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Hypogonadism in men

Last reviewed: 12 Apr 2025
Last updated: 07 Jun 2024

Summary

Definition

History and exam

Key diagnostic factors

  • decreased libido
  • loss of spontaneous morning erections
  • erectile dysfunction
  • gynecomastia
  • infertility
  • micropenis
  • small testes
  • bifid or hypoplastic scrotum
  • cryptorchidism, especially if bilateral
  • segmental dysproportion
  • bitemporal hemianopia
  • low trauma fractures
  • loss of height
  • anosmia
Full details

Other diagnostic factors

  • decreased energy and fatigue
  • absent or incomplete puberty
  • scrotal hypoplasia, hypopigmentation, and absent rugae
  • decreased muscle mass and strength
  • loss of axillary and pubic hair
  • lack of facial hair
  • poor concentration and memory
  • depressed or labile mood
  • sleep disturbance
  • hot flashes and sweats
  • tall stature
  • fine wrinkling of facial skin
Full details

Risk factors

  • genetic anomaly
  • type 2 diabetes mellitus
  • use of alkylating agents, opioids, or glucocorticoids
  • use of exogenous sex hormones and GnRH analogs
  • hyperprolactinemia
  • parasellar tumor or apoplexy of pituitary macroadenoma
  • testicular damage
  • infection
  • varicocele
Full details

Diagnostic tests

1st tests to order

  • serum total testosterone
Full details

Tests to consider

  • serum sex hormone binding globulin (SHBG)
  • calculated free testosterone
  • serum LH/FSH
  • semen analysis
  • CBC
  • serum prolactin
  • serum transferrin saturation and ferritin
  • MRI pituitary
  • genetic testing
  • dual-energy x-ray absorptiometry (DEXA or DXA)
Full details

Treatment algorithm

ONGOING

nongonadal illness

not desiring fertility currently: primary hypogonadism

not desiring fertility currently: secondary hypogonadism

desiring fertility currently: primary hypogonadism

desiring fertility currently: secondary hypogonadism

Contributors

Authors

Richard Quinton, MD FRCP(Edin)

Consultant and Senior Lecturer

Department of Endocrinology, Diabetes & Metabolism

Newcastle upon Tyne Hospitals

Translational & Clinical Research Institute

University of Newcastle upon Tyne

Newcastle upon Tyne

UK

Disclosures

RQ has received speaker fees from Besins Healthcare UK. RQ is an author of a reference cited in this topic.

Channa N. Jayasena, PhD FRCP FRCPath

Consultant and Reader in Reproductive Endocrinology/Andrology

Department of Investigative Medicine

Hammersmith Hospital

Imperial College London

London

UK

Disclosures

CNJ has an investigator-led research grant from LogixX Pharma Ltd. CNJ is supported by a National Institute for Health Research (NIHR) Post-Doctoral Fellowship. CNJ is an author of several references cited in this topic.

Acknowledgements

Dr Richard Quinton and Dr Channa N. Jayasena would like to gratefully acknowledge Dr Charles Welliver, Dr T. Hugh Jones, Dr Milena Braga-Basaria, and Dr Shehzad Basaria, previous contributors to this topic.

Disclosures

CW has worked as a consultant for Coloplast, and as an investigator for Auxilium Pharmaceuticals, Mereo BioPharma, PROCEPT BioRobotics, and Repros; and he is a paid reviewer at Oakstone Publishing and BMJ Best Practice. CW also has a family member who is an employee at Bristol-Myers Squibb. THJ and SB are authors of references cited in this topic. MB declared that she had no competing interests.

Peer reviewers

Randal J. Urban, MD

Professor

Department of Internal Medicine

University of Texas Medical Branch

Galveston

TX

Disclosures

RJU declares that he has no competing interests.

Niki Karavitaki, MBBS, MSc, PhD

Consultant Endocrinologist

Oxford Centre for Diabetes, Endocrinology and Metabolism

Churchill Hospital

Oxford

UK

Disclosures

NK declares that she has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Mulhall JP, Trost LW, Brannigan RE, et al. Evaluation and management of testosterone deficiency: AUA guideline. J Urol. 2018 Aug;200(2):423-32.Full text  Abstract

Jayasena CN, Anderson RA, Llahana S, et al. Society for Endocrinology guidelines for testosterone replacement therapy in male hypogonadism. Clin Endocrinol (Oxf). 2022 Feb;96(2):200-19.Full text  Abstract

Matsumoto AM. Diagnosis and evaluation of hypogonadism. Endocrinol Metab Clin North Am. 2022 Mar;51(1):47-62. Abstract

Bhasin S, Brito JP, Cunningham GR, et al. Testosterone therapy in men with hypogonadism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2018 May 1;103(5):1715-44.Full text  Abstract

European Association of Urology. EAU guidelines on sexual and reproductive health. 2024 [internet publication].Full text

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
  • Differentials

    • Pituitary macroadenoma
    • Prolactinoma
    • Hyperprolactinemia
    More Differentials
  • Guidelines

    • The British Society for Sexual Medicine guidelines on male adult testosterone deficiency, with statements for practice​
    • Hormones and aging: an Endocrine Society scientific statement
    More Guidelines
  • Patient information

    Erection problems

    Fertility problems: some reasons

    More Patient information
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