Low Testosterone (Male Hypogonadism)

Insufficient testosterone production by the testicles is called male hypogonadism or low testosterone. The condition can be caused by various factors, such as injuries or illnesses that affect the hypothalamus, pituitary gland, or testicles. Testosterone replacement therapy is an effective treatment for this condition.

What Is Low Testosterone (Male Hypogonadism)?

Low testosterone, also known as male hypogonadism, occurs when the testicles do not adequately generate the male sex hormone. In individuals assigned male at birth (AMAB), the testicles serve as the sex organs, also known as gonads. The Leydig cells within the testicles are responsible for producing testosterone.

Symptoms of low testosterone vary across different ages. It's natural for testosterone levels in AMAB adults, including cisgender men, non-binary individuals, and transgender women not on feminizing hormone therapy, to diminish as they get older.

Low testosterone and male hypogonadism have several other terminologies:

• Secondary hypogonadism.
  
  
• Hypogonadotropic hypogonadism.
  
  
• Hypergonadotropic hypogonadism.
  
  
• Testosterone deficiency.
  
  
• Testosterone deficiency syndrome.
  
  
• Primary hypogonadism.

What Does Testosterone Do?

Testosterone is a primary androgen hormone that stimulates male characteristics and is a key factor in spermatogenesis. Typically, testosterone levels in those assigned male (AMAB) are significantly higher than those assigned female (AFAB).

Testosterone maintains and develops the following in people assigned AMAB:

• Bone density.
  
  
• Muscle mass.
  
  
• Adequate levels of red blood cells.
  
  
• Sex organs and genitalia.
  
  
• Sense of well-being.
  
  
• Sexual and reproductive function.

Your body maintains a careful balance of testosterone levels in your bloodstream. These levels are typically at their highest in the morning and decrease as the day progresses.

The amount of testosterone produced and released by your testicles is regulated by your hypothalamus and pituitary gland.

First, the hypothalamus releases gonadotropin-releasing hormone (GnRH), which prompts the pituitary gland to release luteinizing hormone (LH). This LH then travels to your gonads (either testicles or ovaries) and stimulates the production and release of testosterone. Additionally, the pituitary gland releases follicle-stimulating hormone (FSH), which aids in sperm production.

Any dysfunction involving your testicles, hypothalamus, or pituitary gland can lead to low testosterone levels, a condition known as male hypogonadism.

What Is A Low Testosterone Level?

Adults are considered to have low blood testosterone if it measures below 300 nanograms per deciliter (ng/dL), according to the American Urology Association (AUA).

Despite this, some healthcare providers and researchers believe that levels below 250 ng/dL should be considered low. Symptoms are taken into account by providers when diagnosing low testosterone.

Who Does Low Testosterone (Male Hypogonadism) Affect?

People with testicles may suffer from male hypogonadism at any age, from birth to adulthood.

There is a higher risk of low testosterone in people who:

• Have chronic medical conditions, such as kidney dysfunction or cirrhosis of the liver.
  
  
• Have poorly managed Type 2 diabetes.
  
  
• Have HIV/AIDs.
  
  
• Have obesity.
  
  
• Have obstructive sleep apnea.
  
  
• Are older.

How Common Is Low Testosterone?

Estimating the prevalence of low testosterone is challenging for researchers due to the varying definitions used in different studies.

According to data, approximately 2% of individuals assigned male at birth may have low testosterone levels. In contrast, studies indicate that more than 8% of individuals assigned male at birth between 50 and 79 years old have low testosterone levels.

What Are The Symptoms Of Low Testosterone?

Age can have a significant impact on the symptoms of low testosterone.

The following symptoms strongly indicate low testosterone in adults assigned male at birth:

• Loss of armpit and pubic hair.
  
  
• Low or zero sperm count (azoospermia), which causes male infertility
  
  
• Shrinking testicles.
  
  
• Hot flashes.
  
  
• Reduced sex drive.
  
  
• Erectile dysfunction..

AMAB adults with low testosterone may also experience the following symptoms:

• Decrease in endurance.
  
  
• Enlarged male breast tissue (gynecomastia).
  
  
• Increased body fat.
  
  
• Decrease in muscle strength and mass.
  
  
• Difficulties with concentration and memory.
  
  
• Depressed mood.

Symptoms Of Low Testosterone In Children

It is possible for children assigned male at birth to have low testosterone before or during puberty:

• Stunted height growth, while arms and legs might still experience disproportionate growth.
  
  
• Limited development of pubic hair.
  
  
• Diminished growth of the penis and testicles.
  
  
• Less pronounced deepening of the voice.
  
  
• Below-average strength and endurance.

What Causes Low Testosterone?

There exist various potential reasons for low testosterone levels. The two categories of male hypogonadism are:

• Primary hypogonadism arises from disorders in the testicles.
  
  
• Secondary hypogonadism is caused by dysfunction in the pituitary gland or hypothalamus.
  
  
• The causes of both primary and secondary hypogonadism can be further classified as either congenital (present at birth) or acquired (developed later in childhood or adulthood).

Causes Of Primary Male Hypogonadism

An individual may experience primary hypogonadism when their testicles cannot produce adequate testosterone levels due to a malfunction.

Primary hypogonadism is also known as hypogonadotropic hypogonadism. This type occurs when the pituitary gland produces more luteinizing hormone (LH) and follicle-stimulating hormone (FSH) in response to low testosterone levels. Usually, the high levels of these hormones would stimulate the production of more testosterone and sperm in the testicles. However, if the testicles are damaged or missing (often due to prior chemotherapy), they cannot respond to the increased levels of gonadotropins. This results in a lack of testosterone and sperm production in the testicles.

Even when testosterone levels are normal, gonadotropins can still be high in primary hypogonadism. Your specialist can advise whether treatment is necessary despite normal testosterone levels.

Several congenital factors can impact the testicles and result in primary hypogonadism, including:

1. Testicular injury or surgical removal.
   
   
2. Orchitis is characterized by the inflammation of one or both testicles. Typically caused by bacterial infections like sexually transmitted infections, but viral infections like mumps can also be a cause.
   
   
3. Application of chemotherapy or radiation therapy to the testicles.
   
   
4. Specific kinds of tumours.
   
   
5. Utilization of anabolic steroids.

Causes Of Secondary Male Hypogonadism

When the hypothalamus and/or pituitary gland are affected, it can lead to hypogonadotropic hypogonadism. This is characterized by low levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), resulting in decreased production of testosterone and sperm.

Congenital factors that can result in secondary hypogonadism comprise:

• Isolated hypogonadotropic hypogonadism (a condition causing insufficient gonadotropin-releasing hormone levels from birth).
  
  
• Kallmann syndrome (an uncommon genetic disorder leading to underdevelopment of nerve cells in the hypothalamus responsible for gonadotropin-releasing hormone production. It can also result in loss of smell).
  
  
• Prader-Willi syndrome (a rare genetic multisystem disorder that can lead to hypothalamus dysfunction).

The following conditions can cause secondary hypogonadism:

 

• Hypopituitarism (This condition may result from an adenoma, infiltrative disease, infection, injury, radiation therapy or surgery that affects your pituitary gland.).
  
  
• Cirrhosis of the liver.
  
  
• Alcohol use disorder.
  
  
• Poorly managed diabetes.
  
  
• Hyperprolactinemia.
  
  
• Obesity.
  
  
• Cushing’s syndrome.
  
  
• Kidney failure.
  
  
• Iron overload (hemochromatosis).
  
  
• HIV/AIDS.
  
  
• Brain or head injury.
  
  
• Obstructive sleep apnea.

Certain medications like estrogens, opioids, psychoactive drugs, metoclopramide, triptorelin, leuprolide, goserelin, and newer inhibitors of androgen biosynthesis used for prostate cancer treatment can exert specific effects on the body.

Late-onset hypogonadism (LOH) is a form of secondary male hypogonadism that arises due to natural ageing. As males grow older, there's a decline in the function of the hypothalamus-pituitary system and Leydig cells, leading to reduced production of testosterone and/or sperm.

LOH and low testosterone are more prevalent in individuals assigned male at birth (AMAB) who have Type 2 diabetes and those who are overweight or obese.

A particular study found that 30% of overweight AMAB individuals had low testosterone levels, whereas only 6% of those within a normal weight range exhibited the same issue. In another study, 25% of AMAB individuals with Type 2 diabetes experienced low testosterone levels, compared to 13% of those without diabetes.

How Is Low Testosterone Diagnosed?

To diagnose low testosterone, a healthcare provider will first conduct a physical exam and ask questions about your medical history, medications, smoking and any current symptoms. Blood tests may also be performed to confirm the diagnosis.

The signs and symptoms of your condition, as well as the results of any blood tests, will be considered by your provider when making a diagnosis. 

What Tests Will Be Done To Diagnose Low Testosterone?

Low testosterone can be confirmed and the cause determined by the following tests:

• Total Testosterone Level blood test: This examination generally necessitates two samples to be taken between 8 a.m. and 10 a.m., as this is when testosterone levels are anticipated to be highest. If you are unwell or have recently recovered from an illness, it's crucial to inform your healthcare provider, as acute sickness might yield an inaccurately reduced outcome.
  
  
• Luteinizing Hormone (LH) Blood Test: This test assists in determining whether low testosterone stems from pituitary gland problems.
  
  
• Prolactin Blood Test: Elevated prolactin levels might indicate issues with the pituitary gland or tumours.

How Is Low Testosterone Treated?

Male hypogonadism, or low testosterone, is commonly treated by healthcare providers through testosterone replacement therapy. This therapy comes in various forms, including:

• Testosterone Skin Gels: As directed, you should apply the gel to clean and dry skin daily. It is crucial to avoid skin-to-skin contact to prevent the transfer of the gel to another person. Testosterone skin gels are widely used in the U.S. for treatment.
  
  
• Intramuscular Testosterone Injections: You or a provider can give Injections into a muscle every 1 to 2 weeks. If administered by a provider, long-acting testosterone injections can be given every ten weeks. Additionally, subcutaneous injection options are available.
  
  
• Testosterone Patches: As instructed, you must apply these patches to your skin daily. To prevent skin reactions, it is essential to rotate their position regularly.
  
  
• Testosterone Pellets: Every three to six months, a medical professional can implant pellets under your skin to provide a sustained and reliable dose of testosterone. This method ensures consistent levels of testosterone over an extended period.
  
  
• Buccal Testosterone Tablets: You should apply these sticky pills to your gums twice daily. The testosterone in the pill will be quickly absorbed into your bloodstream through your gums.
  
  
• Testosterone Nasal Gel: 3 times a day, apply testosterone nasal gel to each nostril.
  
  
• Oral Testosterone: People diagnosed with Klinefelter syndrome or have tumours that have impacted their pituitary gland may take a pill form of testosterone called undecanoate to increase their testosterone levels.

If you have a history of any of the following, you may not be eligible for testosterone replacement therapy:

• Untreated obstructive sleep apnea.
  
  
• An unevaluated lump on your prostate. Everyone considering testosterone replacement therapy must undergo prostate screening before starting this therapy.
  
  
• Prostate cancer.
  
  
• Uncontrolled heart failure.
  
  
• Breast cancer.

What Are The Side Effects Of Testosterone Replacement Therapy?

Testosterone replacement therapy has the following side effects:

• Acne or excessive oiliness of the skin.
  
  
• Mild fluid retention leads to ankle swelling.
  
  
• Stimulation of the prostate, potentially resulting in urinary issues like trouble urinating.
  
  
• Enlargement or sensitivity of the breasts.
  
  
• Aggravation of sleep apnea.
  
  
• Reduced testicle size.
  
  
• Skin discomfort (if using topical testosterone replacement).

Testosterone replacement therapy can cause the following laboratory abnormalities:

• Elevated levels of prostate-specific antigen (PSA).
  
  
• Rise in the count of red blood cells.
  
  
• Reduction in sperm count, leading to infertility, which holds particular significance for younger individuals desiring biological offspring.

Can Low Testosterone Be Prevented?

Low testosterone can be caused by genetic conditions or damage to your testicles, hypothalamus, or pituitary gland, according to medical researchers and healthcare providers.

Keeping testosterone levels normal can be achieved by following the following lifestyle habits:

• Weight management.
  
  
• Avoiding excessive use of alcohol and drugs.
  
  
• Eating a healthy diet.

What Can I Expect If I Have Low Testosterone (Male Hypogonadism)?

Improving low testosterone levels can't be fixed with a one-time solution. Nonetheless, hormone replacement therapy consistently can help in enhancing sex drive, alleviating symptoms of depression, and increasing energy levels for many people who were assigned male at birth (AMAB) and are going through low testosterone. The ttherapy may also lead to an increase in muscle mass and bone density.

Low testosterone levels can negatively affect the body, including a decrease in energy and muscle mass, and a potential increase in mortality rates for those assigned male at birth (AMAB). Testosterone therapy can help increase testosterone levels, potentially improving energy, muscle mass, and bone density. However, it is still uncertain whether normalizing testosterone levels can reduce the heightened mortality risk for those AMAB with testosterone deficiency.

Testosterone replacement therapy is often effective for children assigned male at birth with congenital hypogonadism.

When Should I See My Healthcare Provider About Low Testosterone?

Consistent follow-up visits with a healthcare professional are crucial when undergoing hormone replacement therapy.

Communicate with a healthcare provider if you encounter low testosterone indications, such as reduced libido and hot flashes. They will assess your condition and potentially arrange blood tests.

If a child assigned male at birth hasn't exhibited puberty signs by 14, consult their paediatrician.

If you are experiencing symptoms of low testosterone, such as fatigue, decreased libido, or mood changes, you can consider reaching out to Mobi Doctor for online consultation with experienced professionals. Mobi Doctor offers a convenient platform to seek advice and guidance regarding your health concerns. Through their online services, you can easily connect with healthcare experts, discuss your symptoms, and receive personalized recommendations without hassle. Don't hesitate to explore this accessible option to address your low testosterone concerns and receive expert assistance from the comfort of your own space.