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Multidisciplinary Insights Into the Assessment, Diagnosis, and Management of Hypogonadism


Clinicians face a variety of diagnostic challenges with regard to hypogonadism, including recognizing a constellation of signs and symptoms and not solely looking at decreased testosterone levels. Signs and symptoms are often vague, particularly in middle-aged and older men in whom age-related conditions can overlay symptoms of testosterone deficiency, making it difficult to identify.21-23 Loss of libido and ED are 2 hallmark symptoms of hypogonadism. Lethargy is commonly seen in these men. Mood and behavioral symptoms, specifically depression, irritability, and loss of motivation, may also occur with low testosterone levels.11 Testosterone deficiency has a deleterious effect on bone mass and is a risk factor for osteoporosis. Furthermore, reduced muscle mass and muscle strength is associated with low testosterone levels. Regression of secondary sexual characteristics, such as reduced ancillary and pubic hair, is another sign of hypogonadism in men. Small testes (<4.0 x <2 cm) and gynecomastia suggest possible hypogonadism.

Expert snapshot Conditions seen most often in hypogonadal men at presentation:

  • Lethargy

  • Obesity

  • ED

Older patients


Poor concentration, height loss

Younger patients

vs =

Decreased energy, erectile dysfunction

Factors influencing the signs and symptoms of hypogonadism include age of onset, severity and duration, comorbid illnesses, variations in androgen sensitivity, and effects of previous testosterone therapy.10

The Endocrine Society created guidelines for diagnosing testosterone deficiency in men, emphasizing that a low level of testosterone is a major component of a diagnosis but only part of the syndrome22:

  • Diagnose hypogonadism in men with consistent signs and symptoms as well as low serum testosterone levels

  • Measure morning total testosterone by a reliable assay as the initial diagnostic test

  • Confirm low levels of total testosterone with repeat measurement and/or a free or bioavailable testosterone level

  • Do not diagnosis testosterone deficiency during an acute or subacute illness

Theoretically then, the algorithm for diagnosing hypogonadism should be straightforward: Evaluate a man’s general health and lifestyle and measure his testosterone levels (Figure 4).22 If a man has low levels of testosterone, a luteinizing hormone (LH)

Figure 4. Diagnostic Evaluation of Adult Men With Suspected Hypogonadism22

BT, bioavailable testosterone; FSH, follicle-stimulating hormone; FT, free testosterone; LH, luteinizing hormone; SFA, seminal fluid analysis; SHBG, sex hormone-binding globulin; T, testosterone. Reproduced with permission.


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