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Male hypogonadism

Checked: 23-08-2022 by Vicky Ryan Next Review: 23-08-2020

Overview

These guidelines have been provided by the Endocrinology Team at NBT so pathways might be slightly different at UHBW

Definition

A clinical syndrome that results from a failure of the testes to produce physiological concentrations of testosterone

Abnormalities at the testes produce primary hypogonadism whereas defects of the hypothalamus or pituitary produce secondary hypogonadism

Important points

Primary hypogonadism produces low testosterone, impairment of spermatogenesis and elevated gonadotrophin levels. Causes include Klinefelter’s Syndrome, Cryptorchidism, trauma, some types of cancer chemotherapy, pelvic radiotherapy, infections including mumps

Secondary hypogonadism produces low testosterone, impairment of spermatogenesis and low/normal gonadotrophins. Causes include hyperprolactinaemia, severe obesity, hypothalamic or pituitary tumours, anabolic steroid use, pituitary surgery/irradiation or idiopathic

Distinction between the two is important as it can have therapeutic implications for fertility

Who to refer

Routine Endocrine referral for any patient with hypogonadism (primary or secondary)

Red Flags

Urgent referral in the following cases:

9am cortisol < 100nmolL or symptoms suggestive of acute adrenal insufficiency (see separate adrenal insufficiency guidance)
Visual field abnormalities
Prolactin >5000mU/L – likely to represent a macroprolactinoma as the cause

Before referral

Take a thorough history and clinical examination to ascertain the signs and symptoms of testosterone deficiency

Specific signs – incomplete or lack of sexual development, very small testes (<6mls), loss of axillary/pubic hair
Suggestive signs and symptoms – reduced libido, erectile dysfunction, gynaecomastia, infertility, early onset osteoporosis, hot flushes/sweats
Non-specific symptoms – decreased energy, low mood, poor concentration, mild unexplained anaemia, reduced muscle bulk and strength, increased body fat

Further investigations

FBC, lipid profile, HbA1c and PSA (to guide possible testosterone therapy), LFTs

Measure morning fasting total testosterone

SHBG – measure in those affected by conditions that can alter the SHBG

Obesity
Diabetes mellitus
Steroid use
Hypo and hyperthyroidism
Acromegaly
Nephrotic syndrome and chronic kidney disease
Age >50 years
Cirrhosis
Anti-convulsant use

If the total testosterone and free testosterone are normal – investigate for other causes of the patient’s symptoms

If the total testosterone and free testosterone are low – confirm by repeating a 9am fasting testosterone

LH/FSH:

High – primary hypogonadism
- Request a testicular ultrasound and refer routinely to Endocrinology for discussion regarding karyotype assessment
Low or normal – likely to represent secondary hypogonadism
- Complete pituitary panel – 9am cortisol, ferritin, TSH, free T4, IGF-1, prolactin
- Assess visual fields

Services

Endocrinology NBT

Endocrinology UHBW

Resources

References:

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