Male Hypogonadism: What to Know

Male hypogonadism is a deficiency in the sex hormone testosterone in adult males and male children. Also known as testosterone deficiency or “low T,” male hypogonadism can be caused by conditions affecting the testicles (which produce the hormone in males) or conditions affecting the hypothalamus or pituitary gland (which regulates the production of testosterone).

In adult males, signs of low testosterone include fatigue, irritability, low sex drive, erectile dysfunction, depression, abnormal breast growth, and hot flashes. Low T in boys can cause delayed puberty. In both instances, testosterone replacement therapy is the primary form of treatment.

This article describes the symptoms and causes of male hypogonadism, including how low testosterone is diagnosed and treated in adults and children. It also offers tips on how to manage low testosterone with lifestyle changes and natural remedies.

Male Hypogonadism Symptoms 

Throughout the life of a male, testosterone plays a crucial role in sexual and physical development and function. During puberty, it contributes to growth spurts along with secondary sexual characteristics such as facial hair, increased muscle mass, and the deepening of the voice.

Thereafter, the production of testosterone is essential to libido (sex drive) and the ability to achieve and maintain erections. Testosterone also enhances moods, promotes energy levels, and enhances cognitive skills like memory, reasoning, and alertness.

A drop in normal testosterone, referred to as hypogonadism, can affect all these functions and more.

Physical symptoms of male hypogonadism include:

• Low energy
• Weakness
• Persistent fatigue
• Decreased muscle mass
• Decreased facial and body hair
• Abnormal breast development (gynecomastia)
• Hot flashes

Psychological symptoms of male hypogonadism include:

• Depression
• Difficulty concentration
• Forgetfulness
• Mental fogginess

Sexual symptoms of male hypogonadism include:

Signs of Low Testosterone Based on Age

Because the function of testosterone differs during the stages of life, the impact of hypogonadism can vary based on whether it occurs before, during, or after puberty.

Puberty-Onset Hypogonadism

Signs of hypogonadism at birth are exceptionally rare, affecting 1 of every 5,000 to 10,000 newborn males. Most cases are only recognized during puberty when the lack of testosterone affects sexual and physical development, resulting in delayed puberty.

Puberty is generally considered delayed if physical and sexual changes are not seen by age 14.

Signs of puberty-onset hypogonadism include:

• Smaller stature (although the arms and legs may grow normally and out of proportion to the rest of the body)
• Slowed growth of the penis and testicles
• Slowed development of pubic and facial hair (sometimes with the disproportionate growth of leg and forearm hair)
• Slow deepening (“cracking”) of the voice
• Gynecomastia

If left untreated, puberty-onset hypogonadism may lead to permanent short stature, microorchidism (small testicles), and impaired fertility in some males.

Adult-Onset Hypogonadism

In principle, your testicles should continue to function and produce testosterone from puberty through old age. Though testosterone levels will naturally decline as you age, there will not be the steep decline seen with estrogen levels in females during menopause.

Adult-onset hypogonadism, also known as late-onset hypogonadism, is an abnormal drop in testosterone beyond what would be expected for your age, coupled with the onset of hypogonadal symptoms. The risk increases with age—affecting only 0.1% of males by age 50 but over one of every 20 males by age 70.

In addition to the common signs and symptoms of hypogonadism, persistently low testosterone levels can lead to longer-term complications like:

What Causes Low Testosterone?

The production of testosterone involves a complex interaction between the gonads (testicles in males and ovaries in females), which produce testosterone, and the endocrine system (including the hypothalamus and pituitary gland), which tells the testicles when to produce testosterone.

In males, hypogonadism occurs either because the testicles are not functioning normally or because the hypothalamus and/or pituitary gland are not functioning normally.

Primary Hypogonadism

Primary hypogonadism is caused by a defect of the testicles. The defect can be due to congenital causes (meaning conditions you are born with) and acquired causes (conditions you develop later in life).

Congenital causes of primary hypogonadism include:

Acquired causes of primary hypogonadism include:

Secondary Hypogonadism

Secondary hypogonadism, also known as central hypogonadism or hypogonadotropic hypogonadism, is caused by an injury to the hypothalamus or pituitary gland or the disruption of the hypothalamus-pituitary-adrenal (HPA) axis (a feedback system that directs when hormones are turned on and off).

Congenital causes of secondary hypogonadism include:

• Gonadotropin-releasing hormone (GnRH) deficiency: A genetic disorder that causes low levels of GrRH hormone, which stimulates testosterone production
• Hereditary hemochromatosis: A genetic disorder that causes the accumulation of iron, which can damage the hypothalamus and pituitary gland
• Kallmann syndrome: A genetic disorder affecting the hypothalamus that causes delayed or absent puberty in people of any sex

Acquired causes of secondary hypogonadism include:

• Certain medications: Including corticosteroids, opioids, statins, estrogens, and GnRH analogs that directly or indirectly suppress parts of the HPA axis
• Chronic diseases: Like human immunodeficiency virus (HIV), coronary artery disease, type 2 diabetes, or chronic kidney disease that disrupt communications in the HPA axis
• Excessive exercise: Which increases the production of cortisol, the stress hormone that directly suppresses testosterone production
• Inflammatory diseases: Including sarcoidosis, histiocytosis, and tuberculosis that can directly affect the hypothalamus and pituitary gland
• Metabolic disorders: Like obesity and metabolic syndrome that increase the production of enzymes called aromatase that transform testosterone into estrogen
• Malnutrition: Including severe wasting (cachexia) and eating disorders like anorexia nervosa
• Pituitary tumors: Including benign pituitary adenomas or brain tumors that affect the pituitary gland (including benign meningiomas or cancerous gliomas)

How Male Hypogonadism Is Diagnosed

Male hypogonadism is diagnosed based on low testosterone blood levels and the appearance of symptoms. The process is not always straightforward and may require the input of a hormone specialist known as an endocrinologist to interpret the results.

Physical Exam

The diagnosis of male hypogonadism typically starts with a physical exam and a review of your medical and family histories. This may include a gloved examination of your scrotum, testicles, penis, and breasts.

Some healthcare providers will use a questionnaire called the Androgen Deficiency in Aging Males (ADAM) test to assess the likelihood of hypogonadism based on the following 10 questions (with each “yes” scored as 1 and each “no ” scored as 0):

• Do you have a decreased sex drive?
• Do you have a lack of energy?
• Do you have a decrease in strength or endurance?
• Have you lost height?
• Have you noticed a decreased enjoyment of life?
• Are you sad or grumpy?
• Are your erections less strong?
• Have you noticed a recent deterioration in your ability to play sports?
• Are you falling asleep after dinner?
• Has there been a recent deterioration in your work performance?

While higher scores provide stronger evidence of male hypogonadism, the ADAM test has its limitations and may not be as reliable in males under 50.

Lab Testing

The most important tool for the diagnosis of hypogonadism is the serum testosterone test. This test measures the amount of testosterone in units of nanograms per deciliter of blood (ng/dL). In adult males, the normal range is between 300 and 1,000 ng/dL.

According to guidelines issued by the American Urological Association (AUA). male hypogonadism can be diagnosed when all three of the following conditions are met:

• Two consecutive serum testosterone tests are under 300 ng/dL.
• The blood tests are taken on two separate occasions early in the morning when testosterone levels are at their highest.
• There is at least one symptom of hypogonadism.

For male children, serum testosterone values would need to be adjusted based on their age.

To help narrow the list of causes of hypogonadism, your healthcare provider will order blood tests to measure follicle-stimulating hormone (FSH) and luteinizing hormone (LH). These are hormones produced by the pituitary gland that stimulate the production of sperm cells and testosterone.

When taken together:

• Low testosterone with high FSH and LH levels indicates primary hypogonadism.
• Low testosterone with normal to low FSH and LH indicates secondary hypogonadism.

Based on the findings, other tests may be ordered. These may include a semen analysis and testicular ultrasound to investigate causes of primary hypogonadism, or iron saturation tests and pituitary function tests to investigate causes of secondary hypogonadism.

How Male Hypogonadism Is Treated: Testosterone Replacement Therapy

Testosterone replacement therapy (TRT) is the primary form of treatment for male hypogonadism. TRT is used to normalize testosterone levels with the aim of:

• Improving libido, sexual function, energy levels, well-being, and moods
• Promoting and maintaining secondary male characteristics (virilization)
• Increasing bone density and preventing osteoporosis
• Improving fertility

TRT is available in different forms, including oral tablets, intramuscular injections, implantable pellets, transdermal patches, topical gels, intranasal gels, and under-the-tongue dissolvable films or tablets.

In cases of testicular damage, TRT is the only form of treatment. With congenital disorders or certain chronic diseases, lifelong TRT may be needed. Boys with delayed puberty are typically treated with monthly intramuscular injections for anywhere from three to 12 months.

Depending on the underlying cause, male hypogonadism can sometimes be cured. In other cases, low T may require lifelong management.

Risks and Complications

Despite the potential benefits, there are risks associated with TRT. The risks vary by the dosage, duration of treatment, and method of administration and may include:

TRT is not recommended for people with heart failure as it can worsen the condition. TRT is also avoided in men with untreated prostate or breast cancer as testosterone may stimulate the growth of a tumor.

Most forms of TRT approved by the Food and Drug Administration (FDA) have a negative effect on male fertility and sperm quality.

If a male with low testosterone is trying to raise testosterone and maintain or improve fertility, then fertility-sparing regimens are recommended. Generally, these are with off-label use of drugs such as clomiphene citrate or human chorionic gonadotropin (HCG).

Off-label means using a drug for a purpose other than for which it is approved by the FDA.

Lifestyle Changes and Natural Remedies for Low Testosterone

Although testosterone production will naturally decline with age, testosterone replacement therapy is not always the right solution. Many experts recommend making key lifestyle changes to correct problems that contribute to low testosterone as you get older.

Here are seven lifestyle changes that may help reduce or reverse the risk of hypogonadism:

• Avoid cigarettes and alcohol: Smoking decreases testosterone levels, while excessive alcohol increases the conversion of testosterone to estrogen.
• Avoid opioids: The chronic use of opioid drugs is discouraged. In addition to a high risk of addiction, opioids can rapidly decrease testosterone levels within hours of a dose.
• Exercise routinely: A combination of aerobic and resistance training is known to increase testosterone production. But avoid overtraining which can decrease testosterone levels.
• Get ample sleep: Rapid eye movement (REM) sleep is when the body produces the most testosterone. Getting seven to eight hours of uninterrupted sleep can vastly improve low T levels.
• Maintain an ideal weight: Reducing abdominal fat reduces aromatase levels and, in turn, the conversion of testosterone into estrogen.
• Reduce stress: Stress increases cortisol levels in the same way as excessive exercise. Stress reduction techniques like meditation and deep breathing can counter this effect.
• Try herbal supplements: According to a 2021 review of studies, fenugreek seed extract and ashwagandha root extract have positive effects on testosterone levels. (Even so, half of the reviewed studies were in males under age 40, so the benefits in older males remain uncertain.)

Managing Male Hypogonadism

If you have been diagnosed with male hypogonadism, you may need ongoing care from an endocrinologist to manage the condition. This includes males with congenital causes or who are at risk of osteoporosis, prostate cancer, or heart disease.

Among the considerations:

• Congenital hypogonadism: Males with congenital hypogonadism may require prolonged gonadotropin therapy, sometimes for up to two years, to preserve fertility. Those with small testicles and a history of cryptorchidism tend to be less responsive to fertility treatments.
• Osteoporosis: TRT, along with weight-bearing exercises and osteoporosis drugs, can significantly reduce the risk of hip fractures in males with osteoporosis. While osteoporosis hip fractures are less common in males than females, males are at higher risk of early death if one occurs.
• Prostate cancer: Prior to starting TRT, a prostate-specific antigen (PSA) test should be given to help exclude prostate cancer. Although TRT is avoided in people with untreated prostate cancer, TRT does not increase the risk of prostate cancer.
• Heart disease: While chronic hypogonadism can increase the risk of heart attack and stroke, there remains debate as to whether TRT can trigger these same events in some people. Expert advice is needed. TRT should never be started within six months of a cardiovascular event.

Male vs. Female Hypogonadism

Testosterone is important in people of all sexes. Produced by the ovaries in females, testosterone improves libido and sexual function, enhances cognitive function and moods, and increases bone density, particularly during and after menopause.

Prior to menopause, testosterone levels are 3 times higher than estrogen (although only a fraction of what is seen in males). During and after menopause, testosterone levels can plummet, leading to many of the same sexual, physical, and psychological symptoms seen in males.

Although some experts recommend TRT along with estrogen-replacement therapy for perimenopausal and postmenopausal females, testosterone is not approved for such use in the United States. Even so, testosterone is sometimes prescribed off-label to treat female hypogonadism, albeit with close medical supervision.

Possible risks of TRT in females include endometrial bleeding and masculinizing effects (such as increased facial and body hair and male-pattern baldness). There is also evidence that TRT may increase the risk of hormone-sensitive breast cancers and heart disease. The risk appears to be dose-dependent, meaning that it increases in tandem with higher doses.

Summary

Male hypogonadism is abnormally low testosterone levels in males. Symptoms include fatigue, lack of concentration, low energy, muscle weakness, irritability, depression, low sex drive, erectile dysfunction, and infertility. Hypogonadism in male children can lead to delayed puberty and stunted growth.

Male hypogonadism may be due to the failure of the testicles to produce testosterone (primary hypogonadism) or the failure of the hypothalamus or pituitary gland to regulate the production of testosterone (secondary hypogonadism).

Hypogonadism is diagnosed based on symptoms and a testosterone blood test. Testosterone replacement therapy is the primary form of treatment. Infertile males with secondary hypogonadism may benefit from fertility drugs called gonadotropins.