Sexual Health

Hypogonadism in Men

Testosterone is a crucial hormone for tissue development and growth. It is also essential for sexual differentiation.

But, does that mean we are suffering a type of hypogonadism? What is hypogonadism? How is it diagnosed, and what can we do to boost our testosterone levels naturally?

What is hypogonadism

Hypogonadism is a functional problem in the gonads. These are either the testicles in males or the ovaries in women. They are the primary source of sex hormones. They are equally important in the process of reproduction.

In cases of hypogonadism, these structures stop performing their normal functions. The patient ends up with low levels of sex hormones. A series of signs and symptoms are associated with it. We can include consequences and alterations such as bone density problems (1).

Types of hypogonadism

There are several ways to classify hypogonadism. The most common classification involves the location of the dysfunction in hypogonadal men. This can be either primary or secondary.

It is also essential to consider the association or not to birth defects. Thus, it breaks down into congenital and acquired hypogonadism.

The distinct features of each one are as follows (2):

Primary hypogonadism

In these cases, the dysfunction is located in the testes, and not outside. The majority of congenital problems cause primary hypogonadism, including Turner and Klinefelter syndrome.

Secondary hypogonadism

In secondary hypogonadism, the defect is located outside the gonad. This includes the hypothalamus and other structures that contribute to hormone synthesis. It is also known as hypogonadotropic hypogonadism or central hypogonadism.

Congenital hypogonadism

In these cases, the cause of hypogonadism is a birth defect. It usually results in primary hypogonadism. It is generally treated with testosterone replacement therapy.

Acquired hypogonadism

In acquired hypogonadism, the patient develops healthily, but testosterone production becomes impaired by an external agent, including infections, steroids, and our normal aging process.

Causes of hypogonadism

As you can see, we briefly addressed the causes by reviewing the types of hypogonadism. But let us dive deeper into primary and secondary hypogonadism and see the exact causes of each one of them.

What are the causes of primary hypogonadism?

Primary hypogonadism is caused by genetic disease and other ailments that impair the function of the testicles. The causes include the following (3):

  • Orchitis: It is the inflammation of the testicles. The most common cause is a complication of mumps. When both testicles are affected, patients may develop primary hypogonadism.

  • Undescended testicles: It is also known as cryptorchidism. When both testicles are not descended into the scrotum, the body heat impairs the normal function of the testicles. Thus, total testosterone levels remain low after puberty.

  • Radiotherapy or chemotherapy: Damage to the testicles results in primary hypogonadism. This may be the result of trauma and more frequent cancer treatment (radiotherapy and chemotherapy).

  • Klinefelter syndrome: A congenital problem in males with two sets of X chromosomes instead of one. This results in inadequate production of testosterone.

What are the causes of secondary hypogonadism?

Secondary hypogonadism is more common than primary hypogonadism. Agents and structures outside of the testicles are the leading cause. The most common are as follows (3):

  • Aging: The normal process of aging includes a decrease in the production of testosterone. When it reaches a threshold, this normal decline is diagnosed as secondary hypogonadism. It is the most common form of late-onset hypogonadism.

  • Pituitary gland dysfunction: This gland stimulates testosterone production. Inadequate levels of pituitary hormones impair the glandular function of the testicles, too. This is commonly caused by pituitary tumors or as a result of cancer treatment.

  • Kallmann’s syndrome: It is a genetic problem that affects the release of hormones by the pituitary gland. It is also linked to other symptoms, such as inability to smell and color blindness.

What causes hypogonadism in women?

In women, it is expected to experience a dramatic reduction of sex hormones during menopause. However, post-menopausal women are not diagnosed as hypogonadism patients.

It’s only diagnosed when there is a disruption in the communication between the pituitary gland and the ovaries. Another cause is ovarian deficiency due to chromosomal abnormalities (4).

Signs and symptoms of hypogonadism

It is possible to diagnose hypogonadism in various stages of life by looking at relevant signs and symptoms. In each stage, symptoms will be different from each other.

Symptoms of low testosterone levels depend on the stage of development. It is important to ask whether or not the patient has gone through puberty. Thus, the most relevant symptoms are as follows (2).

  • Not going through normal changes of puberty in boys

  • Short testicle size

  • Gynecomastia (breast tissue in males)

  • Reduced sexual drive

  • Impaired libido

  • Reduction of body hair growth

  • Depression

  • Fatigue and tiredness

In some cases, it can be associated with other symptoms. For example, anosmia in idiopathic hypogonadotropic hypogonadism.

The signs and symptoms above are sometimes concerning for males. That’s especially the case of sexual dysfunction and libido problems. However, these symptoms are not always caused by late-onset hypogonadism or testicular failure.

Still, it is essential to talk to your doctor if your symptoms become a source of distress, and when they create alterations in the family dynamics.

What are the clinical signs of hypogonadism in males?

The most important signs are as follows (2):

  • Delayed puberty: It is the only way to suspect hypogonadism in individual patients. Specific genetic abnormalities, mumps orchitis, and undescended testicles in boys are common causes. In this case, it is reasonable to feel some anxiety about the appearance of body changes during puberty. When they are not still present after 14 years old, a thorough exam should be made to find out the reason.

  • Infertility: It is an important cause of male infertility. The testicles do not only synthesize testosterone. They are fundamental to produce sperm cells and raise your sperm count. Thus, low levels of testosterone are usually associated with fertility problems.

  • Reduced sexual drive: It is one of the most common symptoms of hypogonadism in males. Low sexual drive and sexual dysfunction are probably the most concerning symptoms of low testosterone. It is common in aging men and acquired cases of hypogonadism.

  • Higher susceptibility to fractures: This is a late complication of hypogonadism. Aging men increase their risk of bone fractures when they have deficient levels of testosterone. In this regard, they share similar symptoms to menopause in women.

  • Anemia and reduction of muscle mass: Testosterone contributes to tissue formation. Men without healthy levels of testosterone will have reduced muscle mass, anemia, and other abnormalities. They are related to the inadequate formation of body tissues and contribute to fatigue and muscle weakness.

How is hypogonadism treated?

Treatment for hypogonadism in men includes sex steroid replacement. It is also known as hormone replacement therapy. The main goal of treating patients with a synthetic source of hormones depends on the age of the patient.

In younger patients and cases of delayed puberty, it is meant to trigger puberty in males. The success of therapy is usually measured by taking note of secondary sexual characteristics. Another goal of treatment is guaranteeing normal sexual function, depending on each case.

In such cases, testosterone is usually administered transdermally through patches or gels. It may also be applied as intramuscular injections to ensure a higher level of bioavailable testosterone.

The typical dose is 50 mg of testosterone enanthate every month with titration every 2 weeks. Oral testosterone is not recommended in these cases due to liver toxicity.

In patients who have already reached puberty, the main goal is to maintain bone and muscle mass. It is also an essential part of fertility consultation. It is meant to reduce distress due to sexual dysfunction.

In these patients, testosterone measurements alone are not enough to start testosterone treatment. According to the evidence and best practices guidelines, serum testosterone levels should be compared with signs and symptoms.

Testosterone-containing drugs are administered only when patients have low levels of testosterone and sufficient signs and symptoms (3).

In some instances, surgical resection of nonfunctional testicular tissue is recommended in males. In these cases, orchiectomy is a measure to prevent testicular cancer.

All patients diagnosed with primary or secondary hypogonadism should undergo long-term monitoring. Such monitoring often includes performing tests, adjusting doses, and assessing cardiovascular risk factors.

Why is HCG used in the treatment of hypogonadism?

Human chorionic gonadotropin, also known as hCG, is a popular hormone in pregnancy. It is the one targeted by most pregnancy tests.

In women, this hormone is useful to treat infertility, and it is thought to be a female hormone. That’s why most people are impressed that this hormone can be used to treat hypogonadism in men.

However, hCG is useful to treat men with hypogonadism when they wish to treat infertility.

Side effects of testosterone replacement therapy include shrinking of the testicles and may also include infertility. In these cases, hCG is useful to improve the symptoms of low testosterone. It prevents the side effects of therapy at the same time.

According to studies on this type of therapy, hCG treatment can help these patients increase their testicular volume. It also induces spermatogenesis. For this purpose, it may be combined with other agents, including corifollitropin-alfa (5).

How is hypogonadism diagnosed?

The diagnosis of hypogonadism should include several parts. Initially, there should be a reason for suspicion, which is usually based on symptoms detected by the patient.

It may also include mineral density assessment and other parameters. Then, a doctor should perform a physical exam to make sure there are relevant signs of alteration.

One of the most critical features is evaluation and measure of the testes, their position, and size.

In children and adolescents, the staging of puberty is also important. A series of criteria called Tanner criteria are used. They evaluate secondary sexual characteristics such as size and form of genitalia, pubic hair, axillary hair, and others.

Finally, a series of tests are indicated in males, including testosterone levels. These should be measured at least twice and should be compared to signs and symptoms to diagnose hypogonadism (6). Other hormone levels necessary for the diagnosis include:

  • Follicle-stimulating and Luteinizing hormone levels

  • Prolactin levels

  • Thyroid hormones

  • Karyotyping

  • Seminal fluid examination

  • Testicular biopsies

Best supplements for hypogonadism

Hypogonadal men need testosterone replacement therapy, but they may also include other measures.

In cases of prostate cancer, and when testosterone therapy is not recommended, a healthy diet is mandatory. You need to avoid unhealthy fats, fast foods, and junk.

You have probably wondered whether or not supplementation with vitamin works. Do they increase your testosterone levels? Vitamins are not used to create testosterone. But a few vitamins may improve testosterone deficiency in other ways. They are instrumental in cases of late-onset hypogonadism.


These are the most important vitamins and the reason they are useful:

  • Vitamin B: There are eight types of B vitamins. Almost all of them are important to improve testosterone synthesis. Plus, vitamin B deficiency increases estrogens in men, as well as prolactin. This is another hormone that impairs the normal function of androgens (7).

  • Vitamin C: It has a protective antioxidant activity. Studies show that vitamin C is also able to inhibit cortisol. This hormone is secreted in response to stress. But when cortisol is out of control, it can interfere with testosterone (8).

  • Vitamin D: It is synthesized in the skin. However, sometimes it is useful to supplement. Patients with a deficiency increased their testosterone levels by 25% after taking vitamin D (9).

  • Vitamin E: It has potent antioxidant activity. This vitamin is also related to androgenic signaling. It plays a vital role in maintaining healthy levels of LH and FSH. As a result, people who follow vitamin E supplementations increase their LH, FSH, and testosterone levels (10).

Besides vitamins, there are a few herbal supplements with proven efficacy to increase testosterone levels. The most important are as follows:

  • Ashwagandha: It is an adaptogen substance that reduces stress hormones (cortisol). It is one of the most widely documented adaptogens. Ashwagandha improves well-being, reduces anxiety, and hammers cortisol levels. It improves LH, testosterone production, and sperm quality in healthy and infertile men (11).

  • Ginger: It is a medicinal plant and a popular spice that’s been used in diabetes and many other chronic diseases. In patients with male hypogonadism, it is known to enhance the circulating levels of luteinizing hormone (LH). It has antioxidant activity that protects the gonads against free radicals. It also normalizes the blood pressure and the blood flow to the testes. Studies show that ginger may even increase testicular weigh (12)

  • Fenugreek: Another supplement commonly used to increase testosterone levels is fenugreek. Athletes and healthy men who want to maintain their testosterone levels use fenugreek, and there is some evidence to support their use (13).

Where do you find the best supplements for hypogonadism?

It is important to know where to find the best supplements for hypogonadism. Otherwise, you can be fooled by advertising or products contaminated with steroids and other drugs. Therefore, look for reputed sources of supplements to treat male hypogonadism.

Ask your doctor about any decision you’re about to make. Also, try to read reviews and opinions from previous users before buying. If you have hypogonadism, don’t leave aside medical treatment.

Do continue your follow-up visits. They are required to maintain your hormonal levels in check, especially if you start supplementing with testosterone boosters.

Conclusion

Hypogonadism is much more than low levels of testosterone. It is associated with signs, symptoms, and terrible complications. These include cardiovascular problems and bone fractures.

It is crucial to diagnose and treat hypogonadism early. That’s the only way to avoid its consequences. Diagnosis requires several tests and a thorough physical exam. Medical treatment is based on testosterone replacement therapy, but may also include hCG hormone.

Supplements are also available for hypogonadism, and they contain vitamin B, vitamin C, and other antioxidant vitamins, as well as Ashwagandha, ginger, and fenugreek.

Sources

1. Young, N., Formica, C., Szmukler, G., & Seeman, E. (1994). Bone density at weight-bearing and nonweight-bearing sites in ballet dancers: the effects of exercise, hypogonadism, and body weight. The Journal of Clinical Endocrinology & Metabolism, 78(2), 449-454.
2. Basaria, S. (2014). Male hypogonadism. The Lancet, 383(9924), 1250-1263.
3. Dohle, G. R., Arver, S., Bettocchi, C., Jones, T. H., Kliesch, S., & Punab, M. (2016). EAU guidelines on male hypogonadism. European Association of Urology, Arnhem, The Netherlands, accessed Mar, 21, 2018.
4. Skałba, P., & Guz, M. (2011). Hypogonadotropic hypogonadism in women. Endokrynologia Polska, 62(6), 560-567.
5. Nieschlag, E., Bouloux, P. M. G., Stegmann, B. J., Shankar, R. R., Guan, Y., Tzontcheva, A., … & Behre, H. M. (2017). An open-label clinical trial to investigate the efficacy and safety of corifollitropin alfa combined with hCG in adult men with hypogonadotropic hypogonadism. Reproductive Biology and Endocrinology, 15(1), 17.
6. Bhasin, S., Cunningham, G. R., Hayes, F. J., Matsumoto, A. M., Snyder, P. J., Swerdloff, R. S., & Montori, V. M. (2010). Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 95(6), 2536-2559.
7. Biskind, M. S., & Biskind, G. R. (1942). Effect of vitamin B complex deficiency on inactivation of estrone in the liver. Endocrinology, 31(1), 109-114.
8. Vani, K., Kurakula, M., Syed, R., & Alharbi, K. (2012). Clinical relevance of vitamin C among lead-exposed infertile men. Genetic testing and molecular biomarkers, 16(9), 1001-1006.
9. Pilz, S., Frisch, S., Koertke, H., Kuhn, J., Dreier, J., Obermayer-Pietsch, B., … & Zittermann, A. (2011). Effect of vitamin D supplementation on testosterone levels in men. Hormone and Metabolic Research, 43(03), 223-225.
10. Umeda, F., Kato, K. I., Muta, K., & Ibayashi, H. (1982). Effect of vitamin E on function of pituitary-gonadal axis in male rats and human subjects. Endocrinologia japonica, 29(3), 287-292.
11. Ambiye, V. R., Langade, D., Dongre, S., Aptikar, P., Kulkarni, M., & Dongre, A. (2013). Clinical evaluation of the spermatogenic activity of the root extract of Ashwagandha (Withania somnifera) in oligospermic males: a pilot study. Evidence-Based Complementary and Alternative Medicine, 2013.
12. Banihani, S. A. (2018). Ginger and testosterone. Biomolecules, 8(4), 119.
13. Steels, E., Rao, A., & Vitetta, L. (2011). Physiological aspects of male libido enhanced by standardized Trigonella foenum‐graecum extract and mineral formulation. Phytotherapy Research, 25(9), 1294-1300.

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  1. Bobby Ramrez

    Interesting article , I am going to spend more time researching this topic