What is Male Hypogonadism?

Male hypogonadism is a condition where the body doesn't produce enough testosterone, the primary male sex hormone. Testosterone is essential for male development, sexual function, muscle mass, bone density, and overall well-being.

Types of Hypogonadism:

Primary Hypogonadism (Testicular Failure):

• Problem is in the testicles themselves
• Causes: Klinefelter syndrome, mumps orchitis, testicular injury, chemotherapy/radiation, aging
• Labs: Low testosterone, HIGH LH/FSH (brain trying to stimulate testes)

Secondary (Central) Hypogonadism:

• Problem is in the pituitary gland or hypothalamus (brain signals)
• Causes: Pituitary tumors, medications (opioids, steroids), obesity, sleep apnea, chronic illness, Kallmann syndrome
• Labs: Low testosterone, LOW or normal LH/FSH

Symptoms:

Sexual/Reproductive:

• Decreased libido (sex drive)
• Erectile dysfunction
• Infertility (low sperm count)
• Reduced testicular size

Physical:

• Decreased muscle mass and strength
• Increased body fat (especially abdominal)
• Reduced body and facial hair
• Gynecomastia (breast enlargement)
• Bone loss (osteoporosis)

Psychological/Cognitive:

• Fatigue, low energy
• Depression, irritability
• Difficulty concentrating, "brain fog"
• Hot flashes (in severe cases)

Diagnosis:

Lab Testing (must confirm with 2 morning tests):

• Total Testosterone: <300 ng/dL (morning, fasting) on two separate occasions
• Free or Bioavailable Testosterone: More accurate if SHBG is abnormal
• LH and FSH: Determine primary vs. secondary
• Prolactin: Rule out prolactinoma
• Additional: TSH, CBC, PSA (in older men), semen analysis (if fertility concerns)

Imaging (if secondary hypogonadism):

• MRI of pituitary to rule out tumor

Treatment: Testosterone Replacement Therapy (TRT)

Formulations:

• Injections: IM testosterone cypionate or enanthate (every 1-2 weeks or weekly)
• Topical Gels: Daily application to shoulders/upper arms (AndroGel®, Testim®)
• Transdermal Patches: Daily application
• Pellets: Subcutaneous implants lasting 3-6 months
• Nasal Gel: Natesto® (3x daily)
• Oral: Jatenzo® (newer formulation)

Goals of Treatment:

• Restore testosterone to mid-normal range (400-700 ng/dL)
• Improve symptoms: energy, libido, mood, muscle mass
• Maintain bone density

Who Should NOT Take TRT:

• Men trying to father children (TRT suppresses sperm production)
• Prostate cancer or high PSA
• Severe untreated sleep apnea
• Severe heart failure
• Elevated hematocrit (>50%)

Monitoring on TRT:

• Labs (3-6 months, then annually): Testosterone, hematocrit, PSA (in men >40), lipid panel, liver function
• Symptom assessment: Libido, mood, energy
• Side Effects to Watch: Acne, fluid retention, worsening sleep apnea, mood changes, elevated red blood cells

Fertility Preservation:

If fertility is desired, alternatives to TRT include:

• hCG (Human Chorionic Gonadotropin): Stimulates testosterone AND sperm production
• Clomiphene or Enclomiphene: Increases LH/FSH to boost natural testosterone
• Sperm banking before starting TRT