Male hypogonadism

Overview

Male hypogonadism is a condition in which the body doesn't make enough of the hormone testosterone or enough sperm or both. Testosterone plays a key role in male growth and maturing during puberty.

People can be born with male hypogonadism. Or it can start later in life, often from injury or infection. The cause of the condition and when it starts affect what can be done about it. Testosterone replacement therapy can treat some types of male hypogonadism.

Symptoms

Hypogonadism can begin in the womb, before puberty or during adulthood. Symptoms depend on when the condition starts.

In the womb

If a baby's body doesn't make enough testosterone while in the womb, it can affect the outer sex organs. Depending on when hypogonadism starts and how much testosterone there is, a baby whose genes are male may be born with:

• Female genitals.
• Genitals that are neither clearly male nor clearly female, called ambiguous genitals.
• Male genitals that don't develop fully.

Puberty

Male hypogonadism that occurs in the first 10 years of life can delay puberty or cause incomplete or lack of usual development. It can get in the way of:

• Muscle mass growth.
• The voice getting deeper.
• Growth of body and facial hair.
• Growth of the penis and testicles.

And it can cause:

• The arms and legs to grow more than the trunk of the body.
• Growth of breast tissue, called gynecomastia.

Adulthood

In adults, hypogonadism can change certain physical traits and affect the ability to have children. Early symptoms might include:

• Less sex drive.
• Less energy.
• Depression.

Over time, men with hypogonadism can have:

• Difficulty getting and keeping an erection, called erectile dysfunction.
• Problems having children, called infertility.
• Less hair growth on the face and body.
• Less muscle mass.
• Growth of breast tissue, called gynecomastia.
• Loss of bone mass, called osteoporosis.

Severe hypogonadism also can cause mental and emotional changes. As testosterone decreases, some men have symptoms like those of menopause. These can include:

• Trouble focusing.
• Hot flashes.

When to seek help

Make a medical appointment if you have symptoms of male hypogonadism. Finding the cause of hypogonadism is an important first step to getting the right treatment.

Causes

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

• Primary. This type of hypogonadism comes from a problem in the testicles. It's also called primary testicular failure.
• Secondary. This type of hypogonadism means there's a problem in the parts of the brain that tell the testicles to make testosterone. These parts of the brain are the hypothalamus and the pituitary gland.

  The hypothalamus makes gonadotropin-releasing hormone, which signals the pituitary gland to make follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Luteinizing hormone then tells the testes to make testosterone.

A trait passed through families, also called inherited, can cause either type of hypogonadism. Something that happens later in life, such as an injury or infection, also can cause either type. This is called acquired hypogonadism. At times, primary and secondary hypogonadism occur together.

Primary hypogonadism

Common causes of primary hypogonadism include:

• Klinefelter syndrome. This condition results from a problem of the sex chromosomes X and Y. It's present at birth, called congenital. A male typically has one X and one Y chromosome. In Klinefelter syndrome, there are two or more X chromosomes plus one Y chromosome.

  The Y chromosome holds the genes that controls the sex of a male child and how the child develops. The extra X chromosome in Klinefelter syndrome causes unusual growth of the testicles. This results in too little testosterone.

• Testicles that don't move into place, called undescended. Before birth, the testicles develop inside the belly and move down into their place in the scrotum. Sometimes one or both testicles haven't moved into place by birth.

  This condition often fixes itself within the first few years of life. If not fixed in early childhood, it can cause the testicles not to work correctly or make enough testosterone.

• Mumps orchitis. A mumps infection as a teenager or as an adult can harm the testicles.
• Hemochromatosis. Too much iron in the blood can cause the testicles to fail or the pituitary gland not to work as it should.
• Injury to the testicles. Because they're outside the belly, the testicles can be injured easily. Harm to both testicles can cause hypogonadism. If one testicle is harmed or removed, the other will take over and make the testosterone that's needed.

• Cancer treatment. Chemotherapy or radiation therapy to treat cancer can affect how well the body makes testosterone and sperm. The effects of both treatments often are short-lived. But they can cause lifelong inability to have children.

  Many men get their fertility back within a few months after treatment. But storing sperm before starting cancer therapy is an option for those who want to have children.

Secondary hypogonadism

In secondary hypogonadism, the testicles look typical but don't work the way they should due to a problem with the pituitary or hypothalamus. Several conditions can cause secondary hypogonadism, including:

• Kallmann syndrome. This is an unusual development of the area of the brain called the hypothalamus, which controls the pituitary hormones. This problem also can affect the ability to smell, called anosmia. And it can cause red-green color blindness.

• Pituitary conditions. A condition in the pituitary gland can keep hormones from going from the pituitary gland to the testicles. This affects the making of testosterone. A pituitary tumor or other type of brain tumor near the pituitary gland can cause there to be too little of the hormones needed to spur the making of testosterone and sperm.

  Also, treatment for a brain tumor, such as surgery or radiation therapy, might affect the pituitary gland and cause hypogonadism.

• Inflammatory disease. Certain diseases that cause the immune system to attack healthy tissue, called inflammatory, can affect the making of testosterone. Examples are sarcoidosis, histiocytosis and tuberculosis.
• HIV/AIDS. HIV/AIDS can cause low levels of testosterone by affecting the hypothalamus, the pituitary and the testes.
• Medicines. The use of certain medicines, such as opiates for pain and some hormones, can affect testosterone levels.
• Obstructive sleep apnea. If untreated, this sleep-related breathing condition can cause hypogonadism. The hypogonadism might improve after sleep apnea treatment.
• Obesity. Being significantly overweight at any age might be linked to hypogonadism.
• Aging. Testosterone levels lessen with age. How fast they go down varies from person to person.

Risk factors

Risk factors for hypogonadism include:

• HIV/AIDS.
• Having had chemotherapy or radiation therapy.
• Aging.
• Obesity.
• Not having a good diet, called malnutrition.
• Obstructive sleep apnea.

Hypogonadism can be passed through families, called inherited. If any of these risk factors are in your family health history, tell a member of your healthcare team.

Complications

The complications of untreated hypogonadism differ depending on whether it starts in the womb, at puberty or in adulthood.

Complications might include:

• Unusual genitals.
• Growth of breast tissue, called gynecomastia.
• Not being able to have children, called infertility.
• Not being able to get or keep an erection, called erectile dysfunction.
• The bone-weakening disease called osteoporosis.
• Poor self-image.

Diagnosis

Finding male hypogonadism in childhood can help prevent problems from delayed puberty. Early diagnosis and treatment in men helps protect against osteoporosis and other conditions.

A member of your healthcare team does a physical exam and looks at your sexual maturing. This is to see if your pubic hair, your muscle mass and the size of your testes are typical for your age.

Blood tests can show testosterone levels. Testosterone levels are most often highest in the morning. So blood testing is usually done between 8 and 10 a.m. It might be done on more than one day.

If tests show low testosterone, further testing can help find the cause. These studies might include:

• Pituitary hormone testing.
• Semen analysis.
• Pituitary imaging.
• Gene studies.

Treatment

Adults

Testosterone replacement can raise testosterone levels and help ease the symptoms of male hypogonadism. These include less desire for sex, less energy, less facial and body hair, and loss of muscle mass and bone mass.

For older adults who have low testosterone and symptoms of hypogonadism due to aging, it's less clear how well testosterone replacement works.

Anyone taking testosterone replacement should have a medical checkup and blood tests several times during the first year of treatment and yearly after that. This is to see how well the treatment works and to watch for side effects.

Types of testosterone replacement therapy

Testosterone taken by mouth, also called oral, isn't often used for treatment of hypogonadism. Oral testosterone can cause serious liver problems. And it doesn't keep testosterone levels even.

The U.S. Food and Drug Administration has approved one oral testosterone replacement, testosterone undecanoate (Jatenzo, Tlando, Kyzatrex). The lymph system absorbs it, so it might not cause the liver problems seen with other oral forms of testosterone. It's not used to treat hypogonadism caused by aging.

Other forms you might choose can depend on how easy they are to get and use, how much they cost, and whether insurance covers them. They include:

• Gels. There are several available with different ways of applying them. Depending on the brand, you rub the testosterone into your skin on your upper arm or shoulder (AndroGel, Testim, Vogelxo) or apply it to the front and inner thigh (Fortesta).

  The body soaks in testosterone through the skin. Don't shower or bathe for several hours after a using a gel to give it time to soak in.

  Side effects include skin irritation and, if someone touches you, having the medicine get on someone else. Don't let your skin touch anyone until the gel is fully dry. Or cover the area after putting on the gel.

• Shot. Testosterone cypionate (Depo-Testosterone) and testosterone enanthate (Xyosted) are given in a muscle or under the skin. Symptoms might vary between doses depending on how often you get the shots.

  You or a family member can learn to give testosterone shots at home. If you're not OK with giving yourself shots, a member of your care team can do it for you.

  The shot form of testosterone undecanoate (Aveed) goes deep into a muscle, typically every 10 weeks. A member of your medical team must give it. It can have serious side effects.

• Patch. A patch containing testosterone is put on an arm or the torso each night. Possible side effects are mild or severe skin problems.

• Gum and cheek, also called buccal cavity. Small and puttylike, gum-and-cheek testosterone replacement sends testosterone through the area above the top teeth where the gum meets the upper lip, called the buccal cavity.

  This product, taken three times a day, sticks to the gumline and sends testosterone into the bloodstream. It can irritate the gum.

• Nasal. This testosterone gel (Natesto) can be pumped into the nostrils. This option reduces the risk that medicine will get on someone else through skin contact. This type of testosterone is put into each nostril three times a day. This might make it less easy to use than other methods.
• Pellets put under the skin, called implants. Testosterone-containing pellets (Testopel) are surgically put under the skin every 3 to 6 months.

Testosterone therapy carries risks, including:

• Making too many red blood cells.
• Acne.
• Bigger breasts.
• Sleep problems.
• Growth of the prostate.
• Not making as much sperm.

Risks from testosterone therapy are most often due to doses that are too high. Many of these side effects go away when the dose is lowered. That's why it's so important to have regular follow-up visits with a health care professional, who will monitor the testosterone levels in your blood.

Treatment of infertility due to hypogonadism

If a pituitary problem is the cause, pituitary hormones can be given to help the body make more sperm and restore fertility. A pituitary tumor may need treatment with surgery, medicine, radiation or replacement of other hormones.

There's often no way to help men with primary hypogonadism make sperm. But there are ways to help couples who haven't been able to have children. Assisted reproductive technology offers ways to help.

Treatment for boys

Treatment of delayed puberty in boys depends on the cause. Three to six months of testosterone shots can help start puberty. The testosterone can help increase muscle mass, beard and pubic hair growth, and growth of the penis. This treatment is given only if the bones have matured enough.

Coping and support

Having male hypogonadism can affect how you see yourself. It also can affect your relationships. Talk with a member of your healthcare team about how you can reduce the anxiety and stress that often go with this condition. Counseling might help.

Find out if there are support groups in your area or online. Support groups put you in touch with other people with similar concerns.

Preparing for your appointment

You're likely to start by seeing the person who provides your health care, but you might be referred to someone who specializes in conditions involving the hormone-producing glands, called an endocrinologist.

Here are some tips to help you get ready for your appointment.

What you can do

Make a list of:

• Your symptoms, including any that may seem unrelated to the reason for which you scheduled the appointment, and when they began.
• Key personal information, including any major stresses, recent life changes, and history of childhood illnesses or surgeries.
• All medicines, vitamins or other supplements you take, including doses.
• Questions to ask at your appointment.

For male hypogonadism, some questions to ask include:

• What's the most likely cause of my symptoms?
• Are there other possible causes for my symptoms?
• What tests do I need?
• Is my condition likely to go away or be long-lasting?
• What treatments are there?
• I have other health conditions. How can I best manage them together?
• Are there restrictions I need to follow?
• Where can I find more information?

Be sure to ask all the questions you have about this condition.

What to expect from your doctor

Be prepared to answer questions about your condition, such as:

• Do you have symptoms all the time or do they come and go?
• How bad are your symptoms?
• What, if anything, seems to make your symptoms better?
• What, if anything, seems to make your symptoms worse?
• When did you begin puberty? Did it seem to be earlier or later than others your age?
• Did you have any growth problems as a child or teen?
• Have you hurt your testicles?
• Did you have the mumps as a child or teen? Did you feel pain in your testicles while you had the mumps?
• Did you have testicles that didn't fall into place when you were born?
• Did you have genital surgery or surgery for a groin hernia as a child?
• Do you snore or have disrupted breathing at night?