Male hypogonadism, often referred to as just hypogonadism, is characterized by low production of the hormone testosterone. Testosterone is a natural hormone and the sex hormone for males that develops male sex organs and features, among other roles. As men age they naturally produce less testosterone, but this is different from hypogonadism, which is not natural and has an underlying cause.

Hypogonadism can be treated by treating the underlying cause, but also by supplementing with testosterone. Testosterone therapy comes with risks, including heart attack and stroke, but it is especially risky for men who simply have declining hormone levels due to age. Drug companies making testosterone have come under fire for pushing their supplements for this purpose and putting at risk men who did not need the therapy.

What is Testosterone?

Both men and women produce this natural hormone, but men have it in greater quantities. In boys testosterone is needed for the onset of puberty; it plays a role in the growth of male sex organs, in the development of facial hair, in the deepening of the voice, and in the development of muscles, dense, strong bones, and height. Testosterone is needed for the production of sperm cells and reproduction.

Testosterone production is regulated by the pituitary and hypothalamus glands, which signal the testicles to produce the hormone. The brain and the gland together control its production. Levels of testosterone can vary throughout the day, mostly going from high in the morning to lower at night. Peak testosterone production levels usually occur between the ages of 20 and 30 and then begin to go down starting around age 30 or 35. If something goes wrong with any of the glands involved or the testicles, production may slow earlier than normal and result in hypogonadism.

Signs of Hypogonadism

Hypogonadism can occur at any stage of life, even during fetal development. When a male infant is born with hypogonadism, he may have ambiguous or underdeveloped genitals. In a boy with hypogonadism, a common symptom is a delay in the onset of puberty. He may also experience decreased muscle mass, more growth in the arms and legs than in the trunk of the body, impaired genital growth, a voice that doesn’t deepen, or even growth in breast tissue, called gynecomastia.

Adult men may experience hypogonadism in different ways. Symptoms include erectile dysfunction, a decline in the growth of facial and body hair, gynecomastia, decreased muscle mass, decreased bone mass, and even osteoporosis, and infertility. Other symptoms may include a lowered sex drive, trouble concentrating and thinking, hot flashes, and fatigue.

Causes

There are two types of hypogonadism, classified by where the failure occurs. In primary hypogonadism there is an issue with the testicles, which produce testosterone. In secondary hypogonadism, the problem originates in the pituitary or hypothalamus glands, the glands that signal the testicles to produce and release testosterone.

Either type of hypogonadism can be caused by genetics or by some external, or acquired, cause. Some of the common causes of primary hypogonadism are Klinefelter Syndrome, a sex chromosome defect, undescended testicles, mumps infections, excessive iron in the blood, physical injury to the testicles, or chemotherapy or radiation treatment for cancer.

In secondary hypogonadism the testicles are normal, but other issues may cause the signaling glands to malfunction. Causes include an inflammatory disease, HIV or AIDS, obesity, Kallman syndrome, which is a condition characterized by abnormal development of the pituitary gland, brain tumors and treatment for brain tumors, and certain medications, like opioids or hormone supplements.

Treatment

When treating hypogonadism it is important to try to diagnose it correctly and to determine if there is an underlying condition. Diagnosis usually involves testing hormone levels, analyzing semen, imaging the pituitary gland, and if necessary, conducting a biopsy of the testicles or examining the chromosomes and genetics of the patient.

Treatment of an underlying condition may reverse the hormone problem. If it does not, or the underlying cause cannot be determined, hypogonadism is most often treated by supplementation of artificial hormones. For primary hypogonadism, testosterone replacement therapy is the treatment. fi the pituitary gland is implicated as the cause, other types of hormones can be used to stimulate sperm production for fertility. If fertility is not a concern, testosterone replacement is adequate.

Testosterone Replacement Therapy

Testosterone replacement therapy, or TRT, is designed to be used for men or boys with diagnosed hypogonadism. It is not supposed to be used for men who are simply experiencing natural declines in testosterone as they age. Testosterone therapy can cause serious side effects and comes with risks that are severe enough that TRT is not recommended as a long-term solution. Replacement products may be injections, patches or gels applied to the skin, gum and cheek supplements, nasal supplements, or pellets that can be implanted under the skin.

There are many potential side effects of TRT and these have to be weighed against the benefits. Some of the more common side effects are high blood pressure, mood swings, increased red blood cell production, longer and more frequent erections, and skin irritation with gels and patches. More seriously, TRT can cause the worsening of an enlarged prostate, an increased risk of prostate cancer, low sperm count, edema, and breast growth.

The most serious of all TRT side effects is the possibility that it can cause a blood clot to form, which can lead to a fatal stroke or heart attack. In one study of testosterone supplements the researchers stopped work early because the men on testosterone were having significantly more adverse outcomes as compared to a control group. This included heart attack and stroke.

Hypogonadism vs. Age-Related Testosterone Decline

Drug companies making TRT products have gotten in trouble in recent years for pushing testosterone for men who only suffer from age-related declines in testosterone. Men naturally experience some of the symptoms of hypogonadism as they age, especially a lowered sex drive, fatigue, and loss of muscle mass. Some drug companies used advertising to push these men to ask their doctors about testosterone supplements. This kind of direct-to-consumer marketing is technically legal, but problematic as it caused many men to use TRT and to suffer side effects when they really had no medical need for the treatment.

AbbVie and Abbott Laboratories pushed hard on advertising AndroGel, a gel supplement for TRT. The companies coined the term Low-T to refer to age-related testosterone loss, but made it sound as if it were a true medical condition. This put a lot of men at risk of heart attack and stroke and has spurred a number of lawsuits. Since those advertisements were used, the FDA spoke up and stated that TRT was not to be used in men with normal, age-related testosterone decline. The FDA also instituted a new label warning of the risks of heart attack and stroke.

Propecia

Propecia is another testosterone-related drug that has the potential to cause some serious side effects in men. It is a drug called finasteride that was originally developed to treat enlarged prostate. It inhibits the production of a hormone related to testosterone, called dihydrotestosterone. This hormone is implicated in the enlargement of the prostate and male pattern baldness.

After developing Propecia for prostate treatment, Merck lowered the dose and released it to treat baldness in men. It works well for many men, but some will experience a devastating, long-lasting type of sexual dysfunction that can persist for months or even years and cause emotional and mental distress as well as physical side effects. Merck has been sued over this by men who feel they were not warned of such a serious risk and never would have taken the medication if they had known about it.

Opioids and Hypogonadism

Opioid painkillers, like hydrocodone and oxycodone, are used for moderate to severe and chronic pain, but they are risky drugs. Most of the risks are associated with dependence and the potential for overdose deaths, however, these drugs can also cause hypogonadism. Men who rely on these painkillers for relief may be forced to use TRT to treat the side effect, and this in turn may cause other side effects, or put them at risk for heart attack and stroke.

Male hypogonadism is a condition characterized by low production of testosterone, not related to natural, age-related declines. While treating it is sometimes as simple as supplementing with the hormone, there are some serious risks and men who only have age-related loss of testosterone should be especially aware of these.