Testosterone (T) is an important male hormone. Its main tasks are related to the regulation of sexual functions, sperm production and reproduction, the development of genital organs, the development of male secondary sex characteristics (increase in muscle mass, male-specific hair growth, etc.). In testosterone deficiency, symptoms and complaints related to these functions occur. In this article, I will provide up-to-date information on the causes, symptoms, diagnosis and treatment of low T (deficiency, hypogonadism) in men.

What is/means hypogonadism in men?

Hypogonadism means a lack or low testosterone. Since these patients are deficient in the testosterone hormone, symptoms related to this hormone deficiency are observed. Normally, the T hormone is responsible for the increase in muscle mass, sperm production, hair and beard development, pubic hair growth, penis enlargement and male voice character development during puberty. Testosterone deficiency occurs at different stages of life.

What are the signs/symptoms of low testosterone?

Hypogonadism can begin during fetal development, before puberty or later in adulthood. Symptoms of testosterone deficiency vary according to the age at which the disease occurs.

Symptoms of hypogonadism developing in the fetal period vary according to the degree of T deficiency. Although the child is genetically male, there is a problem in the genital organs;

• Insufficient development of male external genitalia
• Feminine genitalia
• Ambigous genitalia (it is not clear whether the external genitalia is male or female)

Puberty

• Insufficient development of muscle mass
• The lack of development of male voice character
• Insufficient growth of hair, beard, genital area and body hair
• Insufficient development of the penis and testicles
• Longer extremities such as arms and legs compared to the trunk
• Enlargement of the breasts (gynecomastia)

Adult age

• Decreased sexual desire
• A general lack of energy
• Depression and general mood disorder
• Erection problems
• Infertility problems
• Reduction in muscle mass
• Reduction in hair beard and general hair distribution
• Osteoporosis (weakening of bones)
• Mental and emotional problems
• Lack of concentration in daily work
• Hot flashes

What are the causes of low testosterone?

The causes of low testosterone are mainly examined in 2 main groups:

• Primary causes: There is a failure of the testicles, the main organ where testosterone is produced. Due to the problem in the testicles, the testosterone hormone is at low levels.
• Secondary causes: There is a problem in the central nervous system, in organs called pituitary and hypothalamus. These organs secrete testicular stimulating hormones and stimulate the production of testosterone from the testicles. GNRH (gonadotropin-releasing hormone) is secreted from the hypothalamus, which stimulates the pituitary. Hormones called FSH and LH are secreted from the pituitary. As a result of the deficiency of these stimulating hormones (GNRH, FSH, LH), the testicles cannot produce enough T hormone and hypogonadism develops.

What are the causes of primary hypogonadism?

The primary causes of low testosterone in men, that is, due to a disorder in the testicles, are as follows;

• Klinefelter syndrome: This condition is caused by a defect in the X and Y chromosomes. A normal male has one X and one Y chromosome. These patients have one Y chromosome and two or more X chromosomes.
• Undescended testis (cryptorchidism): the testis should normally be located in the scrotum. In some children, the testicles may be in the groin or in the abdomen, not where they should be normally. In this case, because the testicles cannot develop sufficiently, there is an insufficiency in T production.
• Mumps orchitis: Mumps virus can sometimes also infect the testicles. This condition is called orchitis. In mumps orchitis in adult or adolescence, testicular damage may develop and sperm production is impaired.
• Bacterial orchitis: Testicular inflammation caused by different microorganisms may cause testosterone deficiency.
• Testicular trauma: As a result of trauma to the testicles for various reasons, testicular damage and low testosterone may occur depending on the degree of trauma. If a testicle is normal, it’s usually okay.
• Radiotherapy and chemotherapy: In patients undergoing chemotherapy (drug therapy) or radiotherapy (radiation therapy) for cancer, the testicles may have problems in the production of sperm and testosterone.
• Hemochromatosis: This disease is a metabolic disease. As a result of excessive iron accumulation in the testicles and pituitary gland, disruptions in the hormone production of the organs occur. If only one testicle is involved and the other is normal, testosterone production is usually normal.

What are the causes of secondary hypogonadism?

In secondary hypogonadism, the testicles are normal, but there is a problem in the central nervous system (pituitary and hypothalamus) and therefore not enough T hormone can be produced from the testicles. Common causes of secondary hypogonadism are;

• Kallman syndrome: There is a problem in the central nervous system here. Because of this disorder, enough testicular stimulating hormone cannot be secreted from the hypothalamus. Kalmam syndrome may also have vision problems such as olfactory and red-green color blindness.
• Pituitary gland diseases: Pituitary gland tumors in the central nervous system, tumors adjacent to the pituitary gland, the pituitary gland is adversely affected due to previous surgery or radiation. As a result of these, the hormone stimulating the testicles cannot be secreted sufficiently from the pituitary and as a result, low T occurs.
• Chronic inflammatory diseases: Hypogonadism can be seen as a result of diseases affecting the pituitary and hypothalamus such as sarcoidosis, histiocytosis X, tuberculosis.
• HIV/AIDS: These diseases are sexually transmitted diseases. They cause T deficiency by affecting the hypothalamus and pituitary.
• Drug habits: Some hormones, addictive drugs negatively affect T production.
• Diabetes (Diabetes): If diabetes is prolonged and uncontrolled, it reduces T production.
• Excess weight (obesity): Excess weight can reduce T production.
• Advanced age: As a result of aging, T hormone production decreases.
• Genetic diseases: Some genetic diseases affect T production negatively.
• Excessive smoking and alcohol use: Excessive alcohol and smoking affect the hormonal balance negatively.
• Liver and kidney diseases: Cirrhosis and kidney failure impair hormone production.
• Excessive stress: A stressful work environment and social life negatively affect T levels.

What are the risk factors for low testosterone?

There are some risk factors that may adversely affect T formation. These risk factors are preventable factors. If the urologist gives preventive advice to his patients, no serious problems will be encountered. Important risk factors for hypogonadism, ie low testosterone, in men are:

• HIV/AIDS
• Advanced age
• Excess weight
• Nutritional disorders
• Patients who previously received radiotherapy for cancer
• Patients receiving chemotherapy for cancer
• Familial reasons

What kind of problems will occur if low T is not treated?

T deficiency in men can lead to some serious problems if left untreated. Common problems (complications) related to low T are as follows;

• Insufficient development of male genital organs
• Gynecomastia (breast enlargement in men)
• Infertility (infertility)
• Sexual dysfunctions (erectile dysfunction, impotence)
• Weakening in bones (osteoporosis, osteoporosis)
• Person not feeling well
• Concentration problem
• Mental problems
• Problems in social life
• Problems in professional life
• Familial problems

How is low testosterone diagnosed?

Diagnosing T-deficiency is crucial for an appropriate treatment. Early diagnosis and treatment of hypogonadism is very important for the following reasons:

• If treatment is started early in young children, the onset of puberty (adolescence) will not be delayed.
• The development of osteoporosis (bone loss) is prevented
• Hair, beard and hair distribution is regular
• Penis development becomes normal
• Muscle mass development becomes healthier

We can list the steps to be taken to diagnose this disease as follows;

• Examination: In the examination, genital examination (penis and testis examination), male hair growth and muscle development are evaluated.
• Serum testosterone hormone measurement: The ideal time for T measurement is before 10 am.
• FSH and LH test: These are pituitary-derived tests. In the absence of these, the testicles cannot produce enough T.
• Spermiogram: If there is a child problem in adult men, a sperm test is done.
• Radiological tests: Tests such as CT, MRI may be requested to evaluate the pituitary gland.
• Genetic tests: Some genetic tests can be performed when necessary.
• Testicular biopsy: With the biopsy taken from the testicles, it can be understood whether there is sperm production or T production.

What are the preventive treatment methods for low testosterone?

In patients with T deficiency, it is possible to keep hormone levels at normal levels with appropriate lifestyle and diet. In our study on rats, we have shown that rats who regularly do swimming have an increase in T levels compared to those who do not. We presented this study at international congresses and published it in an internationally respected medical journal. We recommend the following to our adult patients to prevent T deficiency;

• Losing weight
• Regular sport
• Not using alcohol and smoking
• Healthy eating
• Control of diabetes

How is low testosterone treated?

Treatment of this disease varies according to the age of the patient. The treatment of the disease differs according to the diagnosis at an early age or later in adolescence.

Treatment of low T in children

 If hormone deficiency is detected before puberty, normal masculine development is achieved with hormone therapy. With the treatment to be applied for 3 or 6 months, puberty begins, pubic and facial hair appears, penis enlargement occurs and an increase in muscle mass is achieved.

Treatment of T deficiency in adult males

There are different ways of treating T deficiency in adults. The doctor chooses the appropriate treatment for the patient. These treatment methods are:

• Testosterone gel: There are different gel-form preparations for this purpose. These are applied to the hairless areas of the body and absorbed from there, thereby increasing the blood hormone.
• Injection therapies: These are long-acting injections. These injections are made every 10-12 weeks, and in this way, the blood hormone level is kept normal for a long time. These treatments must be performed under the control of a urologist. Otherwise, it has serious side effects. We usually prefer these drugs to our patients.
• Patch-shaped medication applications: Applications containing hormones in the form of patches are adhered to the skin.
• Medicines in the form of chewing gum: These are medicines that are chewed in the mouth in the form of gum.
• Nasal sprays: These are drugs that are sprayed into the nostrils and contain testosterone.
• Implants: These are implants that are placed under the skin with a small incision and contain T hormone. It should be renewed every 3-6 months.

What are the complications of hypogonadism treatment?

Testosterone deficiency treatment has some complications, side effects. These occur due to the T hormone. The doctor should consider these during treatment. Side effects due to testosterone therapy are as follows;

• Acne development
• Disruptions in sleep patterns
• Prostate enlargement and prostate cancer in elderly patients
• Overproduction of white cells in the blood
• Disruptions in sperm production
• Changes in breasts

In summary: Testosterone is a very important hormone in men. In its deficiency, problems can be seen according to childhood and adult age. If there is a deficiency in children, the development of the penis is not sufficient, puberty begins late. In case of deficiency in adults, sexual problems, infertility, weakening of muscle mass, failure to develop male characteristics such as hair and beard, and mental problems may occur. In the treatment, the testosterone hormone, which is deficient, must be brought to normal levels. The treatment must be done by a urologist who is an expert in the field.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY