What is Male Hypogonadism?

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The male sex hormone testosterone plays many vital roles in the body. Any fluctuation in its normal serum concentration can lead to serious health problems, such as male hypogonadism, with secondary hypogonadism affecting normal testosterone production due to dysfunction in the pituitary or hypothalamus.

This article talks about male hypogonadism in detail. Keep reading to learn about symptoms, types, causes, diagnosis, and treatments of male hypogonadism.

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Introduction to Male Hypogonadism

Male hypogonadism is a medical condition characterised by low levels of testosterone, which can significantly impact a man’s health and quality of life. This condition can be classified into two main types: primary and secondary hypogonadism. Primary hypogonadism occurs when the testes themselves are unable to produce adequate testosterone. In contrast, secondary hypogonadism is due to issues with the pituitary gland or hypothalamus, which are responsible for signalling the testes to produce testosterone.

Testosterone replacement therapy (TRT) is a common treatment for male hypogonadism. TRT aims to restore normal testosterone levels and alleviate symptoms such as erectile dysfunction, low libido, and fatigue. Understanding the causes and symptoms of male hypogonadism is crucial for proper diagnosis and treatment, ensuring that affected individuals can lead healthier, more fulfilling lives.

What is low testosterone (male hypogonadism)?

Male hypogonadism, also called andropause or low serum testosterone, is a condition in which the testes do not produce enough testosterone, sperm or both.

It can affect men of all ages. A person can be born with hypogonadism or develop it later in life due to disease, infection, drug, or injury. Delayed puberty is often a significant indicator of developmental abnormalities associated with hypogonadism. Hypogonadism affects both men and women.

Male hypogonadism symptoms

The symptoms of male hypogonadism largely depend on what life stage you developed the condition:

Hypogonadism during fetal development

If the body of a developing fetus produces insufficient testosterone, its external sex organs will experience impaired growth. A male infant with male sex chromosomes (XY) may be born with an underdeveloped male sex organ, female sex organ, or ambiguous sex organ (that is neither female nor male).

Hypogonadism during puberty

Puberty is when your body matures and you begin the transition into adulthood. Delayed puberty is often a key sign in diagnosing various forms of hypogonadism, providing crucial insights into underlying hormonal imbalances. If a boy develops male hypogonadism during this phase, he may experience the following symptoms.

• Breast enlargement
• Excessive growth of limbs
• Poor growth of the penis
• Poor growth of facial hair
• Increase in the muscle mass

Hypogonadism during adulthood

In adulthood, male hypogonadism can disturb the normal reproductive system and masculine physical traits. Adult men may experience the following symptoms after developing hypogonadism.

• Trouble getting and maintaining an erection
• Low sex drive
• Erectile dysfunction
• Poor sperm production or infertility
• Anxiety and depression
• Hot flashes
• Loss of facial and body hair
• Loss of bone mass
• Decrease in bone density
• Gynecomastia (development of breast tissues)

Primary and secondary hypogonadism

There are two types of hypogonadism: Primary and secondary hypogonadism.

Primary hypogonadism

Primary hypogonadism occurs when the testes are unable to produce sufficient sex hormones, such as testosterone or estrogen, due to a problem within the glands themselves. It is also referred to as primary testicular failure.

Secondary hypogonadism

Secondary hypogonadism occurs when there is a problem with your hypothalamus or pituitary gland (parts of the brain that regulate testosterone production). Elevated prolactin levels should be measured as part of the hormonal evaluation to screen for possible pituitary adenomas, which can contribute to the condition.

Your hypothalamus secretes gonadotropin-releasing hormone. This hormone tells the pituitary gland to release luteinizing hormone (LH) and follicle-stimulating hormone (FSH). LH tells the testes to form and release testosterone.

Both forms of hypogonadism can be congenital (genetic) or acquired (developed during an individual’s life) disorders. Human chorionic gonadotropin can be used as a replacement therapy for luteinizing hormone to stimulate testosterone production and enhance fertility, with dosage adjustments based on hormone level monitoring and semen analysis.

Male hypogonadism causes

The causes of primary and secondary hypogonadism differ from each other.

Causes of primary hypogonadism

Here are a few common causes of primary male hypogonadism.

• Chemotherapy or radiation therapy: These treatments can have a negative impact on testosterone or sperm formation. They can cause permanent infertility.
• 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. Addison’s disease is an autoimmune disorder where 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.
• Ageing: 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.
• 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 the 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.
• Testicle injury: Since testicles are present outside the abdomen, they can get injured due to an accident. Injury to one testicle does not cause hypogonadism, and you may still be able to produce enough testosterone. Damage to both testicles leads to hypogonadism.
• Klinefelter syndrome: It is a genetic disorder in which boys are born with abnormal sex chromosomes. Instead of having normal male sex chromosomes (XY), they have an additional X chromosome (XXY). X and Y are sex chromosomes that determine gender. Men are XY, while females are XX. The presence of an extra X chromosome influences intellectual and physical development.
• Undescended testicles: During fetus development, testes form inside the abdomen of the foetus. After birth, they drop into the scrotum, their normal place. As the name of the disorder indicates, an undescended testicle is a condition whereby the testicles fail to move into the scrotum. It can be treated surgically, but when left unchecked, it can lead to male infertility or no testosterone production.
• Hemochromatosis: If your blood has an abnormally high amount of iron in it, it can cause testicular failure, leading to no testosterone production.

Causes of secondary hypogonadism

Enlisted below are some common causes of secondary hypogonadism.

• Pituitary disorder: Any pituitary disorder, such as a pituitary tumour, can reduce the production of pituitary hormones (LH and FSH) that control testosterone production. The presence of a pituitary tumor can disrupt hormone release, leading to testosterone deficiency. The deficiency of pituitary hormones leads to testosterone deficiency. People who have had testosterone surgery or therapy in their lives may also experience this problem. Pituitary disorders can significantly impact hormone release necessary for testicular function and testosterone production.
• Obesity: Having an abnormally high body weight at any age can reduce free testosterone levels in your bloodstream.
• Medication: Certain medications, like opioids containing pain medications, can decrease testosterone production.
• Ageing: A decline in testosterone production is a natural ageing phenomenon. After age 30, about a 1 per cent reduction in total testosterone levels occurs per year in men.
• Kallmann’s syndrome: It is the abnormal development of the hypothalamus that sends signals to the pituitary gland for the production of LH and FSH. This genetic disorder causes a delay or the absence of puberty.
• Inflammatory illness: Some inflammatory diseases, such as tuberculosis and sarcoidosis,s affect the pituitary gland’s performance. Therefore, they can also contribute to low testosterone levels.

Risk Factors

Male hypogonadism can be influenced by a variety of factors, some of which are beyond one’s control. Genetic disorders, such as Klinefelter syndrome, where an individual has an extra X chromosome, can predispose someone to this condition. Similarly, undescended testicles, a condition where the testes fail to move into the scrotum before birth, can also increase the risk.

Certain medical conditions, including diabetes, obesity, and chronic obstructive pulmonary disease (COPD), are significant risk factors for developing male hypogonadism. Additionally, pituitary gland dysfunction, which affects hormone production, can lead to secondary hypogonadism. Treatments like radiation therapy and chemotherapy, often used for cancer, can also impair testosterone production.

Identifying and managing these risk factors is essential to prevent or delay the onset of male hypogonadism. Regular medical check-ups and a proactive approach to health can make a significant difference.

How is it diagnosed?

Physical exam

Your doctor will ask you to describe your symptoms in detail. Based on your current health condition and described symptoms, they will perform a physical examination. During the exam, they may analyse your breast size, muscle mass, penis growth, and the amount of body hair you have.

Blood tests

These tests are performed to check hormone levels in the blood. It is important to understand that testosterone levels can sometimes fall within the normal range while other hormone levels may be abnormal, which requires a nuanced understanding for proper diagnosis and treatment of hypogonadism. Your LH, FSH, and testosterone levels are measured. If your testosterone levels are low and LH and FSH levels are normal, you may have primary hypogonadism. On the other hand, if your LH and FSH levels are low, it may mean you have secondary hypogonadism.

These tests are typically performed in the morning because your hormone levels are highest at this time.

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Imaging

Imaging tests like CT scans and MRIs are used to identify an abnormality in the pituitary gland. They show whether an individual has a pituitary tumour or not.

Semen analysis

Semen analysis does not directly determine whether you have hypogonadism. Instead, it’s used to build a more complete profile of your hormonal health. Semen analysis measures the quantity and quality of sperm, so if the results are abnormal, it could suggest underlying hormonal issues like hypogonadism.

Treatment

Testosterone replacement therapy (TRT) is used to treat primary male hypogonadism. The use of exogenous testosterone in TRT can effectively address symptoms of testosterone deficiency but may impair spermatogenesis, raising concerns about subsequent fertility outcomes. It comes in different forms, such as:

• Skin patches: They are applied to different body parts. Doctors recommend that their patients apply a skin patch every day.
• Injections: Testosterone injections are usually given every 12 to 14 days. Oral testosterone undecanoate is another convenient TRT option that offers predictable absorption.
• Testosterone gels: It is usually applied to the arms and upper back. Make sure you do not transfer it to others through skin-to-skin contact as medicated gels are typically flammable. Therefore, you should let it fully dry before you go near the fire. Testosterone enanthate is a long-acting injectable treatment option that can help stimulate androgen production and spermatogenesis.
• Pellets: They are the size of a rice grain. They are implanted under the skin. Testosterone pellets have a size equal to a rice grain. They contain crystallised testosterone that is gradually released for up to a few months before a new pellet is implanted. Transdermal testosterone options like gels and patches provide consistent blood levels and are another effective TRT method.

If your hypogonadism is due to a pituitary tumour, your doctor will recommend treatments that can remove or shrink the tumour. These treatments include:

• Medication
• Radiation
• Surgery

Benefits of Testosterone Replacement Therapy

TRT aims to elevate your testosterone levels. It can reverse the effects of low testosterone levels. Millions of men have this treatment every year to restore their testosterone levels and improve their quality of life. Decreased lean body mass is a common outcome of testosterone deficiency, and TRT can help mitigate this issue.

Here are a few Testosterone therapy benefits that people experience.

• It increases bone density and strengthens them.
• It improves your sex drive.
• It helps you gain an erection.
• It improves your mood.
• It reduces body fat and helps you gain lean muscle mass.
• It may improve your memory and cognitive health.

TRT also has some side effects. Talk to your doctor about them to ensure you select the safest treatment plan.

Who should not have TRT?

Testosterone treatment is not for all. People suffering from the following problems should not have this treatment, as it can worsen their condition. Additionally, there are potential risks of cardiovascular events associated with testosterone replacement therapy (TRT), as some studies have raised concerns about TRT increasing the risk of cardiovascular issues.

• Prostate cancer
• Breast cancer
• Severe sleep apnea
• Heart failure

Complications and Related Conditions

Untreated male hypogonadism can lead to several serious complications. One of the most concerning is osteoporosis, a condition where bones become weak and brittle due to decreased bone density. Men with hypogonadism may also experience a reduction in muscle mass and cognitive decline, affecting their overall quality of life.

Additionally, there is an increased risk of developing cardiovascular disease and prostate cancer. Hormone-related disorders, such as erectile dysfunction, low libido, and infertility, are also common among men with hypogonadism. These conditions can significantly impact mental health, leading to anxiety and depression.

Early diagnosis and treatment are crucial to mitigate these risks. Testosterone replacement therapy (TRT) is often used to treat male hypogonadism, helping to restore normal testosterone levels and improve symptoms. However, it is essential to discuss the potential benefits and risks with a healthcare provider to ensure the best possible outcome.

Can male hypogonadism be prevented?

No, there is no possible way to prevent hypogonadism that is caused by injury to the testes/pituitary gland or a genetic abnormality. However, you can improve your lifestyle, regularly exercise, maintain a healthy body weight, eat a balanced diet and manage stress to naturally boost your testosterone levels.

Living with Male Hypogonadism

Living with male hypogonadism requires a comprehensive approach to manage symptoms and prevent complications. Lifestyle modifications play a crucial role in this process. Maintaining a healthy weight through regular exercise and a balanced diet can help manage symptoms and improve overall health. Incorporating stress management techniques, such as meditation and yoga, can also alleviate symptoms of anxiety and depression.

Working closely with a healthcare provider is essential to develop a personalised treatment plan. This plan may include testosterone replacement therapy (TRT) or other medications to manage hormone levels. Regular monitoring of testosterone levels, bone density, and other health parameters is crucial to ensure effective management of the condition.

With proper treatment and lifestyle modifications, men with hypogonadism can lead active and healthy lives. It is important to stay informed and proactive about one’s health, seeking medical advice and support when needed.

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Conclusion

Male hypogonadism is a chronic disease, and it requires life-long treatment. If your hypogonadism is treatable, you should discuss it with your doctor to learn how you can reduce the symptoms of the illness and improve the quality of your life. Click the contact button above to speak to one of our specialised TRT doctors and discuss your options!

References/Bibliography/Further Reading/Scientific Studies

https://www.nih.gov/news-events/nih-research-matters/understanding-how-testosterone-affects-men

https://www.healthline.com/health/low-testosterone/warning-signs

Nedresky, D. and Singh, G., 2021. Physiology, luteinizing hormone. In StatPearls [Internet]. StatPearls Publishing.

Corona, G., Rastrelli, G. and Maggi, M., 2013. Diagnosis and treatment of late-onset hypogonadism: systematic review and meta-analysis of TRT outcomes. Best Practice & Research Clinical Endocrinology & Metabolism, 27(4), pp.557-579.

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