Low Testosterone

Male Hypogonadism

All men undergoing fertility testing will be checked for hormonal imbalances that could be contributing to their infertility. One important hormone necessary for proper sexual functioning in men is testosterone. When a man is found to have a testosterone deficiency, it can signal a common disorder known as hypogonadism.

Definition

Male hypogonadism is a condition in which the body doesn't produce enough of the sex hormone testosterone. As many as 5 million men in the United Sates may not produce enough testosterone — the hormone that plays a key role in masculine growth and development during puberty.

Testosterone's effects begin after conception, stimulating the formation of male sex organs. The hormone continues to play an important role through puberty and adulthood by triggering male characteristics and maintaining sex drive.

You may be born with hypogonadism, or it can develop later in life from injury or infection. The effects — and what you can do about them — depend on the cause and at what point in your life hypogonadism occurs.

During fetal development, low testosterone can cause incomplete formation of sex organs. Low testosterone levels before puberty can permanently affect growth and development. After puberty, the development of hypogonadism is more likely to cause temporary problems that may improve with treatment. Some types of hypogonadism can be treated with testosterone replacement therapy.

What Does Testosterone Do?

Testosterone, often referred to as the male hormone although females do produce small amounts of the hormone as well, is a hormone that is produced in the testicles. It is responsible for the growth and development of the sex and reproductive organs in men. Additionally, testosterone contributes to the deepening of a man’s voice during puberty, fat distribution, and bone mass. Testosterone also helps to keep a man’s energy levels up as well as encourage his sex drive and fertility.

Much like women, whose production of estrogen and progesterone taper off as they age, testosterone levels begin to decline as a man gets older. These naturally-occurring low testosterone levels can contribute to a decreased sex drive in older men. Yet, low testosterone levels earlier in life are not natural and can produce many unwanted physical changes, including infertility. A common culprit for these falling testosterone levels: hypogonadism.

Symptoms

Hypogonadism can occur during fetal development, puberty or adulthood. Depending on when it develops, the signs and symptoms differ.

Fetal Development

If the body doesn't produce enough testosterone during fetal development, growth of external sex organs may be impaired. Depending at when it develops, and how much testosterone is present, a child that is genetically male may be born with:

  • Female genitals

  • Ambiguous genitals (genitals that are neither clearly male or female)

  • Underdeveloped male genitals

Puberty

During puberty, male hypogonadism may slow growth and affect development. It can cause:

  • Decreased development of muscle mass

  • Lack of deepening of the voice

  • Impaired growth of body hair

  • Impaired growth of the penis and testicles

  • Excessive growth of the arms and legs in relation to the trunk of the body

  • Development of breast tissue (gynecomastia)

Adulthood

In adult males, hypogonadism may alter certain masculine physical characteristics and impair normal reproductive function. Signs and symptoms may include:

  • Erectile dysfunction

  • Infertility

  • Decrease in beard and body hair growth

  • Increase in body fat

  • Decrease in size or firmness of testicles

  • Decrease in muscle mass

  • Development of breast tissue (gynecomastia)

  • Loss of bone mass (osteoporosis)

Hypogonadism can also cause mental and emotional changes. As testosterone decreases, some men may experience symptoms similar to those of menopause in women. These may include:

  • Fatigue

  • Decreased sex drive

  • Difficulty concentrating

  • Hot flashes

  • Irritability

  • Depression

Causes

Testosterone Binding [T = testosterone; SHBG = sex-hormone-binding globulin. Source: Braunstein GD. Testes. In: Basic & Clinical Endocrinology. 5th ed. Stamford, CT: Appleton & Lange; 1997:403-433.]

Male hypogonadism means the testicles don't produce enough of the male sex hormone testosterone. There are two basic types of hypogonadism:

  • Primary. This type of hypogonadism — also known as primary testicular failure — originates from a problem in the testicles.

  • Secondary. This type of hypogonadism indicates a problem in the hypothalamus or the pituitary gland — parts of the brain that signal the testicles to produce testosterone. The hypothalamus produces gonadotropin-releasing hormone, which signals the pituitary gland to make follicle-stimulating hormone (FSH) and luteinizing hormone. Luteinizing hormone then signals the testes to produce testosterone.

Either type of hypogonadism may be caused by an inherited (congenital) trait or something that happens later in life, such as an injury or an infection (acquired).

Primary Hypogonadism

Common causes of primary hypogonadism include:

  • Klinefelter 's Syndrome This condition results from a congenital abnormality of the sex chromosomes, X and Y. A male normally has only one X and one Y chromosome. In Klinefelter's syndrome, two or more X chromosomes are present in addition to one Y chromosome. The Y chromosome contains the genetic material that determines the sex of a child and related development. The extra X chromosome that occurs in Klinefelter's syndrome causes abnormal development of the testicles, which in turn results in underproduction of testosterone.

  • Undescended Testicles Before birth, the testicles develop inside the abdomen and normally move down into their permanent place in the scrotum two months before birth. One or both of the testicles may not be descended at birth. This condition often corrects itself within the first few years of life without treatment. If not corrected in early childhood, it may lead to malfunction of the testicles and reduced production of testosterone.

  • Mumps Orchitis If a mumps infection involving the testicles in addition to the salivary glands (mumps orchitis) occurs during adolescence or adulthood, long-term testicular damage may occur. This may affect normal testicular function and testosterone production.

  • Hemochromatosis Too much iron in the blood can cause testicular failure or pituitary gland dysfunction affecting testosterone production.

  • Injury to the testicles. Because of their location outside the abdomen, the testicles are prone to injury. Damage to normally developed testicles can cause hypogonadism. Damage to one testicle may not impair testosterone production.

  • Cancer Treatment Chemotherapy or radiation therapy for the treatment of cancer can interfere with testosterone and sperm production. The effects of both treatments often are temporary, but permanent infertility may occur. Although many men regain their fertility within a few months after treatment ends, preserving sperm before starting cancer therapy is an option that many men consider.

  • Normal Aging Older men generally have lower testosterone levels than younger men do. As men age, there's a slow and continuous decrease in testosterone production. The rate that testosterone declines varies greatly among men. As many as 30 percent of men older than 75 have a testosterone level that's below normal.

Secondary Hypogonadism

  • In Secondary Hypogonadism the testicles are normal but function improperly due to a problem with the pituitary or hypothalamus. A number of conditions can cause secondary hypogonadism, including:

  • Kallmann Syndrome Abnormal development of the hypothalamus — the area of the brain that controls the secretion of pituitary hormones — can cause hypogonadism. This abnormality is also associated with impaired development of the ability to smell anosmia.

  • Pituitary Disorders An abnormality in the pituitary gland can impair the release of hormones from the pituitary gland to the testicles, affecting normal testosterone production. A pituitary tumor or other type of brain tumor located near the pituitary gland may cause testosterone or other hormone deficiencies. Also, the treatment for a brain tumor such as surgery or radiation therapy may impair pituitary function and cause hypogonadism.

  • Inflammatory Disease Certain inflammatory diseases such as sarcoidosis, histiocytosis, tuberculosis and some fungal infections involve the hypothalmus and pituitary gland and can affect testosterone production, causing hypogonadism.

  • HIV/AIDS This virus can cause low levels of testosterone by affecting the hypothalamus, the pituitary and the testes.

  • Medications The use of certain drugs, such as opiate pain medications and some hormones, can affect testosterone production.

  • Obesity Being significantly overweight at any age may be linked to hypogonadism

Risk Factors

Risk factors for hypogonadism include:

  • Kallmann syndrome

  • Undescended testicles as an infant

  • Mumps infection affecting your testicles

  • Injury to your testicles

  • Testicular or pituitary tumors

  • HIV/AIDS

  • Klinefelter's syndrome

  • Hemochromatosis

  • Previous chemotherapy or radiation therapy

Hypogonadism can be inherited. If any of these risk factors are in your family health history, inform your doctor. Be aware of and watch for signs and symptoms of hypogonadism.

Complications

The complications of untreated hypogonadism differ depending on what age it first develops — during fetal development, puberty, or as an adult.

Fetal development. If hypogonadism begins during fetal development, a baby may be born with ambiguous or abnormal genitalia.

Puberty. If hypogonadism develops before puberty, a lack of body hair and impaired penis and testicle growth may occur.

Adult. Infertility, erectile dysfunction, decreased sex drive, fatigue, muscle loss or weakness, enlarged male breasts, decreased beard and body hair growth, and osteoporosis are possible complications of hypogonadism in adults.

Tests And Diagnosis

Your doctor may test your blood level of testosterone if you have any of the signs or symptoms of hypogonadism. Early detection in boys can help prevent problems from delayed puberty. Early diagnosis and treatment in men offers better protection against osteoporosis and other related conditions.

Doctors base a diagnosis of hypogonadism on symptoms and results of blood tests that measure testosterone levels. Because testosterone levels vary and are generally highest in the morning, blood testing is usually done early in the day.

If tests confirm you have low testosterone, further testing can determine if a testicular disorder or a pituitary abnormality is the cause. Based on specific signs and symptoms, additional studies can pinpoint the cause. These studies may include:

  • Hormone testing

  • Semen analysis

  • Pituitary imaging

  • Genetic studies

  • Testicular biopsy

Testosterone testing also plays an important role in managing hypogonadism. This helps your doctor determine the right dosage of medication, both initially and over time.

Treatment

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