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Figure 5. Classification of Hypogonadism22,24

HPG, hypothalamic-pituitary-gonadal.

concentration should be obtained to determine whether the low level is the result of a defect at the testicular level or at the

hypothalamic-pituitary-gonadal axis (Figure 5).22,24 however, diagnosis is not that simple.

In practice,

There is no established threshold for testosterone that defines hypogonadism; there is no “magic number.”25 Further, measurements vary depending on circadian and circannual rhythms, episodic secretion, variations in assays, and variations in SHBG concentrations.22

Expert snapshot

Question: What range of testosterone levels prompts further investigation?

Answer: 200 to 400 ng/dL

According to the Endocrine Society, a man should be screened for hypogonadism if he presents with any of the following conditions22:

  • Sellar mass, radiation to the sellar region, or other diseases of the sellar region

  • Medications that affect testosterone production or metabolism

  • Weight loss associated with human immunodeficiency syndrome

  • End-stage renal disease or maintenance hemodialysis

  • Moderate to severe chronic obstructive lung disease

  • Osteoporosis or low-trauma fracture (particularly in younger men)

  • Type 2 diabetes or metabolic syndrome


Physical examination and history

A detailed physical examination and comprehensive history is important in the diagnosis of hypogonadism.24 Specifics that should be elicited and documented in this process are outlined in Table 2.

Table 2. Evaluating Adult Men With Suspected Hypogonadism

  • Comprehensive history22,24

  • Gynecomastia22,24

  • Secondary sexual characteristics (decreased body hair, decreased beard growth)22,24

  • Testicular examination, noting size and consistency22,24

    • Approximate ranges for normal adult testes24

      • Volume 20-30 mL

      • Length 4.5-6.5 cm

      • Width 2.8-3.3 cm

  • Prostate assessment, noting palpability24

  • Body mass index22


Several tools are available to screen for testosterone deficiency in men, but each one lacks sensitivity or specificity. Therefore, it might be preferable to use probing questions.

Expert snapshot

Because time constraints are always an issue, office questionnaires for medical history and reasons for visit should include 1 or 2 questions to trigger further investigation by the physician into causes of low testosterone.

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