What is the management approach for a patient with hypergonadism (elevated testosterone level of 2000) and hypogonadotropic hypogonadism (low Follicle-Stimulating Hormone (FSH) and Luteinizing Hormone (LH))?

Elevated Testosterone with Low FSH/LH: Hypogonadotropic Hypergonadism

This patient has exogenous testosterone use or androgen abuse until proven otherwise, and testosterone therapy must be immediately discontinued to prevent irreversible testicular damage and infertility. 1, 2

Immediate Diagnostic Priority

Stop all testosterone supplementation immediately - this hormonal pattern (testosterone 2000 ng/dL with suppressed LH/FSH) is pathognomonic for exogenous androgen administration, which suppresses the hypothalamic-pituitary-gonadal axis through negative feedback. 1, 2

Critical History Elements

• Direct questioning about testosterone use - including gels, injections, patches, or "supplements" purchased online or from gyms, as patients often do not volunteer this information. 2
• Anabolic steroid use - specifically ask about bodybuilding supplements, performance enhancers, or any injectable substances. 1
• Medication review - corticosteroids and opioids can cause secondary hypogonadism, but would present with LOW testosterone, not elevated levels. 3

Differential Diagnosis (If Exogenous Use Denied)

While exogenous testosterone is by far the most common cause, rare alternatives include:

• Androgen-secreting tumors - testicular Leydig cell tumors or adrenal tumors can produce autonomous testosterone, though these typically present with unilateral testicular mass or adrenal imaging abnormalities. 1
• hCG-secreting tumors - germ cell tumors can stimulate testosterone production, but would show elevated β-hCG levels. 1

Essential Laboratory Workup

• Repeat morning testosterone on at least two separate occasions after 4-6 weeks of confirmed abstinence from all supplements to confirm persistent elevation. 1
• Measure serum prolactin - if testosterone remains low after stopping exogenous sources, prolactin should be checked as hyperprolactinemia suppresses LH/FSH. 1, 4
• β-hCG levels - to exclude hCG-secreting tumors if exogenous use is definitively ruled out. 1
• Estradiol measurement - exogenous testosterone aromatizes to estradiol, which can cause gynecomastia and further suppress gonadotropins. 1
• Hemoglobin/hematocrit - testosterone levels this high significantly increase polycythemia risk (Hct >54% requires intervention). 1

Imaging Studies (If Tumor Suspected)

• Testicular ultrasound - if unilateral testicular enlargement or mass is palpated, to evaluate for Leydig cell tumor. 1
• Adrenal CT/MRI - only if DHEA-S is markedly elevated suggesting adrenal source. 1
• Pituitary MRI - NOT indicated in this scenario, as elevated testosterone with low gonadotropins indicates negative feedback suppression, not pituitary pathology. 1

Management After Exogenous Testosterone Cessation

Recovery Timeline

• Gonadotropin recovery - LH/FSH typically begin rising within 2-4 weeks of stopping testosterone, but full axis recovery may take 3-12 months depending on duration and dose of use. 1, 5
• Testicular function - prolonged high-dose testosterone can cause permanent Leydig cell damage and irreversible infertility, particularly if used for >2 years. 5

Fertility Considerations

If the patient desires fertility and has been using testosterone:

• Avoid testosterone monotherapy permanently - it suppresses spermatogenesis and causes infertility. 3, 2
• Consider hCG therapy (1500-2000 IU subcutaneously 3 times weekly) to stimulate endogenous testosterone production while preserving fertility. 3
• Add FSH or hMG if spermatogenesis does not recover after 6 months of hCG alone. 3, 6
• Obtain baseline semen analysis after 3 months off testosterone to assess recovery. 1

If Underlying Hypogonadism Exists

Only after confirming testosterone normalizes off exogenous sources:

• Repeat morning testosterone measurements - if levels fall below 300 ng/dL on two occasions, true hypogonadism may exist. 1
• Measure LH/FSH when testosterone is low - if gonadotropins remain low with low testosterone, this indicates true secondary hypogonadism requiring endocrine evaluation. 1, 4
• Check prolactin if LH/FSH remain low - hyperprolactinemia is a treatable cause requiring pituitary MRI if persistently elevated. 1, 4

Monitoring for Complications

• Hematocrit monitoring - levels >54% require phlebotomy or dose reduction if on prescribed testosterone therapy. 1
• Cardiovascular risk assessment - supraphysiologic testosterone increases ASCVD risk factors including dyslipidemia and hypertension. 1
• Bone density assessment - if chronic hypogonadism is confirmed after cessation, DEXA scan is indicated. 3
• PSA measurement - in men over 40 before any testosterone therapy initiation. 1

Common Pitfalls

• Failing to directly ask about testosterone use - patients often consider over-the-counter or gym-sourced products as "supplements" rather than medications. 2
• Initiating pituitary workup prematurely - elevated testosterone with low gonadotropins is negative feedback, not pituitary disease; pituitary MRI is only indicated when testosterone AND gonadotropins are BOTH low. 1, 4
• Missing the fertility window - testosterone-induced azoospermia may be irreversible if use exceeds 2 years; early intervention with hCG/FSH is critical. 3, 5
• Overlooking polycythemia - testosterone levels of 2000 ng/dL carry significant thrombotic risk from secondary erythrocytosis. 1