Male Hypogonadism (Low Testosterone)

Low testosterone, also known as male hypogonadism, occurs when the body doesn’t produce enough of the sex hormone, testosterone, responsible for regulating male sexual function, bone density, muscle mass, mood, and even the growth of body hair. When testosterone levels drop below normal, it can significantly impact a man’s physical health, emotional wellbeing, and overall quality of life.

Some men are born with hypogonadism, while others develop it later in life due to injury, illness, or conditions that affect the testicles or parts of the brain that control hormone production – the pituitary gland and hypothalamus. Testosterone levels also naturally decline with age. Late-onset hypogonadism is often linked to chronic conditions such as Type 2 diabetes, obesity, and metabolic syndrome.

Doctors may check for low testosterone when a patient presents with symptoms such as erectile dysfunction, reduced libido, fatigue, depression, loss of muscle mass, or osteoporosis.

Treatment depends on the underlying cause and the stage of life at which it occurs. In many cases, testosterone replacement therapy (TRT) can help restore hormone levels and improve both physical and emotional symptoms.

What is testosterone?

Testosterone is the main sex hormone (androgen) found in both men and women and is
secreted by the gonads: testes in men, and by the ovaries in women (albeit in much smaller
amounts). The production of testosterone is controlled by the hypothalamus in the brain and
pituitary gland (a small gland at the base of the brain). Too little, or too much, testosterone can affect our physical and mental health.

In men, testosterone helps develop and maintain:

• the sex organs and genitalia
• sexual and reproductive function
• sperm production
• bone health
• adequate levels of red blood cells
• muscle mass
• typical male characteristics, such as facial and body hair and deepening of the voice

Testosterone increases significantly in puberty and tapers off from about age 30.
Testosterone, or “T” levels, naturally decrease by around 1% each year after age 30, but never
deplete completely, even as you age.

Normal testosterone (T) levels
This is the range for normal male testosterone levels, according to SA-based Ampath Laboratories.

* The lab machines used to test blood.
Total testosterone: overall testosterone in your blood.
Free testosterone: testosterone that is active in the body and can be used.

Low testosterone (T) levels
Doctors typically assess both hormone levels and symptoms before diagnosing male hypogonadism. In adult men, low testosterone may be a sign of pituitary gland dysfunction, which affects hormone regulation. In adolescents, low testosterone can result in delayed puberty.

High T levels
For children – both boys and girls – excessively high testosterone levels may bring on early puberty. In adult women, high testosterone levels may cause the development of masculine features, and also may be a sign of polycystic ovarian syndrome.

Is testosterone a steroid?

Natural testosterone is a steroid, referred to as an anabolic-androgenic steroid. “Anabolic” relates to increased muscle size and “androgenic relates to the development of male characteristics, namely body hair, the genital organs and muscle mass.

When you hear the term “anabolic steroids”, it’s generally referring to lab-made variations of testosterone injected into the body.

What is male hypogonadism?

Male hypogonadism is when men produce too little testosterone.

Types of male hypogonadism:

1. Primary hypogonadism. This comes from a problem in the testicles. It’s also known as primary testicular failure.
2. Secondary hypogonadism. This comes from a problem in the hypothalamus or the pituitary gland, the parts of the brain that signal the testicles to produce testosterone. Primary and secondary hypogonadism can occur together.
3. Late-onset or adult-onset hypogonadism. This has elements of both primary (testicular failure) and secondary (pituitary or hypothalamic failure) hypogonadism. It develops as men age. It’s more common in men who are obese, or if they have Type 2 diabetes, metabolic syndrome, cardiovascular diseases, HIV, or cancer.

Symptoms

Signs and symptoms of low testosterone can begin in utero, during childhood or adulthood.

Adulthood

In adult men, the signs of male hypogonadism is low testosterone levels (diagnosed through testing), as well as any of these symptoms (they may differ from person to person):

• Low sex drive (libido)
• Erectile dysfunction (ED) – the inability to get or keep an erection, and loss of spontaneous erections
• Reduced testicle size
• Lowered sperm count
• Less semen
• Infertility
• Breast enlargement or tenderness
• Less energy
• Reduced muscle mass
• Reduced bone mass
• Shrinking testicles
• Increased body fat
• Sleep disturbance
• Mild anaemia
• More irritability, difficulty concentrating, and depressed mood
• Hot flushes (when testosterone levels are very low)

Over time, low testosterone may cause:

• Loss of armpit and pubic hair
• Low red blood cells and smaller testes

Puberty

Low testosterone in boys can delay puberty or cause abnormal development. It can hamper:

• Development of muscle mass
• Voice deepening
• Growth of body and facial hair
• Growth of the penis and testicles
• Strength and endurance
• Growth in height, but possibly with overly long limbs

And it can also cause the:

• Development of breast tissue

Foetal development

If the body doesn’t produce enough testosterone during foetal development, it can impair the growth of the external sex organs. This can result in a male baby being born with:

• underdeveloped male genitals
• genitals that are neither clearly male nor clearly female (ambiguous genitals)
• female genitals

Low testosterone and fertility
Low testosterone does not cause infertility, but rather it’s a symptom of an underlying fertility
issue like shrinking of the testes.

Causes

The causes of primary and secondary hypogonadism are either congenital (at birth) or acquired,
which means that it developed in childhood or adulthood.

1. Primary hypogonadism (problems in the testicles)

2. Secondary hypogonadism (problems with the pituitary gland/hypothalamus)

Risk Factors

Risk factors for low testosterone includes:

• Age – its more common in older men
• Obesity
• Type 2 diabetes
• Chronic medical conditions, such as kidney dysfunction or cirrhosis of the liver
• HIV/AIDs
• Previous chemotherapy or radiation therapy

Complications

The complications for low testosterone differ depending on whether it develops in adulthood, at puberty or in utero. These may include:

• Enlarged male breasts
• Infertility
• Erectile dysfunction
• Osteoporosis
• Abnormal genitalia
• Poor self-image

How is it diagnosed?

Diagnosing hypogonadism can be complex: before being able to give a diagnosis, healthcare providers will have to do a series of blood tests and exclude all the other possible causes for your symptoms.

To determine the cause and confirm low testosterone, doctors will do a physical exam, take a medical history and order the following blood tests:

• Total testosterone (TT) level blood test: It measures both free and attached testosterone. This test is done in the morning, when testosterone levels are usually at their highest. Usually, two samples are required.
• Luteinizing hormone (LH) blood test: This tests if there is an issue with the pituitary gland.
• Prolactin blood test: High prolactin levels may be a sign of pituitary gland issues or tumours.

Testosterone levels when diagnosing late onset/adult-onset hypogonadism

* The Roche and Beckman platforms are lab machines used to test blood.

• Total testosterone: overall testosterone in your blood.
• Free testosterone: testosterone that is active in the body and can be used.

Once low testosterone is confirmed, the doctor may order more tests to determine the cause. This could include:

• Hormone testing
• Semen analysis
• Pituitary imaging
• Genetic studies
• Testicular biopsy
• Bone density test

Treatment

The main treatment for low testosterone is testosterone therapy, which is used to improve the symptoms associated with low testosterone and maintain sex characteristics.

There are various forms of testosterone therapy, and the doctor will determine which method is best based on the cause, the man’s concern for fertility, preferences and availability in SA:

• Intramuscular testosterone injections:
  • Short-acting: self-administered injection into the muscle every 1 to 2 weeks.
  • Longer-acting: healthcare provider-administered injection into the muscle every 10 weeks; its gradually released over a period of time.
• Testosterone skin gels/solutions. The gel is applied directly onto the skin of the upper arm, shoulder or inner thigh every day. It can transfer to others via the skin, so one would have to wait till it’s completely dry before touching someone.
• Testosterone pellets or implants. These are surgically implanted under the skin every three to six months.
• Testosterone patches. The patches can be put on the back, abdomen or arm.
• Buccal testosterone tablets. These sticky tablets are applied to the gums twice a day, where its absorbed quickly into the bloodstream.
• Nasal gel. This is applied into the nostril three times a day.
• Oral testosterone. This is testosterone in tablet form and is usually given to those who have low testosterone caused by medical conditions such as Klinefelter syndrome or damaged pituitary glands.

For anyone on some form of testosterone therapy, you will need regular checkups with your doctor, as well as blood tests, to monitor your condition.

Before starting any testosterone treatment, you will have to do prostate screening. You will not receive testosterone replacement therapy if you have:

• Prostate cancer
• An unevaluated lump on your prostate.
• Breast cancer
• Uncontrolled heart failure

Testosterone therapy is not recommended if you have:

• Prostate or breast cancer (or suspected)
• Elevated prostate specific antigen (PSA) levels
• High number of red blood cells
• Untreated sleep apnea
• Heart attack or stroke within the last 6 months
• Blood clots
• Plans to have children

IMPORTANT NOTE: Testosterone therapy is only recommended for hypogonadism patients.

Lifestyle changes to raise testosterone levels

The following lifestyle changes can help raise T levels, however, with factors like age, you may not be able to prevent low testosterone completely:

• Lose weight: As body fat increases, levels of aromatase (an enzyme necessary for sperm synthesis) begin to rise. Too much aromatase causes testosterone levels to drop below the normal value for your age. For those who are overweight (a BMI of 25 or over) or obese, studies have shown that for every one-point drop in your BMI, your testosterone levels can rise by as much as one point.
• Exercise: A combination of aerobic (high intensity) exercises and resistance/ weight training (working larger muscles) has been shown to increase testosterone production.
• Manage stress: Long-term stress can lower your testosterone. Research has shown that a sudden rise in the levels of the hormone cortisol (released under stress) can quickly reduce testosterone.
• Get good quality sleep. Poor sleep has been linked to lower testosterone levels, so get in at least 7 hours of sleep a night. Sleep deprivation has also been linked to chronically high cortisol (see point above).
• Watch your alcohol intake. When you drink alcohol, your testosterone levels can drop as quickly as 30 minutes thereafter. Some research has shown that excessive alcohol consumption can decrease testosterone levels. Heavy alcohol use can also lead to reduced testicular function and even shrinking of the testes.
• Avoid endocrine disruptors (chemicals which disrupt hormones). Try to minimise daily exposure to endocrine disruptors – such as parabens and bisphenol-A (BPA) – which may affect testosterone levels. Parabens are commonly found in shampoos, conditioners, lotions and facial and shower cleansers, and BPA and phthalates are commonly found in plastics. Use products labelled “paraben-free” and “BPA-free”.
• Supplement, if necessary. Vitamin D and zinc are two important micronutrients that support healthy testosterone levels. Get regular sun exposure or consider vitamin D supplementation. Zinc supplements have also been found to increase testosterone levels, especially for those with testosterone deficiency.

Living and managing

• Lifestyle changes, such as losing weight, exercising, and avoiding alcohol, can boost your testosterone levels, but it may not work for everyone.
• If you’re on testosterone therapy, you will need regular follow-ups with your doctor.
• Male hypogonadism can affect your self-image and your relationships. If you’re dealing with anxiety related to this condition or if you’re having relationship problems, speak to your healthcare provider about personal therapy or family counselling.