How to diagnose hypogonadism?

How to diagnose hypogonadism in men?

The symptoms of hypogonadism may vary from individual to individual. In late-onset hypogonadism many symptoms resemble those of aging and as a consequence this condition is often undiagnosed. Various diagnostic procedures are available to confirm hypogonadism in a patient who presents with symptoms or signs of testosterone deficiency. These include:

    Medical history

    Sexual function
    Cardiovascular disease

    General physical examination

    blood pressure
    evaluation of secondary sexual characteristics
    testicle examination
    waist circumference measurement
    distribution of fat

    Laboratory tests

    Determination of testosterone values
    Determination of testosterone values

    Repeat measurement of morning total testosterone (when levels of serum testosterone can be expected to be higher because of the diurnal rhythm of testosterone) using a reliable assay is recommended by international professional societies in the field as the most widely accepted parameter to establish the presence of hypogonadism in combination with consistent symptoms and signs. In some men, determination of free or bioavailable testosterone may be appropriate.1,2

    Measurement of testosterone levels in the diagnosis of hypogonadism

    Calculate the bioactive testosterone circulating in Plasma

    Values for normal testosterone ranges vary among laboratories depending on the commercial assay employed, and local values should be consulted when a diagnosis of hypogonadism is considered. There is no generally accepted lower limit of normal.

    Testosterone Concentration:
    12-35 nmol/L
    Free Testosterone:
    250 pmol/L (72 pg/mL)

    A morning testosterone concentration in the blood of 12-35 nmol/L or free testosterone levels above 250 pmol/L (72 pg/mL) can be considered normal. There is general agreement that no testosterone treatment is required.

    Testosterone Concentration:
    < 12-35 nmol/L
    Free Testosterone:
    180 pmol/L (52 pg/mL)

    The European Association of Urology (EAU), International Society for the Study of the Aging Male (ISSAM), International Society of Andrology (ISA), European Academy of Andrology (EAA) and American Society of Andrology (ASA) suggest that serum total testosterone levels below 8 nmol/L (231 ng/dL) or free testosterone below 180 pmol/L (52 pg/mL) require testosterone replacement therapy.

    In addition, concentrations of the pituitary hormones can be measured. They provide information as to whether the testosterone deficiency is due to disorders of testicular function or of the hypothalamic-pituitary system.

    Since symptoms of testosterone deficiency become manifest between 8 and 12 nmol/L (231–346 ng/dL), trials (3– >6 months) of treatment can be considered in men with a clinical picture of testosterone deficiency and borderline testosterone levels when alternative causes of these symptoms have been excluded.1,2

    Please consult guidelines relevant to your country of practice as country-specific differences in the diagnosis and treatment of hypogonadism exist.

    Supplementary tests

    Supplementary tests, like a bone density test for suspected osteoporosis or tests to exclude other diseases that may explain the symptomatology, may be necessary. The physician’s experience and, in some cases, the observation of clear clinical benefits after the initiation of testosterone therapy may provide confirmation of a diagnosis of hypogonadism. 

    The measurement of testosterone levels in the diagnosis of hypogonadism is summarized in the text box below


    Treatment guidelines

    Diagnosis and treatment algorithm


    1. Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in adult men with androgen deficiency syndromes: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2006; 91(6): 1995-2010.
    2. Wang, C., E. Nieschlag, R. Swerdloff, et al. Investigation, treatment and monitoring of late-onset hypogonadism in males: ISA, ISSAM, EAU, EAA and ASA recommendations. Eur J Endocrinol 2008, 159(5): 507-514.
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