Male Hypogonadism & Testosterone Deficiency A Practical Guide for Patients & Primary Care Physicians

Author: Dr. Md. Abdul Bari Robel, MBBS, DEM
Diabetes, Thyroid, Obesity & Hormone Specialist

Introduction

Male hypogonadism is a clinical syndrome caused by deficient testosterone production and/or impaired sperm production. Diagnosis requires compatible symptoms together with consistently low morning serum testosterone on repeat testing.

Classification

Type	Laboratory Pattern	Common Causes
Primary	Low testosterone, high LH/FSH	Testicular failure, chemotherapy, orchitis, Klinefelter syndrome
Secondary	Low testosterone, low/normal LH/FSH	Pituitary or hypothalamic disorders, hyperprolactinaemia
Functional	Low testosterone with reversible suppression	Obesity, chronic illness, medications

Symptoms

Sexual	Non-sexual
Reduced libido	Fatigue
Erectile dysfunction	Reduced muscle mass
Infertility	Low bone density
Reduced morning erections	Depressed mood

Diagnostic Algorithm

Symptoms → Morning total testosterone (repeat to confirm if low) → LH/FSH ± prolactin, SHBG (when indicated) → Determine primary vs secondary hypogonadism → Consider pituitary MRI if clinically indicated → Individualized management.

Recommended Investigations

Investigation	Purpose
Morning total testosterone	Confirm biochemical deficiency
LH & FSH	Classify primary vs secondary
Prolactin	Evaluate pituitary disease
SHBG	Interpret testosterone in selected patients
CBC, PSA (appropriate patients), LFT	Baseline before testosterone therapy
Pituitary MRI	Suspected secondary hypogonadism

Testosterone Replacement Therapy

Preparation	Advantages	Monitoring
Gel	Stable levels	Testosterone, hematocrit, PSA as appropriate
Intramuscular injection	Long dosing interval	Assess trough levels and adverse effects
Long-acting injection	Convenient	Regular follow-up

Important Clinical Points

• Do not start testosterone solely on the basis of a single low testosterone result.
• Men wishing to preserve fertility generally should not receive exogenous testosterone as first-line therapy.
• Treat reversible causes such as obesity, sleep apnoea, medications, or systemic illness when possible.

Contraindications (Examples)

Avoid or defer testosterone therapy in men with untreated prostate or breast cancer and evaluate carefully in those with significant erythrocytosis or other guideline-defined contraindications.

References

• Endocrine Society Clinical Practice Guideline: Testosterone Therapy in Men with Hypogonadism.
• American Urological Association Guideline: Testosterone Deficiency.
• European Association of Urology Guidelines on Sexual and Reproductive Health.