Low Testosterone

Low testosterone means you don’t make enough of the hormone testosterone. Special cells (called Leydig cells) in your testicles make this hormone.

Testosterone levels naturally drop in men, so this is a common condition. Levels can drop 1% per year starting in your late 30s. Healthcare providers consider testosterone levels below 300 nanograms per deciliter (ng/dL) as low in adults. Providers call it male hypogonadism when you have symptoms along with these low levels. You can have different symptoms depending on your age.

You might also hear low testosterone called:

• Primary hypogonadism (hypergonadotropic hypogonadism)
• Secondary hypogonadism (hypogonadotropic hypogonadism)
• Late-onset hypogonadism
• Functional hypogonadism
• Testosterone deficiency
• Low T

Why testosterone matters

Testosterone is the main male sex hormone. It helps male features like a deepening voice and body hair growth develop. It’s much higher in men than in women.

In men, testosterone helps:

• Develop and maintain sex organs and genitalia
• Build muscle mass
• Make enough red blood cells
• Keep bones strong
• Boost energy and mood
• Support sex drive and fertility

Symptoms of low testosterone

Low testosterone symptoms (low T symptoms) can vary a lot. Sexual symptoms of low testosterone are the most specific. They include:

• Low libido
• Loss of morning or spontaneous erections
• Trouble attaining or maintaining an erection

Other symptoms that highly suggest hypogonadism in men include:

• Loss of armpit and pubic hair
• Shrinking testicles
• Hot flashes
• Low or zero sperm count (azoospermia)

Other signs and symptoms include:

• Depressed mood
• Concentration and memory issues
• Increased body fat
• Enlarged male breast tissue (gynecomastia)
• Decrease in muscle strength and mass
• Decrease in endurance

Symptoms in children

Boys with low testosterone before or during puberty may have:

• Slowed growth in height
• Reduced development of pubic hair
• Reduced growth of their penises and testicles
• Less voice deepening
• Lower-than-normal strength and endurance

Male hypogonadism causes

There are several possible causes of low testosterone. Any issue with your testicles, hypothalamus or pituitary gland can cause low testosterone. This is because your hypothalamus and pituitary gland release hormones that lead to the production and release of testosterone. These signals from your brain normally control how much testosterone your testicles make and release.

A testicular disorder causes primary hypogonadism. This means it’s a problem with the testicles. Another name for it is hypergonadotropic hypogonadism.

A problem with your pituitary gland or hypothalamus causes secondary hypogonadism. This means it happens for reasons other than the testicles.

You can be born with this condition (congenital) or develop it as a child or adult (acquired).

Causes of primary male hypogonadism

Primary hypogonadism happens when your testicles aren’t making normal levels of testosterone. If you have damaged or missing testicles, they can’t respond to increased levels of hormones from your pituitary gland.

As a result, your testicles make too little or no testosterone and sperm.

Conditions present at birth that affect your testicles and can lead to primary hypogonadism include:

• Absence of testicles at birth (anorchia)
• Undescended testicles (cryptorchidism)
• Leydig cell hypoplasia (underdevelopment of Leydig cells in your testicles)
• Klinefelter’s syndrome (a genetic condition in which males are born with an extra X chromosome)
• Noonan syndrome (a rare genetic condition that can cause delayed puberty, undescended testicles or infertility)
• Myotonic dystrophy (part of a group of inherited disorders called muscular dystrophies)

Other issues that affect your testicles and can lead to primary hypogonadism include:

• Testicle injury or removal
• Inflammation of one or both testicles from an infection (orchitis)
• Chemotherapy or radiation therapy to your testicles
• Certain types of tumors
• Iron overload
• Sarcoidosis
• Alcohol use disorder

Causes of secondary male hypogonadism

Conditions that affect how your hypothalamus and/or pituitary gland work cause secondary hypogonadism. This is known as hypogonadotropic hypogonadism because there are low levels of hormones. Those low levels cause decreased testosterone and sperm production.

Congenital conditions that can lead to secondary hypogonadism include:

• Isolated hypogonadotropic hypogonadism (a condition that causes low levels of a certain hormone from birth)
• Kallmann syndrome (a rare genetic condition that affects your hypothalamus)
• Prader-Willi syndrome (a rare genetic disorder that can leave you without enough hormones)

Most males with symptoms of low testosterone don’t have a problem with their pituitary glands or testicles. They usually have an issue from having obesity or diabetes. Also, being sick briefly stops testosterone production.

Other acquired conditions that can lead to secondary hypogonadism include:

• Pituitary gland that doesn’t make enough hormones (hypopituitarism)
• High levels of prolactin (hyperprolactinemia)
• Iron overload
• Brain or head injury
• Cushing syndrome
• Cirrhosis of the liver
• Kidney failure
• HIV/AIDS
• Alcohol use disorder
• Anabolic steroid use
• Obstructive sleep apnea
• Certain medicines, including some for prostate cancer, digestive issues or pain
• Use of opiates and medicines to treat opioid dependence

Late-onset hypogonadism (LOH) is a type of secondary male hypogonadism. LOH and low testosterone are more common in those who have Type 2 diabetes, overweight and/or obesity.

Risk factors

Male hypogonadism can affect you at any age. Low testosterone is more likely to affect you if you:

• Are older than 45
• Have obesity
• Have poorly managed Type 2 diabetes
• Have obstructive sleep apnea
• Have chronic medical conditions, like kidney dysfunction or cirrhosis of the liver
• Have HIV/AIDs

How to lower your risk

Lifestyle habits that may help keep testosterone levels normal include:

• Maintaining a weight that’s healthy for you
• Eating healthy foods
• Being physically active
• Sleeping seven hours a night and treating sleep apnea if you have it
• Avoiding too much use of addictive substances

How doctors diagnose low testosterone

If you have signs and symptoms of low testosterone, a healthcare provider will give you a physical exam. They’ll also ask questions about your medical history, medicines you take, substance use and any symptoms you have.

To make a diagnosis, a provider will consider your signs and symptoms. If you have symptoms, they’ll order blood tests.

The following tests can help confirm low testosterone and find the cause:

• Total testosterone level blood test: This test usually requires two separate blood samples in the morning. This is when testosterone levels should be at their highest. Tell your provider if you’re sick, as illness can temporarily lower testosterone levels.
• Luteinizing hormone (LH) blood test: This test can help find out whether low testosterone is due to an issue with your pituitary gland.
• Prolactin blood test: This test looks for high prolactin levels, which may be a sign of pituitary gland issues or tumors.

How is it treated?

Eating nutritious foods and getting physical activity are the first treatments for low testosterone. If that doesn’t help after six to 12 months, or you have severe symptoms, you may get other treatment.

This may include medicine to help you produce testosterone or long-term testosterone therapy. This has several different forms, like:

• Testosterone skin gels: You apply the gel every day to clean, dry skin. It’s important that you don’t transfer the gel to another person through skin-to-skin contact.
• Testosterone injections: You or a provider can inject this into a muscle every one to two weeks. Providers can inject you with long-acting testosterone every 10 weeks. You can also inject this under your skin instead.
• Testosterone pellets: A specialist implants these pellets under your skin every three to six months. The pellets give you steady, long-term dosages.
• Testosterone nasal gel: You apply a testosterone gel into each nostril three times a day.
• Oral testosterone: A pill form of testosterone is available for people with low testosterone from specific medical conditions. These include Klinefelter syndrome and tumors that have damaged the pituitary gland.

You may not be able to receive this treatment if you have a history of:

• Prostate cancer
• An untreated lump on your prostate
• Poorly managed high blood pressure
• Recent heart attack or stroke
• Enlarged prostate
• Breast cancer
• Unmanaged heart failure
• Untreated obstructive sleep apnea

Other treatments, like clomiphene citrate, are available for those who want to be able to have children.

When should I see my healthcare provider?

If you have symptoms of low testosterone, talk to a healthcare provider. They’ll assess you and may order blood tests. If your child isn’t showing signs of puberty by the age of 14, talk to their provider.

If you’re taking hormone replacement therapy, you’ll need regular follow-up visits with a healthcare provider. These may be once or twice a year.

Questions you may want to ask your provider include:

• How often do I need to check my testosterone level?
• What caused low testosterone in my case?
• Which treatment is best for me?
• How long will I need to take hormone replacement therapy?
• What type of monitoring will I need while I’m getting treatment?

What can I expect if I have male hypogonadism?

There’s no one-time fix for low testosterone in men. But hormone replacement therapy helps improve sex drive, symptoms of depression and energy levels. Treatment may also boost muscle mass and bone density. Low testosterone may lead to weak bones (osteoporosis) or heart and blood vessel disorders.

For congenital hypogonadism, testosterone replacement therapy often helps prevent problems linked to delayed puberty.