Treatment of Low Energy Due to Hypogonadism
Testosterone replacement therapy is the treatment of choice for low energy due to hypogonadism, with transdermal preparations recommended as first-line therapy for most hypogonadal men due to their ability to produce normal serum testosterone concentrations and patient convenience. 1
Diagnosis of Hypogonadism
Before initiating treatment, proper diagnosis is essential:
- Morning total testosterone concentration should be drawn between 8 AM and 10 AM
- Free testosterone level by equilibrium dialysis should be measured, especially in obese patients
- Sex hormone-binding globulin level should be checked in patients with obesity
- If testosterone levels are subnormal, they should be repeated
- Measure luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to distinguish primary (testicular) from secondary (pituitary-hypothalamic) hypogonadism
Additional workup for secondary hypogonadism:
- Serum prolactin
- Iron saturation
- Pituitary function testing
- MRI of sella turcica if indicated 1
Treatment Options
First-line therapy:
- Transdermal testosterone preparations (gel, patch)
- Advantages: Stable day-to-day testosterone levels, avoids discomfort of injections
- Disadvantages: Potential skin irritation, variable absorption, higher cost, risk of transfer to others 1
Alternative options:
Intramuscular testosterone injections
- Advantages: Lower cost, less frequent administration, good for patients with reduced self-management skills
- Disadvantages: Fluctuating testosterone levels, injection discomfort 1
Implantable testosterone pellets
- Advantages: Long-term option
- Disadvantages: Requires implantation procedure 1
Special considerations:
- For men with hypogonadotropic hypogonadism interested in fertility:
- Human chorionic gonadotropin (hCG) injections (500-2500 IU, 2-3 times weekly)
- FSH injections may be added after testosterone levels normalize on hCG 1
Monitoring
- Test testosterone levels 2-3 months after treatment initiation or dose change
- Once stable levels are confirmed, monitor every 6-12 months
- For injections: measure levels midway between injections
- Target normal testosterone range (300-800 ng/dL in most laboratories) 1
Expected Benefits for Low Energy
Testosterone replacement in men with hypogonadism has been associated with:
- Improved energy levels (90% of patients report lack of energy as most bothersome symptom) 1
- Weight loss
- Improved insulin resistance
- Improved metabolic parameters
- Increased lean body mass
- Improved sexual function and quality of life 1
Important Cautions
- Do not use exogenous testosterone in men interested in current or future fertility as it suppresses spermatogenesis 1
- Recovery of sperm after cessation of testosterone therapy may take months or even years
- Carefully evaluate cardiovascular risk before initiating therapy, especially in elderly men 2
- Consider testosterone assessment only in patients with signs and symptoms of hypogonadism including decreased energy, libido, muscle mass, body hair, hot flashes, gynecomastia, or infertility 1
Testosterone replacement therapy should be initiated when morning free testosterone is frankly low on at least two separate assessments and a complete hypogonadism workup has been performed to rule out other causes of hypogonadism unrelated to the primary condition.