is applied to the skin to provide a steady supply of testosterone. A new patch is applied after 24 hours. It is mostly applied on the back, abdomen, thighs, and upper arms. You should apply a new patch to a different site, as applying it to the same old site can cause skin irritation.

    Intramuscular injections: They are available in the market in different doses. Your doctor will choose the one that suits your current testosterone levels and may adjust your dose from time to time to ensure you get the best possible results.

    Pellets: They are inserted into the skin through a small incision. Doctors usually implant them near the hip and then replace them after 6 months.

    Oral tablets: They are taken 1 to 3 times a day. However, they are not very commonly used compared to the methods mentioned above. It is mainly because of their side effects like bloating, lack of appetite, diarrhoea, and headache.


    Risks associated with TRT

    Like other treatments, TRT also causes side effects. That is why this treatment is not for all. Doctors first take a medical history and conduct certain tests to evaluate your overall health and decide whether to give you testosterone or not.

    Its common side effects are:

    • May worsen your condition if you have a pre-existing prostate cancer
    • May worsen your sleep apnea symptoms
    • May cause congestive heart failure


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    Summing it up

    Primary hypogonadism affects the sexual and physical health of men around the world. If you are suffering from it, you should get timely treatment to improve the quality of your life.

    TRT is the most effective treatment used to reduce signs and symptoms of hypogonadism. Reach out to a hormone specialist to get started with it and improve your overall well-being. 


    References/Bibliography/Scientific studies/Further reading

    Kumar, P., Kumar, N., Thakur, D.S. and Patidar, A., 2010. Male hypogonadism: Symptoms and treatment. Journal of advanced pharmaceutical technology & research1(3), p.297.

    Basaria, S., 2014. Male hypogonadism. The Lancet383(9924), pp.1250-1263.

    FINDLAY, J.C., PLACE, V. and SNYDER, P.J., 1989. Treatment of primary hypogonadism in men by the transdermal administration of testosterone. The Journal of Clinical Endocrinology & Metabolism68(2), pp.369-373. 

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    This article has been researched and written based on scientific evidence and fact sheets that have then been crossed checked by our team of doctors and subject matter experts.

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    About the Author: Mike Kocsis

    Mike KocsisMike Kocsis has an MBA with a focus on healthcare administration and is an entrepreneur and medical case manager for Balance My Hormones Ltd which offers medical services in the UK and Europe. Mike has over 20 years of experience in the healthcare sector, much of that working with people who have hormone imbalances. Mike has appeared on podcasts and radio and is an expert speaker on the subject of hormone imbalance. He specialises in Testosterone Replacement Therapy (TRT) and Hormone Replacement Therapy (HRT) and has helped thousands of people suffering from hormone imbalances recover and regain control of their lives. You can follow him on LinkedIn and on the Balance My Hormones YouTube Channel.

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