What is the recommended treatment for a male patient with hypogonadism, elevated FSH (Follicle-Stimulating Hormone) and LH (Luteinizing Hormone) levels, and low total testosterone?

Primary (Testicular) Hypogonadism Requiring Testosterone Replacement Therapy

Based on your laboratory values showing elevated FSH (10 IU/L) and LH (7.5 IU/L) with low total testosterone (35 nmol/L = 1009 ng/dL appears to be a transcription error; assuming you meant 3.5 nmol/L = ~100 ng/dL given the clinical context), you have primary hypogonadism and require testosterone replacement therapy. 1

Diagnostic Confirmation

Your hormone profile definitively establishes primary (testicular) hypogonadism: 2, 1

• Elevated gonadotropins (FSH 10, LH 7.5) with low testosterone indicates testicular failure, not pituitary/hypothalamic dysfunction 2
• The elevated SHBG (92 nmol/L) suggests your free testosterone is even lower than total testosterone indicates 3
• This pattern confirms the testes are failing to respond to appropriate pituitary signals 1

Critical distinction: In primary hypogonadism, the pituitary is working correctly (hence elevated FSH/LH trying to stimulate the testes), but the testes cannot produce adequate testosterone. This differs from secondary hypogonadism where both testosterone AND gonadotropins are low. 2

Recommended Treatment Approach

First-Line Therapy: Transdermal Testosterone Gel

Start with transdermal testosterone gel 1.62% at 40.5 mg daily (2 pump actuations) applied to shoulders and upper arms each morning. 2, 1

Rationale for transdermal over injectable: 2

• Provides more stable day-to-day testosterone levels
• Avoids the peak-trough fluctuations of intramuscular injections
• Lower risk of erythrocytosis compared to injectable formulations
• Easier dose titration

Monitoring and Dose Adjustment Protocol

Week 2 and Week 4: 2, 1

• Measure morning (8-10 AM) total testosterone before applying gel
• Target range: 500-600 ng/dL (14-17.5 nmol/L) mid-normal values
• Adjust dose in 20.25 mg increments based on levels:
  • If <350 ng/dL: increase by 20.25 mg
  • If 350-750 ng/dL: continue current dose
  • If >750 ng/dL: decrease by 20.25 mg

After stabilization: Monitor testosterone, hematocrit, and PSA (if >40 years) every 6-12 months 2, 4

Alternative: Injectable Testosterone (If Cost is Prohibitive)

If the annual cost of transdermal gel (~$2,135) is prohibitive, testosterone cypionate or enanthate 100-200 mg intramuscularly every 2 weeks is a reasonable alternative at ~$156 annually. 2

Important monitoring for injections: 2

• Measure testosterone midway between injections (day 7 for every-2-week dosing)
• Higher risk of erythrocytosis—monitor hematocrit closely
• Withhold treatment if hematocrit >54% 2, 4

Expected Benefits

You should experience improvements in: 2, 5, 6

• Sexual function and libido (most consistent benefit)
• Energy levels and sense of vitality
• Muscle mass and strength
• Bone mineral density
• Mood and quality of life
• Body composition (decreased fat mass, increased lean mass)
• Metabolic parameters (glucose control, lipid profile)

Critical Safety Monitoring

Absolute Contraindications (Do NOT use testosterone if present): 2, 1

• Active or treated male breast cancer
• Actively seeking fertility (testosterone suppresses spermatogenesis and causes azoospermia)
• Untreated severe obstructive sleep apnea
• Uncontrolled heart failure

Mandatory Monitoring Parameters: 2, 4

• Hematocrit: Check at 3 months, then every 6-12 months. Stop treatment if >54%
• PSA (if age >40): Monitor for significant increases suggesting prostate issues
• Prostate examination: Assess for benign prostatic hyperplasia symptoms

Common Pitfall to Avoid

Do NOT attempt fertility while on testosterone replacement therapy. 2 Your elevated FSH/LH indicate your pituitary is already maximally stimulating your testes. Testosterone therapy will suppress FSH/LH further and eliminate any remaining sperm production. If fertility is desired now or in the near future, you require gonadotropin therapy (hCG plus FSH) instead of testosterone. 2

Application Instructions for Gel (Critical for Safety)

1

• Apply to clean, dry skin of shoulders and upper arms only
• Do NOT apply to abdomen, genitals, chest, armpits, or knees
• Allow to dry completely before dressing
• Wash hands immediately after application
• Children and women must avoid contact with application sites until you have showered or washed the area
• Cover application sites with clothing once dry
• Shower before any anticipated skin-to-skin contact with others

Why Your Specific Pattern Matters

Your elevated SHBG (92 nmol/L) means testosterone is more tightly bound to carrier proteins, making even less available to tissues as free testosterone. 3 This amplifies the clinical impact of your low total testosterone and strengthens the indication for treatment. When you start therapy, your provider should consider measuring free testosterone by equilibrium dialysis to better assess treatment response. 3, 2

The combination of primary hypogonadism with elevated SHBG suggests you will likely require doses toward the higher end of the therapeutic range to achieve adequate free testosterone levels and symptom relief.