What is the primary treatment for hypogonadism (low sex hormone production)?

Primary Treatment for Hypogonadism

Testosterone replacement therapy (TRT) is the primary treatment for hypogonadism, with the specific approach depending on whether the condition is primary (testicular) or secondary (hypothalamic-pituitary) in origin. 1, 2

Diagnosis and Classification

• Diagnosis requires both persistent specific symptoms and confirmed testosterone deficiency through biochemical testing 3
• Morning serum total testosterone measurements should be repeated to confirm low levels 2
• Classify as primary (elevated LH/FSH) or secondary (low/normal LH/FSH) hypogonadism to guide treatment approach 2

Treatment Options Based on Type of Hypogonadism

Primary Hypogonadism (Testicular Failure)

• Testosterone replacement therapy is the only effective treatment 1, 4
• Available formulations include:
  • Intramuscular testosterone injections (cypionate or enanthate) administered every 2-3 weeks 2, 1
  • Transdermal preparations (gels, patches) providing more stable day-to-day testosterone levels 2
  • Long-acting injectable testosterone undecanoate for patients preferring less frequent administration 5

Secondary Hypogonadism (Hypothalamic-Pituitary Dysfunction)

• For patients NOT concerned about fertility:
  • Testosterone replacement therapy as described above 2, 1
• For patients wishing to preserve fertility:
  • Human chorionic gonadotropin (hCG) is the first-line treatment (500-2500 IU, 2-3 times weekly) 3
  • Add follicle-stimulating hormone (FSH) after testosterone levels normalize on hCG if needed 3, 6
  • Pulsatile gonadotropin-releasing hormone (GnRH) therapy may be used for hypothalamic defects but is not currently approved in the US or Europe 3, 6

Important Considerations

• Fertility concerns: Exogenous testosterone suppresses spermatogenesis and should NOT be prescribed to men interested in current or future fertility 3
• Recovery of sperm after cessation of testosterone therapy can take months or even years 3
• For obese patients with secondary hypogonadism, weight loss through diet and exercise can improve testosterone levels 3, 2
• Monitor testosterone levels 2-3 months after treatment initiation and after any dose change 2

Expected Benefits of Treatment

• Improved sexual function and libido 2
• Potential improvements in body composition, energy levels, and mood 2
• Possible improvements in metabolic parameters (glucose, insulin resistance, lipid profile) 2

Potential Side Effects and Monitoring

• Erythrocytosis (elevated hematocrit), particularly with injectable forms 2
• Fluid retention, potential worsening of benign prostatic hyperplasia 2
• Regular monitoring of hematocrit, PSA, and testosterone levels is essential 2

Treatment Algorithm

1. Confirm diagnosis with symptoms plus low testosterone levels on two separate morning measurements 3, 2
2. Determine if primary or secondary hypogonadism through LH/FSH levels 2
3. Assess fertility desires:
   • If fertility desired: Use gonadotropins (hCG ± FSH) for secondary hypogonadism 3, 7
   • If fertility not a concern: Testosterone replacement therapy 2, 1
4. Select testosterone formulation based on patient preference, cost considerations, and risk profile 2, 5
5. Monitor response and adjust treatment as needed 2

Remember that testosterone therapy is contraindicated in men with breast cancer and should be used with caution in men with severe lower urinary tract symptoms 3, 2.