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Male hypogonadism. Dr.: Wael Farrag Ass. Prof. Internal Medicine Tanta Univ. Male hypogonadism is the inability of the testicles to produce testosterone, sperm or both. The condition also is known as testosterone deficiency.
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Male hypogonadism • Dr.: Wael Farrag • Ass. Prof. Internal Medicine • Tanta Univ.
Male hypogonadism is the inability of the testicles to produce testosterone, sperm or both. The condition also is known as testosterone deficiency. Testicles (testes) are external genital organs that are part of the male reproductive system. These two oval-shaped organs reside in a pouch of skin (scrotum) that hangs below the abdomen and behind the penis.
In addition to producing the sperm cells that are necessary for reproduction, the testicles secrete the male hormone testosterone. This hormone plays an important role in the development and maintenance of typical masculine physical characteristics. During fetal development, testosterone is necessary to form male genital organs.
During puberty, testosterone is essential for the development of secondary sexual characteristics, such as facial hair, greater muscle mass and a deeper voice. In adult males, testosterone maintains muscle mass and strength, fat distribution, bone mass, sperm production, sex drive and potency. Treatment of male hypogonadism depends on the cause and may involve testosterone replacement therapy.
Causes Hypogonadism is the deficiency of sex hormone production by the gonads — the testicles in men and the ovaries in women. These sex organs produce the hormones testosterone and estrogen, which ultimately determine the differences between men and women.
The two basic types of male hypogonadism are: Primary. This type of hypogonadism — also known as primary testicular failure — originates from an abnormality in the testicles. Secondary. This type of hypogonadism indicates a defect in the brain or in the pituitary gland that's connected to the brain and that controls hormone production. If chemical messages from the pituitary gland to the testicles aren't sent, impaired testicular function occurs.
Male hypogonadism can have many causes. Certain diseases and other malfunctions of the testicles or pituitary gland can cause testosterone deficiency. • Common causes of primary hypogonadism include: • Klinefelter's syndrome. This condition results from a congenital abnormality of the sex chromosomes, X and Y. A male normally has only one X and one Y chromosome. In Klinefelter's syndrome, two or more X chromosomes are present in addition to one Y chromosome. The Y chromosome contains the genetic material that determines the sex of a child and related development. The extra X chromosome that occurs in Klinefelter's syndrome causes abnormal development of the testicles.
Undescended testicles. Before birth, the testicles develop inside the male infant's abdomen and normally move down into their permanent place in the scrotum two months before birth. One or both of the testicles may not be descended at birth. This condition often corrects itself within the first few years of life without treatment. If not corrected in early childhood, it may lead to malfunction of the testicles. A boy born with an undescended testicle has a higher risk of infertility and testicular cancer.
Mumps orchitis. If a mumps infection involving the testicles in addition to the salivary glands (mumps orchitis) occurs during adolescence or adulthood, long-term testicular damage may occur. This may affect normal testicular function. Hemochromatosis. Too much iron in the blood can cause testicular failure or pituitary gland dysfunction.
Injury to the testicles. Because of their location outside the abdomen, the testicles are prone to injury. Damage to normally developed testicles can cause hypogonadism. Damage to one testicle may not impair testosterone production.
Cancer treatment. Chemotherapy or radiation therapy for the treatment of cancer can interfere with testosterone and sperm production. The effects of both treatments often are temporary, but permanent infertility may occur. Although many men regain their fertility within a few months after treatment ends, preserving sperm before starting cancer therapy is an option that many men consider.
Normal aging. Older men generally have lower testosterone levels than younger men do. As men age, there's a slow and continuous decrease in testosterone production. The rate that testosterone declines varies greatly among men. As many as 30 percent of men older than 75 have a testosterone level that's below normal.
In Secondary Hypogonadism • the testicles are normal but function improperly due to a problem with the pituitary or hypothalamus. A number of conditions can cause secondary hypogonadism, including: • Kallmann's syndrome. Defective development of the hypothalamus — the area of the brain that controls the secretion of pituitary hormones — can cause hypogonadism.
Impaired release of hormones by the hypothalamus causes inadequate secretion of pituitary and testicular hormones, resulting in testosterone deficiency. This abnormality is also associated with impaired development of the olfactory nerves at the front of the brain, causing the inability to smell (anosmia).
Pituitary disorders. An abnormality in the pituitary gland can impair the release of hormones from the pituitary gland to the testicles, affecting normal testosterone production. A pituitary tumor or other type of brain tumor located near the pituitary gland may cause testosterone or other hormone deficiencies.
HIV/AIDS. This virus can cause low levels of testosterone by affecting the hypothalamus, the pituitary and the testes. Medications. The use of certain drugs, such as opiate pain medications and some hormones, can affect testosterone production.
Also, the treatment for a brain tumor such as surgery or radiation therapy may impair pituitary function and cause hypogonadism. Inflammatory disease. Certain inflammatory diseases such as sarcoidosis, histiocytosis, tuberculosis and some fungal infections involve the hypothalmus and pituitary gland and can affect testosterone production, causing hypogonadism.
Risk factors • Risk factors for hypogonadism include: • Kallmann's syndrome • Undescended testicles as an infant • Mumps infection affecting your testicles • Prior trauma to your testicles • Testicular or pituitary tumors • HIV/AIDS • Klinefelter's syndrome • Hemochromatosis • Previous chemotherapy or radiation therapy
Hypogonadism can be hereditary. If any of these risk factors are in your family health history, inform your doctor. Be aware of and watch for signs and symptoms of hypogonadism.
Signs and symptoms The effects of male hypogonadism depend primarily on the stage of life at which they occur. They can occur during fetal development, puberty or adulthood. During each of these stages, the signs and symptoms are distinct.
Fetal development The sex chromosomes X and Y — you receive an X from your mother and either an X or a Y from your father — determine whether the gonads in an embryo develop into ovaries (XX) or testicles (XY). If testicles form, the hormone testosterone is produced and male sex organs develop.
Production of too little hormone by the gonads during early fetal development may impair the growth or functions of the internal and external sex organs. This can cause a condition in which the sex of the child is not clear by external examination at birth (ambiguous genitalia).
PubertyMale hypogonadism present at the time of puberty may slow growth and affect normal development. Body changes may include: • Decreased development of muscle mass • Lack of deepening of the voice • Impaired growth of body hair • Impaired growth of the penis and testicles • Excessive growth of the arms and legs in relation to the trunk of the body • Development of breast tissue (gynecomastia)
AdulthoodHypogonadism in adult males may alter certain masculine physical characteristics and impair normal reproductive function. Signs and symptoms may include: • Erectile dysfunction • Infertility • Decrease in beard and body hair growth • Increase in body fat • Decrease in size or firmness of testicles • Decrease in muscle mass • Development of breast tissue • Loss of bone mass (osteoporosis )
Mental and emotional changes also can accompany hypogonadism. As testosterone decreases, some men may experience symptoms similar to those of menopause in women. These may include: • Fatigue • Decreased sex drive • Difficulty concentrating • Hot flashes • Irritability • Depression
Examination 1- Testicular size; A- Adolescence: Tanner’s scoring.
Pubic Hair: P1 = preadolescent, no public hair. P2 = sparse, long slightly pigmented, downy hair. P3 = the hair is darker, coarser and curlier. P4 = adult type of hair covering a small limited area. P5= adult hair, in quantity and type of hair spreading as inverse traingle
Genital : G1 = Preadolescent, testes, scrotum and penis are as in early childhood. G2= scrotum and testes enlargement with reddening of scrotal skin. G3 = increase in length and breadth of penis. G4 = further enlargement of penis, scrotum and testes. The scrotum skin is darkened. G5= adult size of penis, scrotum and testes. No further enlargement of these organs after stage G5.
Examination • B- after Puberty: Normally 4-7 cm in length. • 2- Signs of secondary sexual characters: • * Chest and body hair, density of pubic hair. • 3- Gynecomastia: • The condition occurs in primary hypogonadism. • Cause: Deficient conversion of estradiol to testosterone by the aromatase enzyme. The condition occurs in primary hypogonadism.
4- Body proportions: • Tall stature: • Absence of testosterone at puberty causes delay in epiphyseal closure leading to continuous action of growth hormone that causes increase in length of logn bones. • Eunichoid proportions: • The lower body segment LS is 2cm more than the upper body segment U.S. • Arm span 5cm more than the height.
Screening and diagnosis Your doctor may test for a decreased testosterone blood level if you have any of the signs or symptoms of hypogonadism. Early detection in boys can help prevent adverse effects of delayed puberty. Early diagnosis and treatment in adult men offers better protection against osteoporosis and other related conditions.
Doctors base a diagnosis of hypogonadism on symptoms and results of blood tests that measure testosterone levels. Because testosterone levels vary and are generally highest in the morning, blood testing is usually done early in the day.
Diagnosis: • 1- Serum testosterone: • Total. • Free in conditions altering sex hormone binding globulin (SHBG) e.g. obesity. • Multiple measurements are advised due to the episodic secretion of testosterone. • Maximum at 8 am and minimum at 8 p.m.
2- Semen analysis: • Sperm count. • Sperm motility. • 3- Testicular biopsy. • 4- Pituitrary gonadotrophins: • FSH, LH • 5- Karyotyping: • Klinefelter syndrome. • 6- MRI for CNS: • - Space occupying lesions
Sperm count Testosterone FSH LH Primary hypogonadism Decreased Decreased Increased Increased Semineferous tubular damage Decreased Decreased Increased Increased Secondary Hypogonadism Normal of decreased decreased decreased decreased
When to seek medical advice See a doctor if you or your child has any signs or symptoms of male hypogonadism. Establishing the cause of hypogonadism is an important first step to getting appropriate treatment. You or your child may require a consultation with an endocrinologist, a physician who specializes in the hormone-producing (endocrine) glands. If your primary care physician suspects the condition is present, he or she may refer you to an endocrinologist. Or, you may ask for a referral yourself.
Treatment Treatment for male hypogonadism depends on the cause and if you're concerned about fertility. For hypogonadism caused by testicular failure, doctors use male hormone replacement (testosterone replacement therapy, or TRT). Although there's often no effective treatment to restore fertility in a man with primary hypogonadism, assisted reproductive technology (ART) may be helpful. ART covers a variety of techniques designed to help couples who have been unsuccessful in achieving conception.
If a pituitary problem is the cause, pituitary hormones may succeed in stimulating sperm production and restoring fertility. TRT can be used if fertility is not an issue. A pituitary tumor may require surgical removal, medication, radiation or the replacement of other hormones.
In boys, TRT can stimulate puberty and the development of secondary sex characteristics, such as increased muscle mass, beard and pubic hair growth, and growth of the penis. Pituitary hormones may be used to stimulate testicle growth. An initial low dose of testosterone with gradual increases may help to avoid adverse effects. In adult men, TRT can restore sexual function and muscle strength and prevent bone loss. In addition, men receiving TRT often experience an increase in energy, sex drive and sense of well-being.
Several testosterone delivery methods exist. Choosing a specific therapy depends on your preference of a particular delivery system, the side effects and the cost. Methods include: • Injection. Intramuscular testosterone injections are safe and effective. Injections are given approximately every two weeks. You may experience fluctuations in symptom relief between doses. You or a family member can learn to administer this method of TRT at home.
If you're uncomfortable administering injections, a nurse or doctor can give the injection. </1i> • Patch. A patch containing testosterone (Androderm) is applied each night to your back, abdomen, upper arm or thigh. The site of the application is rotated to maintain seven-day intervals between applications to the same site to lessen skin reactions.
Gel. You rub testosterone gel (AndroGel, Testim) into your skin on your lower abdomen, upper arm or shoulder. As the gel dries, your body absorbs testosterone through your skin. Gel application of testosterone replacement therapy appears to cause fewer skin reactions than patches. Avoid showering or bathing for several hours after an application to ensure adequate absorption. A potential side effect of the gel is the possibility of transferring the medication to your partner. You can avoid this by avoiding skin-to-skin contact until the gel is completely dry or by covering the area after an application .
Gum and cheek (buccal cavity). Striant, a small putty-like substance, delivers testosterone through the natural depression above your top teeth where your gum meets your upper lip (buccal cavity). This product rapidly adheres to your gumline and, as exposed to saliva, softens into a gel-like form, allowing testosterone to be absorbed directly into your bloodstream.
Side effects may include gum irritation or pain, bitter taste or headache. A recent study found this form of testosterone therapy may deliver a steadier dose of testosterone throughout the day. Oral. Taking testosterone orally is not recommended for long-term replacement. Testosterone taken by this method may cause an unfavorable cholesterol profile and increase your risk of blood clots and heart and liver problems.
Coping skills Adolescents with hypogonadism may have problems fitting in socially due to delayed sexual development. Testosterone replacement therapy can induce puberty, and when it's given at a slow pace that allows time for adjustment to physical changes and new feelings, it can be an effective treatment.
If hypogonadism occurs during adulthood, make lifestyle and dietary changes to prevent osteoporosis. Regular exercise and adequate amounts of calcium and vitamin D to maintain bone strength are important to reduce the risk of osteoporosis. The recommended daily allowance (RDA) for calcium is 1,000 milligrams (mg) for men younger than 65 and 1,500 mg a day for men older than 65. All men should get between 400 and 800 international units of vitamin D daily.
A supportive family that understands the diagnosis of hypogonadism is important. You may need psychological or family counseling. Support groups can help people with hypogonadism and related conditions cope with similar situations and challenges.
