Hypogonadism in men

Last reviewed: 24 Aug 2023
Last updated: 15 Aug 2023



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
More key diagnostic factors

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
Other diagnostic factors

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
More risk factors

Diagnostic investigations

1st investigations to order

  • serum total testosterone
More 1st investigations to order

Investigations 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)
More investigations to consider

Treatment algorithm


nongonadal illness

not desiring fertility currently: primary hypogonadism

not desiring fertility currently: central hypogonadism

desiring fertility currently: primary hypogonadism

desiring fertility currently: central hypogonadism



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



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




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.


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.


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


Department of Internal Medicine

University of Texas Medical Branch




RJU declares that he has no competing interests.

Niki Karavitaki, MBBS, MSc, PhD

Consultant Endocrinologist

Oxford Centre for Diabetes, Endocrinology and Metabolism

Churchill Hospital




NK declares that she has no competing interests.

  • Differentials

    • Pituitary macroadenoma
    • Prolactinoma
    • Hyperprolactinemia
    More Differentials
  • Guidelines

    • Evaluation and management of testosterone deficiency: AUA guideline
    • Testosterone therapy in men with hypogonadism
    More Guidelines
  • Patient leaflets

    Erection problems

    Fertility problems: some reasons

    More Patient leaflets
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