Symptoms of Low Testosterone (Hypogonadism)
Low testosterone (hypogonadism) presents with a specific constellation of symptoms including reduced energy, reduced endurance, diminished work/physical performance, fatigue, depression, reduced motivation, poor concentration, impaired memory, irritability, infertility, reduced sex drive, and erectile dysfunction. 1
Primary Symptoms
Sexual Function Symptoms
- Decreased libido (reduced sex drive)
- Erectile dysfunction
- Decreased volume of ejaculate
- Infertility
Physical Symptoms
- Reduced energy and endurance
- Increased fatigue
- Diminished muscle mass and strength
- Increased body fat (especially central adiposity)
- Decreased bone density
- Loss of body and facial hair
- Gynecomastia (enlarged breast tissue in men)
- Anemia
Psychological and Cognitive Symptoms
- Depression
- Anxiety
- Irritability
- Reduced motivation
- Poor concentration
- Impaired memory
- Diminished sense of well-being and vitality
Special Clinical Presentations
In certain populations, low testosterone may present with additional or specific symptoms:
- Men with HIV: Higher risk of hypogonadism, especially those on protease inhibitors 1
- Men with diabetes: Higher prevalence of hypogonadism with pronounced sexual dysfunction 1
- Older men: Often called "andropause" or "androgen deficiency of the aging male" with gradual onset of symptoms 1
Diagnostic Considerations
The diagnosis of testosterone deficiency requires:
- Consistently low total testosterone levels (<300 ng/dL) on at least two separate morning measurements 1
- Presence of symptoms and/or signs consistent with low testosterone 1
High-Risk Populations
Consider measuring testosterone levels even without symptoms in men with:
- Unexplained anemia
- Bone density loss
- Diabetes
- History of chemotherapy or testicular radiation
- HIV/AIDS
- Chronic narcotic use
- Male infertility
- Pituitary dysfunction
- Chronic corticosteroid use 1
Common Pitfalls in Diagnosis
- Relying on a single testosterone measurement: Diagnosis requires at least two separate morning measurements 1
- Using screening questionnaires alone: These are not recommended for diagnosis due to variable sensitivity and specificity 1
- Ignoring the need for symptoms: Laboratory values alone are insufficient; clinical symptoms must be present 1
- Overlooking the timing of blood draws: Testosterone should be measured in the early morning when levels are highest 1
- Failing to consider age-related decline: Testosterone levels naturally decrease with age at approximately 1.6% per year starting in mid-30s 1
Treatment Considerations
Treatment decisions should be based on:
- Severity of symptoms
- Laboratory confirmation of low testosterone
- Patient's goals (particularly regarding fertility)
- Presence of contraindications
The American College of Physicians suggests discussing testosterone treatment only for men with sexual dysfunction who want to improve sexual function, with periodic reevaluation within 12 months 1.
Remember that testosterone replacement therapy carries potential risks including erythrocytosis, fluid retention, and concerns about prostate health that must be weighed against benefits 1.