What is the management plan for a 30-year-old male with hypogonadism, low LH, and low testosterone levels?

Management of Secondary Hypogonadism with Suppressed LH

This 30-year-old male has secondary (hypogonadotropic) hypogonadism requiring immediate evaluation for pituitary pathology and fertility-preserving treatment options, not testosterone replacement therapy. 1

Critical Diagnostic Clarification

Your laboratory values appear to contain reporting errors that need immediate verification:

• Testosterone 33.1 mmol/L (if accurate) = approximately 9,540 ng/dL, which is supraphysiologic and inconsistent with hypogonadism 1
• Free testosterone 980 nmol/L (if accurate) = approximately 282,000 ng/dL, which is physiologically impossible 1
• LH <0.1 is profoundly suppressed, indicating either secondary hypogonadism OR exogenous androgen use 1, 2

Most likely scenario: These values suggest either laboratory error in units OR exogenous testosterone/anabolic steroid use causing suppression of the hypothalamic-pituitary-gonadal axis. 2, 3

Immediate Evaluation Required

1. Confirm True Hormone Status

• Repeat morning (8-10 AM) total testosterone using an accurate, reliable assay on at least two separate occasions 1
• Measure LH and FSH simultaneously to confirm hypogonadotropic pattern 1
• Obtain detailed medication/supplement history, specifically asking about testosterone, anabolic steroids, opioids, or GnRH agonists/antagonists 2

2. Rule Out Pituitary Pathology (MANDATORY)

If testosterone is truly low with LH <0.1, this patient requires:

• Serum prolactin measurement - elevated prolactin can indicate prolactinoma 1
• Pituitary MRI - men with testosterone <150 ng/dL and low/low-normal LH require imaging regardless of prolactin levels to identify non-secreting adenomas 1
• If prolactin is elevated, repeat measurement to exclude spurious elevation, then refer to endocrinology 1
• Assess other pituitary hormones (TSH, cortisol, IGF-1) to rule out combined pituitary hormone deficiency 1, 2

3. Evaluate for Secondary Causes

• Iron studies - hemochromatosis can cause hypogonadotropic hypogonadism 1, 4
• HIV testing - HIV infection is associated with hypogonadism 1, 2
• Review for systemic diseases - chronic illness, organ failure can suppress gonadotropins 2, 4

Treatment Algorithm

If Fertility is Desired (Age 30 Makes This Critical)

Testosterone replacement therapy is absolutely contraindicated if fertility is a consideration. 1, 3

• First-line: Gonadotropin therapy (hCG with or without FSH) to stimulate testicular function and preserve spermatogenesis 1, 5
• Alternative: Selective estrogen receptor modulators (SERMs) like clomiphene for men with secondary hypogonadism wishing to preserve fertility 1
• Aromatase inhibitors may also be considered in combination with other therapies 1

If Fertility is NOT Desired

Only after confirming true hypogonadism and completing pituitary evaluation:

• Testosterone replacement therapy improves sexual function, well-being, muscle mass, and bone density 1
• Transdermal preparations (gel/patch) provide stable daily testosterone levels and are generally preferred 1, 3
• Injectable testosterone esters are cost-effective alternatives with less frequent dosing 1, 4
• Monitor testosterone levels at 2-3 months after initiation, then periodically 1, 3
• Target testosterone range: 350-750 ng/dL 3

Critical Pitfalls to Avoid

• Never start testosterone without ruling out pituitary tumor - this can mask serious pathology 1, 4
• Never use testosterone in men desiring fertility - it suppresses spermatogenesis and can cause azoospermia 1, 3
• Never diagnose hypogonadism on single measurement - requires two morning samples 1
• Never ignore exogenous androgen use - anabolic steroids, testosterone, or SARMs will suppress LH and cause secondary hypogonadism 2, 3

Monitoring on Treatment

• Hematocrit - testosterone increases red blood cell production 3
• Prostate examination and PSA - baseline and periodic monitoring 1, 3
• Lipid panel and glucose - testosterone affects metabolic parameters 1
• Bone density - if prolonged hypogonadism was present 1

Referral Indications

Immediate endocrinology referral if: 1

• Persistently elevated prolactin
• Pituitary mass on imaging
• Multiple pituitary hormone deficiencies
• Testosterone <150 ng/dL with low LH (requires MRI first) 1