Hypogonadism: Treatment, Diagnosis, and Prognosis

Hypogonadism is a condition where the sex glands produce little or no sex hormones. The sex glands are the testes in men and the ovaries in women. Testosterone is produced in the testes and estrogen is produced in the ovaries. These are the two main sex hormones produced by men and women, respectively.

Sex hormones control sexual characteristics, such as breast and testicular development as well as pubic hair growth. In addition, both testosterone and estrogen play major roles in the male and female reproductive systems, including menstrual cycles and sperm production. Humans would not survive without sex hormones!

Hypogonadism is also called gonad deficiency. In males, it may be called low testosterone/andropause and in women, prior to menopause, primary ovarian insufficiency. Thankfully, hypogonadism can usually be easily treated with hormone replacement therapy (HRT).

Types of Hypogonadism

There are two types: primary and central. Primary hypogonadism occurs when the gonads, or sex organs, have an issue in sex hormone production. The cells in the gonads are receiving the hormonal messages from the brain to produce testosterone or estrogen, but for some reason aren't doing so.

Central, or secondary, hypogonadism occurs when the hypothalamus and pituitary gland in the brain are not sending the right signals and one or both of them are experiencing issues doing their jobs. They are supposed to produce the hormone messengers that travel to the gonads and signal them to produce the sex hormones.

So What Causes Hypogonadism?

In primary hypogonadism, the causes include:

• autoimmune disorders: a condition where your immune system is accidentally attacking itself instead of foreign infectious agents. The immune system will mistake different cells of your body as a foreign agent such as protective coverings of nerves (multiple sclerosis), the joints (rheumatoid arthritis) or even the entire body (Lupus).
• Turner syndrome: a genetic condition that only affects females where one of her X chromosomes is missing or just partially missing. It requires ongoing medical care and causes several developmental issues including heart defects, failure of ovaries to develop and short height.
• Klinefelter syndrome (XXY Syndrome): a genetic condition that only affects males where he is born with an extra X chromosome copy. Symptoms and signs include smaller than normal testicles, reduced muscle mass, body and facial hair and enlarged breast tissue. It can lead to reproductive issues due to decreased sperm production.
• undescended testes (cryptorchidism): This happens before a baby is born and is when a testicle does not move down into the scrotum. It does require treatment as there is a higher risk of testicular cancer, torsion and the development of a hernia near the groin. Normally, the testicles descend into the scrotum because sperm cannot be produced at body temperature. If both testicles are affected, this can lead to infertility.
• radiation exposure: Exposure sources include chemotherapy and especially scatter radiation when patients with rectal cancer are treated with pelvic radiation. Other cancers can be treated with radiation therapy as well, leading to exposure. The radiation can damage the testicles, leading to impaired testosterone production.
• liver and kidney diseases: Chronic alcoholism, causing liver disease or impairment, leads to an impaired hypothalamic-pituitary axis. Systemic diseases can indirectly harm testicular function via gonadotropin suppression and eventually cause testicular failure. Testicular failure is associated with liver disease, alcoholism, chronic renal disease, rheumatic diseases and others.
• mumps involving the testicles: Mumps is caused by a virus and causes the swelling of the salivary glands and jaw. If the disease makes its way to the testicles, it can damage them. This damage can then affect testosterone production.

In central hypogonadism, the causes include:

• Kallmann syndrome (atypical development of the hypthalamus): The production of hormones in the hypothalamus that affect sexual development is impaired. Boys suffer from micropenis and undescended testicles. Secondary sex characteristics will also not develop during puberty. The hypothalamus is not producing enough testosterone.
• obesity: The most significant risk factor for testosterone deficiency in men. Obesity can cause increased levels of several hormones including oestrogens and causes hormonal imbalance. Hypogonadism itself can cause more weight gain, thus creating a self-perpetuating cycle.
• nutritional deficiencies: If the body is not getting proper nutrition, this can negatively affect the hypothalamic-gonadotropin hormonal axis. This is especially seen in girls who have eating disorders, causing amenorrhea (temporary loss of menstruation). The hormones insulin and leptin, which are affected by food intake and nutrition, are important links between nutrition and the gonadotropin axis. The adverse effects can be reversed.
• inflammatory diseases: These diseases include allergies, inflammatory bowel disease, autoimmune, hepatitis, etc. Chronic inflammation can cause damage to the body's healthy tissues and if these tissues include the gonads, hypogonadism can result.
• HIV: It is common to see HIV patients also exhibiting low testosterone levels -- approximately 70% of patients.
• pituitary gland or hypothalamic injury: An injury to the pituitary gland or hypothalamus, either physical trauma from an accident or from radiation can cause disproportionate hormonal release and signaling.
• pituitary gland tumors: These are also called pituitary adenomas and are noncancerous tumors that do not spread past the skull. A tumor can cause the pituitary gland to release either too many or too little of the hormones it typically releases. Symptoms include hormonal imbalance, headaches and loss of vision from pressure.
• opioid or steroid use/abuse: This is also called opioid-induced endocrinopathy when the opioid use suppresses the sex hormones. In general, opioids lower the levels of oxytocin, testosterone and estradiol in the human body.

Symptoms of Hypogonadism

Women who have primary ovarian insufficiency may experience:

• slow or no breast growth
• body hair loss
• low or no sex drive
• hot flashes
• lack of menstruation
• breast discharge

Men who have low testosterone may experience:

• body hair loss
• breast growth
• reduced growth of penis and testicles
• muscle loss
• hot flashes
• low or no sex drive
• erectile dysfunction
• fatigue
• infertility

Diagnosis of Hypogonadism

The first step in diagnosing hypogonadism is a physical exam. An examination of the amount of body hair, muscle mass and sex organ growth is compared to the standard amount or growth expected for the age range of the patient.

The next step involves a blood test. The level of sex hormones is measured as well as follicle-stimulating hormone (FSH) and luteinizing hormone. Both of these hormones work together in the male and female body to regulate the developments, growth and maturation of the reproductive system.

Both estrogen and testosterone levels are highest in the morning and this is when the blood will be drawn. Men may also be asked to supply a semen sample to check the sperm count as hypogonadism can lower a man's sperm count.

Other measurements may be taken including iron, prolactin and thyroid hormones. Hypogonadism symptoms are sometimes mistaken for thyroid issues as they both involve hormonal imbalance. Iron has a tendency to affect the levels of sex hormones in your blood. Prolactin is another hormone that promotes breast development and the production of breast milk. It's a good idea to check the levels of several hormones if hypogonadism is suspected to get more of a bigger picture as to what exactly is going on and what is high/low.

Lastly, an ultrasound may be used to look at the ovaries to check for cysts or polycystic ovary syndrome. MRIs or CT scans could be ordered to check for tumors on the pituitary gland.

Treatment of Hypogonadism

For women, the best treatment will be increasing the amount of sex hormones, such as estrogen therapy. This could be via patches or pills. If the female patient experiences low sex drive, she may be prescribed low doses of testosterone.

For men, testosterone replacement therapy will be utilized. The methods of supplementing testosterone include injections, patches, gels or creams.

Hypogonadism is a chronic condition and will most likely need to be treated for life, depending on what caused it. If it was caused by nutritional deficiencies, it may be easily corrected by supplementing with the lacking nutrients. If it is from a tumor on the pituitary gland, removal of the tumor may get things back in working order. Otherwise, once treatment is stopped, the sex hormone levels may decrease again.

If you think you may be suffering from hypogonadism (low testosterone or primary ovarian insufficiency) feel free to contact our HRT clinic to discuss your symptoms and how to get tested for the condition. We have representatives available to talk for free with no-obligation about any concerns you may have. Contact us via the contact form or simply give us a call!

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