Primary hypogonadism symptoms. Hypogonadism: what to do if there is a lack of sex hormones. Laboratory diagnostic methods
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Hypogonadism in men occurs due to insufficient testosterone production or the absence of endogenous testosterone. Hypergonadotropic hypogonadism develops due to gonadotropic insufficiency. Primary hypogonadism can occur due to genetic reasons or abnormal development of acquired diseases. Almost all forms of hypogonadism in men after puberty occur due to severe forms of obesity and tumor diseases.
Symptoms of hypogonadism
In middle-aged men, the symptoms of testicular failure are less pronounced. Therefore, it is more difficult to diagnose hypogonadism in men. Signs of the disease depend on the age category in which the deficiency appeared, its causes and duration. The following symptoms indicate a lack of testosterone in adult men:
- sexual desire is reduced
- potency disorder
- fatigue, which is accompanied by a depressed mood
- secondary sexual characteristics regress
- lean body mass and strength decrease
- obesity
- hyponedism
The doctor selects methods and recommendations for treating the disease individually for each patient. Initial treatment consists of eliminating the cause of the disease, as well as reducing the symptoms of the disease.
Hormonal treatment
The main treatment for hypogonadism, as well as hepargonadotropic hypoganism, for both men and women is to take hormonal drugs (replacement therapy). Hormonal preparations for men contain testosterone, and for women they contain estrogen.
Hormonal medications can be taken in the form of:
- tablets
- injections
- gel
- transdermal patch
- crystal implants
The decision on how to treat the disease, the duration of treatment and in what doses to take the drugs is made by the treating doctor (endocrinologist). When choosing a treatment method, the doctor takes into account the patient’s age category, body characteristics and also the symptoms of the disease.
How to take hormones
- Pills. Basically, hormonal drugs in the form of tablets are taken according to the instructions for use of the drug.
- Injections. Injections are administered intramuscularly once every three to four weeks.
- Gel. Testosterone gel should be applied to the skin in the shoulder or upper arm area, and can also be applied to the stomach. It is not allowed to apply the gel to the genital area. The required dose of testosterone gel per day is calculated by the doctor for each patient individually.
- Transdermal patch. Manufacturers currently offer two types of transdermal patches. The first type is a hormonal patch that is glued to the scrotum area. The second type - the patch must be glued to the body. In most cases, treatment is recommended using a hormonal patch, which is glued to the scrotum area.
- Crystal implants. Crystal implants are implanted through a small incision in the inner forearm. Thanks to such implants, the required dose of testosterone is evenly released into the blood over the course of six months.
Hormone (replacement) therapy will not cure infertility if a man has primary hypogonadism.
If the child has primary androgen deficiency, then treatment must be carried out by stimulating testosterone levels with drugs that do not contain hormones.
Therapy with hormones is not allowed if the patient has the following health problems:
- malignant neoplasms of the genital organs
- liver diseases
- renal failure
- problems with the cardiovascular system
- carcinoma
- hypertension
- secondary androgen deficiency
The main treatment if the patient has signs of secondary hypogonadism is to eliminate the cause that provoked this disease, i.e.:((banner2-left))
- Initially, you need to give up bad habits (drinking alcohol, smoking).
- If the patient has normogonadotropic androgen deficiency, physical therapy is prescribed. Normogonadotropic androgen deficiency necessarily includes dietary nutrition.
- General restorative therapy is carried out.
It is necessary to treat the most important cause that provokes textile failure - this is the underlying disease, for example:
- diabetes
- Itsenko-Cushing syndrome
- adrenal tumors, etc.
Also, therapy for hypergonadotropic hypogonadism includes taking gonadotropins and androgens for a long time.
During systematic treatment, secondary sexual characteristics are restored, potency is slightly restored, and symptoms (osteoporosis, delayed bone development) are reduced.
Side effects
Like all drugs, testosterone can cause the following side effects:
- erythrocytosis
- acne
- gynecomastia
- an increase in the size of the prostate
- growth of existing prostate carcinoma
- liver dysfunction
- Possible progression of prostate cancer
- heart failure
Surgical treatment
If conservative therapy does not give positive results, then in the future it is necessary to carry out treatment in men using surgical intervention.
Surgical intervention in men involves the following:
- testicular transplantation is performed
- if the male genital organ is not developed, then phalloplasty is performed
If left untreated in men, androgen deficiency can cause osteoporosis, and with the help of replacement therapy, bone density increases.
It is impossible to imagine the full functioning of a man’s body without the adequate functioning of the gonads and their production of hormones. Any failures in this system lead to the appearance of somatic diseases. Dyslipidemia, atherosclerosis, obesity, cerebral ischemia - this is not the entire list of possible complications. There are many definitions of this disorder in medical reference books. For example, androgen deficiency or testicular failure. However, among them, the most accurate and accurate concept is considered to be “hypogonadism” in men. What does this condition mean, for what reasons does it arise, can it be cured - detailed answers to these questions are presented in today’s article.
Brief description of the disorder
Hypogonadism is a disease characterized by functional inferiority of the gonads. In representatives of the stronger sex, they are represented by the left and right testicle. Nature specifically provided for exactly their number in pairs. Testicular tissue is sensitive to harmful environmental factors. In case of loss of functional abilities, the body must have a kind of reserve. The regenerative abilities of the testicles are very modest.
Their main purpose is reproduction. Lack of the ability to produce sperm deprives a man's body of the ability to reproduce. The mechanisms of such disorders are laid down at the initial stage of the reproductive cycle. Therefore, infertility developing against this background is considered very dangerous. It is almost impossible to restore the function of pathologically altered elements of testicular tissue.
Hypogonadism in men is characterized by the following features:
- gradual decrease in the level of sex hormones;
- reduction of qualitative and quantitative characteristics of seminal fluid;
- underdevelopment of the genital organs;
- hormonal imbalance throughout the body.
According to statistics, hypogonadism syndrome in men occurs in 1% of the world's population. However, this information is conditional, since only registered cases of pathology are taken into account. Treatment must be carried out under the supervision of an endocrinologist and andrologist. Hormone therapy is most often used. If it is ineffective, surgical intervention for plastic surgery and prosthetics of the reproductive system organs is prescribed.
Main causes of the disease
The development of the pathological process occurs as a result of a decrease in the number of produced hormones or a violation of biosynthesis. The etiological factors for the occurrence of the disease include:
- congenital anomalies caused by changes in the structure of the testicles and/or seminiferous tubules;
- the influence of toxins on the body of the expectant mother (alcohol, nicotine, drugs);
- carrying out radiation or chemotherapy;
- long-term use of hormonal and antibacterial drugs;
- diseases of infectious origin (orchitis after measles, vesiculitis);
- varicose veins of the testicles;
- living in an area with unfavorable environmental conditions.
The causes of hypogonadism in men determine the forms of the pathological process. Each of them is characterized by a certain course.
Types of violation
Depending on the underlying cause, gonadal insufficiency is divided into primary, secondary and so-called age-related. How are they different from each other? The primary form of the disease is otherwise called testicular pathology. In this case, disruption of the testicles occurs under the influence of negative external factors. Secondary hypogonadism in men is associated with abnormalities in the pituitary-hypothalamus circuit. This system, through the hormones produced, is responsible for the functioning of the testicles. The age-related variant of the disease is considered a kind of male menopause. Doctors still cannot explain the reasons for its appearance.
The following classification is based on the period of life in which the disease arose. The embryonic form is characterized by the appearance of a pathological process during fetal development. Prepubertal is diagnosed before the onset of puberty (around age 14). The postpubertal variant of the disease occurs after development has completed
Considering the amount of androgens produced, the following types of the disease are distinguished:
- Hypergonadotropic hypogonadism. In men, this form of the disease manifests itself in the form of damage to the testicular tissue of the testicles. It is accompanied by increased production of pituitary hormones. At the same time, testosterone levels are significantly reduced.
- Characterized by a decrease in the synthesis of gonadotropins. As a result, the amount of testosterone produced is reduced.
- Normogonadotropic hypogonadism. In men, this form of the pathological process leads to disruption of the testicles, but the production of pituitary hormones remains within normal limits. The disease is often combined with obesity.
Depending on the etiology, it is customary to distinguish congenital, acquired and idiopathic forms. In the latter case, the main cause of the pathology remains unknown.
Primary hypogonadism
The disease can be either acquired or congenital. Most often, pathology occurs in the prenatal period. The boy is born with a small penis and an underdeveloped scrotum. As the disease progresses, the clinical picture changes. In adolescence, boys with this diagnosis exhibit excess body weight, initial manifestations of gynecomastia and a low degree of hair growth.
Acquired primary hypogonadism in men develops against the background of inflammation of the seminal glands with the following disorders:
- orchitis;
- vesiculitis;
- epididymitis;
- piggy;
- chicken pox.
This form of the disease is considered the most common. It occurs in every fifth man with previously diagnosed infertility.
Secondary hypogonadism
Secondary hypogonadism can also be congenital or acquired. In the first case, the development of the disease is preceded by a violation of the secretion of hormones from the pituitary gland and hypothalamus. It often accompanies the following genetic disorders:
- Prader-Willi syndrome;
- Maddock syndrome;
- Pasqualini's syndrome.
The acquired form of the disease is usually a consequence of inflammatory processes in the membranes of the brain. Among them are meningitis, arachnoiditis and encephalitis.
Symptoms of the disease in young children
The clinical picture of the pathological process is largely determined by the age of the patient. Its development from an early age is usually accompanied by the following symptoms:
- puberty disorder;
- the appearance of symptoms of eunuchoidism (excessively tall stature, small shoulders, long limbs);
- absence of folds on the scrotum;
- small penis size;
- gynecomastia.
If you have one or more symptoms from the list above, you should immediately seek advice from a specialized specialist.
Symptoms of the disease in adolescents
The development of the disease in adolescence is characterized by the same symptoms as in the prepubertal period. The clinical picture may be complemented by decreased libido and excess weight. When visiting a doctor, the thyroid glands are usually detected. Outwardly, sick young men clearly show underdevelopment of the muscular system.
Symptoms of the disease in adults
Hypogonadism in men over 30 years of age is less pronounced. The disease is accompanied by the appearance of multiple fat folds on the body. Over time, the skin loses its former elasticity and becomes dry. Fatigue, emotional lability, and a tendency to depression appear. Unfortunately, representatives of the stronger sex go to the hospital in exceptional cases. Usually when it comes to infertility or erectile dysfunction.
Such inattention to one's own health can result in serious consequences. The pathological process begins to spread not only to but gradually moves to other organs and tissues. Lack of proper therapy can lead to disability.
Diagnostic methods
You should not be alarmed prematurely by the diagnosis of hypogonadism in men. The doctor should tell you what this condition means at the first consultation. After all, if symptoms of the disease appear, you must immediately contact a qualified specialist. Despite the fairly clear clinical picture, clinical examination will be required to confirm the disease. It includes the following activities:
- physical examination;
- Ultrasound of the pelvic organs;
- karyotype study;
- Analysis of urine;
- spermogram;
- blood test for hormones.
The examination is prescribed for each patient individually. Therefore, the list of clinical activities may vary slightly. Based on the results obtained, the doctor confirms or refutes the preliminary diagnosis and prescribes therapy.
Features of treatment
The choice of a specific method of therapy remains with the doctor and is determined taking into account the cause of the disease. Treatment of hypogonadism in men usually has several goals: combating the underlying disease, preventing infertility, and preventing the occurrence of tumors in the testicular tissue.
Congenital and prepubertal forms of pathology are often accompanied by infertility. It is not possible to eliminate this problem. If endocrinocytes in the testicles are preserved, stimulating therapy is recommended. Children are prescribed non-hormonal medications, and adults are prescribed androgens. In the absence of endocrinocytes, you need to take hormonal medications throughout your life.
In the secondary form of the pathological process, gonadotropic medications are prescribed in small dosages. If necessary, they are combined with testosterone. A certain role in the treatment of the disease belongs to exercise therapy and the intake of vitamin complexes.
All medications are prescribed individually, taking into account the health status and age of the patient. In some cases, the use of hormonal replacement therapy is not recommended. For example, with cancer of the prostate gland. Chronic lung diseases, smoking, and apnea attacks are relative contraindications. In these situations, the decision to take testosterone drugs is made individually.
Surgical intervention
If hypogonadism in a man is caused by physical abnormalities in the development of the genital organs, surgery is indicated. Today, various intervention options are used to eliminate pathology. For example, in case of underdevelopment of the penis, phalloplasty is used, in case of cryptorchidism, testicular reduction is performed. To eliminate a cosmetic defect, a synthetic testicle is implanted. Any of the listed operations is carried out using microsurgical techniques.
Prognosis for recovery
Primary hypogonadism, especially congenital, can be partially corrected. We are talking about restoring the anatomical and functional abilities of the sexual organ. However, modern medicine cannot normalize ejaculation. The only option to return lost reproduction is IVF through sperm retrieval. In this case, intratesticular spermatogenesis must be preserved.
A different prognosis awaits patients diagnosed with secondary hypogonadism. In men, treatment of this disease in most cases gives positive results. Therefore, doctors most often manage to restore reproductive function.
Prevention measures
No specific prevention of this disease has been developed. Among the general recommendations, doctors name the following:
- timely treatment of any diseases;
- proper nutrition, absence of bad habits, exercise;
- undergoing examination by “male” doctors for preventive purposes once a year.
The tips listed above, unfortunately, do not always help prevent hypogonadism in men. At its first manifestations, you should immediately seek help from a specialist. The sooner the doctor prescribes therapy, the faster the recovery process will go.
Hypogonadism in men is a condition in which the body does not produce enough testosterone and/or sperm. Testosterone plays a key role in the growth and development of men during puberty. Some are born with hypogonadism, while others develop the disorder later, most often due to injury or infection. In this material we will look at the symptoms, causes and solutions to this important problem.
Hypogonadism: symptoms
This disorder develops:
- During the development of the fetus in the womb,
- During the period before puberty,
- During adulthood.
Symptoms of hypogonadism depend on when exactly the condition developed.
During fetal development in the womb (genetic disorder)
If the body does not produce enough testosterone during fetal development, this leads to impaired growth of the external genitalia. Depending on the level of testosterone and at what period of fetal development hypogonadism appeared, a boy may be born with:
- Underdeveloped male genitalia,
- Female genital organs,
- Indeterminate genitalia are sexual organs that are neither male nor female.
Symptoms of hypogonadism during puberty
In this case, there is a delay or “incompleteness” of puberty. Symptoms may include:
- Slow development of muscle mass,
- The voice is not rough enough
- Poor body hair growth
- Poor growth of the penis and testicles,
- Excessive growth of arms and legs in relation to the body,
- Breast enlargement (gynecomastia).
Symptoms of hypogonadism in adult men
In this case, the disorder affects certain physical characteristics and reproductive function. Symptoms include:
- Infertility,
- Poor beard and body hair growth,
- Decrease in muscle mass,
- Breast enlargement (gynecomastia),
- Loss of bone mass ().
Hypogonadism in men can also cause mental and emotional changes. When testosterone levels decline, some men experience the same symptoms that women experience after menopause:
- Fatigue,
- Decreased sexual desire,
- Difficulty concentrating
- Hot flashes.
What are the causes of hypogonadism?
There are 2 main types of this disorder: primary and secondary. Let's look at them in more detail:
- Primary, or hypergonadotropic, occurs due to problems in the testes (testicles).
- Secondary, or hypogonadotropic hypogonadism - indicates problems in the hypothalamus or pituitary gland. These are the two most important parts of the brain that signal the testes to produce testosterone. The hypothalamus produces gonadotropin-releasing hormone, which signals the pituitary gland to produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The latter, in turn, causes the testicles to synthesize testosterone.
Any type of hypogonadism can be either inherited (congenital) or acquired. Sometimes both forms of this disorder develop simultaneously.
Causes of the primary form
Among the most common reasons:
- Klinefelter's syndrome. This condition is a consequence of a congenital abnormality in the sex chromosomes X and Y. Normally, a man has one X chromosome and one Y chromosome. With Klinefelter syndrome, a man has 2 or more X chromosomes in addition to the Y chromosome. The Y chromosome contains the genetic material that determines gender and child development. The extra chromosome X causes abnormal testicular development, which in turn leads to decreased testosterone production.
- Undescended testicles. Before birth, the testicles, which develop inside the abdomen, descend into their designated place - the scrotum. Sometimes one or both testicles do not descend. This condition often corrects on its own within the first few years of a child's life. If this anomaly is not corrected in early childhood, it can lead to testicular dysfunction and hypogonadism.
- Mumps orchitis is an inflammation of the testicle caused by paramyxovirus. In this case, damage to the testicles may occur, which will disrupt their function and testosterone production.
- Hemochromatosis. Too much iron in the blood can cause testicular failure or pituitary dysfunction.
- Testicular injury. Since this organ is located outside the abdominal cavity, it is susceptible to injury. Damage to normally developing testicles can lead to hypogonadism. Trauma to one testicle does not affect testosterone production.
- Undergoing radiation or chemotherapy. These procedures can cause changes in sperm and testosterone production. Often these changes are only temporary, but sometimes they lead to permanent infertility.
Causes hypogonadotropic hypogonadism ( secondary )
In the secondary form, the testicles are normal, but their function is impaired due to problems in the hypothalamus or pituitary gland. Many pathologies may be to blame, including:
- Kallmann syndrome. This is an abnormal development of the hypothalamus, a brain structure that controls the production of pituitary hormones. This disorder is also associated with loss of smell (anosmia) and red-green color blindness.
- Pathologies of the pituitary gland. Problems in the pituitary gland can interfere with the release of hormones from the pituitary gland to the testicles, which will affect testosterone production. A tumor in the pituitary gland can cause a deficiency of not only testosterone, but also other hormones. In addition, treatment of a brain tumor (surgery or radiation therapy) can impair pituitary function and cause hypogonadism.
- Inflammatory disease. Some inflammatory diseases, such as sarcoidosis, histiocytosis, and inflammatory diseases, affect the hypothalamus and pituitary gland. This, in turn, can affect testosterone production.
- /AIDS. This disease also affects the hypothalamus and pituitary gland.
- Taking certain medications. Testosterone production can be affected by certain hormone medications and opioid pain medications.
- . The accumulation of excess body weight can affect the production of the “male” hormone at any age.
- Natural aging process. Typically, older men have lower testosterone levels than younger men. As the body ages, there is a slow and continuous decrease in the hormone.
- Concomitant illnesses or stress. The functioning of the reproductive system can temporarily stop due to both physiological stress (due to illness or surgery) and due to severe emotional stress.
Hypogonadism: treatment
Treatment for adults
The appropriate treatment regimen depends on the underlying cause and whether the man plans to have children. In the primary form of the disease, the urologist prescribes hormone replacement therapy with testosterone. Synthetic testosterone helps restore muscle strength and prevent bone loss. In addition, the patient becomes more energetic, his sex drive increases and erections become stronger.
If the cause is hidden in problems with the pituitary gland, the urologist prescribes pituitary hormones. They help stimulate sperm production and restore reproductive function. For a pituitary tumor, surgery, medication, or radiation therapy are prescribed.
Treatmenthypogonadism in boys
In boys, hormone replacement therapy helps stimulate puberty and the development of secondary sexual characteristics. The latter include the growth of muscle mass, beard, penis and pubic hair. To stimulate testicular growth, doctors prescribe pituitary hormones. To avoid side effects, as well as to simulate a slow increase in testosterone, it is recommended to start with low dosages.
Kinds hormone replacement therapy
There are several ways to take a synthetic form of testosterone. The choice of a particular one depends on the patient’s preferences, the cost of the drugs and side effects. The patient has several options:
- Intramuscular injections. Testosterone injections (testosterone cypionate or testosterone enanthate) are safe and effective.
- Testosterone containing patches. Androderm patches are applied to the back, stomach, shoulder or thigh before going to bed.
- Gels. Depending on the brand, the gel is applied to the upper arm or shoulder joint, armpits, or to the front or inner thigh. As the gel dries, testosterone is absorbed by the body through the skin. The gel causes fewer skin reactions than patches.
- Oral medications. Long-term use of testosterone in the form of tablets is not recommended - otherwise, liver problems may occur.
- Nasal gels. In this case, the gel is applied to each nostril 3 times a day. This method of taking testosterone is the most inconvenient.
Treating hypogonadism with hormone replacement therapy carries various risks. Possible complications include:
- Development ,
- Formation of a benign tumor in the prostate gland,
- Gynecomastia,
- Limited sperm production
- Spread of existing prostate cancer
- Formation of blood clots in the veins,
- Heart attack.
Remember, the best prevention is regular examinations and periodic examinations of the body. If you are experiencing symptoms of hypogonadism, please contact.
Sources:
- Male hypogonadism, Mayo Clinic,
- Hypogonadism, Healthline,
- Hypogonadism, Cleveland Clinic.
Hypogonadism- a pathological condition caused by a decrease in the level of androgens in the body.
According to the pathogenetic principle, primary hypogonadism is distinguished, associated with damage to the glandular tissue of the testes, and secondary, caused by pathological changes in the diencephalic-pituitary system.
Primary (hypergonadotropic) hypogonadism is a disease caused by a decrease in androgen production due to a pathological process in the testes.
Etiology and pathogenesis. The causes of damage to the glandular tissue of the testes are different. Their congenital aplasia or hypoplasia is possible as a consequence of the pathological course of pregnancy (infections, intoxications, poor nutrition of the mother, etc.).
Damage to the testicles in childhood and adolescence is possible, caused by infection (measles, mumps, rubella), intoxication (including alcohol), trauma, and radiation exposure.
The basis of the pathogenesis is the reduced production of androgens, which is accompanied by impaired sexual development during puberty, delayed skeletal differentiation, metabolic disorders, decreased libido and potency, and infertility.
Clinical manifestations depend on the age at which the testicular damage occurred.
With the development of the pathological process in early childhood, there is a sharp underdevelopment of the genital organs and a subsequent absence of secondary sexual characteristics.
Eunuch-like body proportions are formed: high stature, disproportionately long limbs, excessive fat deposition in the hips, pelvis, and abdomen.
The muscles are poorly developed, the voice remains high, the hair on the face, armpits and pubis is sparse, the skin is pale, thin, and gynecomastia often occurs.
With hypogonadism that develops in the postpubertal period, there are eunuch-shaped body proportions, there is a decrease in libido, potency, and infertility.
Diagnostics. Hormonal studies are of great importance.
Testosterone levels are reduced, the concentration of gonadotropic hormones is increased. The determination of 17-KS excretion is of particular importance. It is advisable to determine the concentration of prolactin.
In some cases, a testicular biopsy is indicated.
Ultrasound of the pelvic organs allows us to judge the location of the testicles when they are dystopic.
Radiologically, in childhood hypogonadism, a lag in bone age from the passport age is revealed.
All patients with hypogonadism should undergo genetic testing to exclude chromosomal abnormalities.
This primarily concerns patients with cryptorchidism.
Treatment. Replacement therapy with testosterone propionate is carried out at a dose of 50 mg 2-3 times a week.
For childhood hypogonadism, it is advisable to start treatment at the age of 11-12 years, which helps prevent the formation of eunuch-like body proportions. When a positive effect is achieved, the dose of testosterone propionate is reduced to 50 mg/week.
Long-acting preparations Sustanon-250, Onnadren-250, 1 ml IM once a month, 10% testenate solution, 1 ml once every 10 days, are easy to use. Nebido is a long-acting drug (1000 mg of testosterone undecanoate in 4 ml solution) for intramuscular injection, used once every 3 months.
With adequate therapy, secondary sexual characteristics develop satisfactorily, overall well-being improves, muscle strength is restored, skeletal formation, libido, and potency are normalized.
Secondary (hypergotdotropic) hypogonadism- a disease associated with a decrease in the production of GG with a subsequent decrease in the production of androgens.
Etiology and pathogenesis. A decrease in HT production can be the result of various pathological processes in the diechephalo-pituitary system of tumors, neuroinfections, vascular disorders, traumatic injuries, etc.
Genetic factors play a role.
In some patients, hypogonadism is associated with hyperprolactinemia and other disorders in the endocrine system (hypothyroidism, hypercortisolism, etc.). The appearance of the main symptoms of the disease is associated with insufficient production of GG, leading to androgen deficiency.
Often, GG deficiency is combined with a deficiency of other tropic hormones of the adenohypophysis.
Clinical manifestations. Symptoms of the disease depend on the degree of insufficiency of the adenohypophysis and the age at which the pathological process developed.
Symptoms of hypogonadism are especially pronounced when the disease occurs in early childhood.
When the disease develops in the postpubertal period, the symptoms of hypogonadism are moderately expressed, the most common complaint is a decrease in libido and potency, and obesity often develops.
Some patients experience insufficiency of other endocrine glands: hypothyroidism, hypocortisolism, etc.
In some congenital forms of the disease, along with hypogonadism, there are developmental defects (Kallamesh syndrome is characterized by hypogonadism in combination with anemia, deafness, syndactyly, etc.). Diagnostics. A decrease in the concentration of GG and testosterone is characteristic, and sometimes hyperprolactinemia is detected.
It is necessary to study the seminal fluid, which makes it possible to indirectly judge the hormonal status.
Azoospermia is often detected.
Sometimes a testicular biopsy is performed.
Using radiation diagnostic methods, the diencephalo-pituitary region is examined.
An examination is carried out to exclude insufficiency of other endocrine glands.
Treatment. Stimulating therapy with gomadotropic hormones is indicated. Chorionic gonadotropin is used at a dose of 1500-3000 units 2 times a week for 2 months with a month break between courses.
If there is no sufficient effect, androgen replacement therapy is indicated (see section “Primary hypogonadism”).
Correction of insufficiency of other endocrine glands is mandatory.
If a tumor is detected in the diencephalo-pituitary system, radiation therapy or surgical treatment is performed.
For the treatment of non-tumor forms of hyperprolactinemia, parlodel (5-7.5 mg/day), bromocriptine (2.5-3.75 mg, 1/2 tablet 2-3 times a day) is used.
Elena Shvedkina
endocrinologist, “Be Healthy” Clinic
city: St. Petersburg
Testosterone is the predominant hormone in the blood of men, produced mainly (95 %) by the testicles, in much smaller quantities by the adrenal cortex; formed from cholesterol. About 6 mg of testosterone is released into the blood plasma per day, and a small amount is deposited in the testicles. In plasma, testosterone is transported using sex steroid binding globulin (SSBG) or other blood proteins such as albumin. A small part circulates in the blood in free form.
![](https://i2.wp.com/katrenstyle.ru/upload/userfiles/vrach_2016_05_%D0%BB%D0%B5%D0%BA%D1%86%D0%B8%D1%8F_01.png)
Classification
Depending on the level of damage to the hypothalamic-pituitary system, the following are distinguished:
- hypergonadotropic hypogonadism (primary) in men. Testosterone production by the testicles is reduced or absent. Here we can distinguish congenital forms (Klinefelter syndrome - Fig. 1, anorchidism) and acquired forms (trauma, radiation, chemotherapy, other toxic lesions of the testicles, late initiation of treatment for cryptorchidism);
- hypogonadotropic (secondary) hypogonadism in men. Pituitary hormones that stimulate testosterone secretion are reduced or absent. This group also includes congenital forms (Kalman syndrome, isolated LH deficiency, other rare congenital diseases accompanied by hypogonadism), and acquired forms (tumors of the pituitary gland and hypothalamus, their surgical treatment or radiation therapy, hemorrhages in them, etc.);
- normogonadotropic hypogonadism. This condition is characterized by low testosterone production with normal levels of gonadotropins. It is based on mixed disorders in the reproductive system, expressed not only in primary damage to the testicles, but also in hidden insufficiency of hypothalamic-pituitary regulation. Typical examples are hypogonadism in obese men, hypogonadism with hyperprolactinemia (Fig. 2) and hypothyroidism, age-related hypogonadism (Fig. 3), iatrogenic hypogonadism;
- hypogonadism due to target organ resistance (feminization as a result of tissue receptor resistance to androgens; 5α-reductase deficiency; deficiency of estrogens, which in physiological concentrations are modulators of the normal effects of testosterone).
Figure 1. Example of patients with Klinefelter's sign
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Based on the time of occurrence, prepubertal and postpubertal hypogonadism can be distinguished.
Clinical picture
The clinical picture of the disease depends on the time of occurrence of the disorder and is presented in Table 1.
Table 1. Main signs of hypogonadism
There are nonspecific signs that may lead a clinician to suspect hypogonadism:
- oligo- and azoospermia;
- pathological fractures (discrepancy between the strength of the traumatic factor and the severity of the injury);
- osteopenia;
- moderate anemia (normochromic, normocytic);
- increase in adipose tissue;
- depression, sleep disturbance, memory loss.
Diagnosis of hypogonadism
The diagnosis of hypogonadism in men is established on the basis of anamnesis, clinical picture, confirmed by laboratory and instrumental studies. Recent guidelines recommend that the diagnosis of hypogonadism should only be made in men with symptoms, appearance, and clearly decreased serum testosterone levels. However, an analysis of the level of morning total testosterone in serum is recommended as an initial diagnostic test for hypogonadism.
Figure 2-3. Different types of hypogonadism
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To calculate the level of free testosterone, you can use the online calculator www.issam.ch/freetesto.htm.
Table 2. Testosterone standards
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If necessary, determine the levels of SSSH, FSH, LH, prolactin. High risk factors for developing hypogonadism:
- space-occupying formations of the hypothalamic-pituitary region;
- surgical interventions and/or radiation in the area of the sella turcica;
- long-term use of glucocorticoids, ketoconazole, opioids;
- diabetes mellitus, infertility, osteopenia and osteoporosis.
General population screening is not practical.
To identify a group at risk of hypogonadism, specialized questionnaires can be used.
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Treatment of hypogonadism in men
When starting to treat hypogonadism, the doctor sets a number of goals:
- elimination of androgen deficiency (restoration of potency, libido, well-being and behavior);
- ensuring virilization (growth of hair on the face and body according to the male type, change in voice timbre, physique, increase in muscle mass, enlargement of the penis and testicles, pigmentation of the scrotum, development of folding), if possible, ensuring fertility;
- potentially - reducing cardiovascular risks, preventing osteoporosis.
Depending on whether it is necessary to restore fertility, the choice of therapy is between hormone replacement therapy (HRT) with testosterone preparations, on the one hand, and preparations of human chorionic gonadotropin (hCG), luteinizing hormone (LH), follicle-stimulating hormone (FSH) and gonadotropin- releasing hormone (GRH) - on the other.
There are a large number of dosage forms of testosterone for intramuscular, subcutaneous, transdermal, oral and buccal use. However, testosterone HRT leads to a decrease in testicular volume and suppression of spermatogenesis.
Therefore, if testicular function is preserved and hypogonadism is of hypothalamic or pituitary origin, either hCG, LH, FSH drugs, or pulsatory administration of GnRH are used. These hormones increase the production of your own testosterone, which leads to the induction of spermatogenesis and restoration of fertility.
Clinical case
Patient K. (39 years old) consulted an endocrinologist with complaints of sexual dysfunction (decreased sexual desire, erectile dysfunction), general weakness, increased fatigue, shortness of breath during exercise, episodes of increased blood pressure (maximum up to 165/100 mm Hg .), excess weight, ineffectiveness of physical activity and diets. He said that he follows the principles of rational nutrition and regularly visits the gym. The above complaints have been bothering me for the last year. He was not independently treated or examined.
Objectively upon examination:- height - 183 cm;
- weight - 127 kg;
- BMI - 37.9 kg/m2;
- waist circumference (WC) - 123 cm;
- hip circumference (HC) - 135 cm;
- OT/OB - 0.91;
- Blood pressure - 145/90 mm Hg. Art., heart rate - 82 beats per minute.
Hair growth in the armpits, chest, anterior abdominal wall, and groin area is unremarkable. Bilateral false gynecomastia. The external genitalia are formed correctly, without any peculiarities.
When using the ADAM questionnaire, positive answers to 8 out of 10 questions, which indicates the severity of symptoms of androgen deficiency in this patient.
Laboratory indicators:- total cholesterol - 6.4 mmol/l (normal 3.1–5.2);
- LDL - 3.8 mmol/l (normal 0–3.3);
- triglycerides - 2.6 mmol/l (normal - less than 2.3);
- total testosterone - 7.2 nmol/l (normal 12.0–41.0);
- SSSG - 28.9 pmol/l (normal 12.9–61.7);
- LH - 4.7 U/l (normal 2.5–11.0);
- TSH - 1.8 mU/l (normal 0.25–4.0);
- prolactin - 243 IU/l (normal 50–610);
- estradiol - 164 pmol/l (normal 20–240);
- total PSA - 0.6 ng/ml (normal range 0–4).
According to ultrasound of the prostate gland, no echographic signs of pathology were identified.
The patient was diagnosed with normogonadotropic hypogonadism. Metabolic syndrome: Abdominal obesity (2nd degree). Arterial hypertension. Dyslipidemia.
Treatment goals:Normalization of testosterone levels. A prolonged form of testosterone (testosterone undecanoate 1000 mg) was prescribed intramuscularly according to a dose titration regimen to maintenance.
Weight loss and maintenance. It is recommended to follow the principles of a balanced diet with limited consumption of fats and easily digestible carbohydrates, table salt, as well as additional aerobic exercise (active walking for 1 hour a day).
When assessing the results of therapy after 10 months, the patient noted significant positive dynamics in general well-being - improvement in erectile function (increased sexual desire, increased frequency of spontaneous erections), disappearance of complaints about fatigue, depressed mood; stabilization of blood pressure to 130/80 mmHg. Art. Objectively, upon examination, there was a decrease in all anthropometric indicators: weight - 99 kg, BMI - 29.5 kg/m2, WC - 88 cm, TB - 109 cm, WC/TB - 0.81. During treatment, all hormonal and biochemical parameters also normalized. In the future, it was decided to continue therapy with monitoring of laboratory parameters once every six months.
What's new?
As information accumulates about the importance of androgens for the functioning and health of the male body, male hypogonadism is becoming the subject of special attention. In recent years, a growing body of scientific research has supported the use of testosterone replacement therapy in adult men. The main goal is to achieve testosterone concentrations in the blood that are as close as possible to physiological values in men with normal testicular function.
With age, the level of sex hormones decreases, ultimately manifesting itself in a state of age-related testosterone deficiency (andropause) in men. From about age 30 onwards until the end of life, a man loses on average about 1.5–2.0 % of free, most active testosterone every year. It is believed that men who initially have higher levels of testosterone in youth have a greater chance of not experiencing the manifestations of age-related androgen deficiency for as long as possible.
The Massachusetts Male Aging Study (MMAS), published in 1994, found that low free testosterone was a risk factor for insulin resistance and type 2 diabetes.
The existence of age-related androgen deficiency is officially recognized: according to the International Society for the Study of Older Men (ISSAM), the International Association of Andrology (ISA) and the European Association of Urology (EAU), late-onset hypogonadism (LOH) is defined as a clinical and biochemical syndrome , which occurs in adulthood, characterized by typical clinical symptoms in combination with low levels of testosterone in the blood, which can lead to a significant deterioration in the quality of life and adversely affect the functioning of many organs and systems of the body. A decrease in the level of sex hormones is one of the key moments of aging and age-associated diseases.
The causes and connections between hypogonadism and the development of concomitant diseases are being actively studied. A high prevalence of hypogonadism in obese men was found (up to 100% with a waist circumference of more than 102 cm). Low plasma testosterone levels are associated with manifestations of metabolic syndrome, cardiovascular disease, insulin resistance and type 2 diabetes mellitus (DM). Testosterone therapy in men with hypogonadism results in a decrease in adipose tissue volume.
Appropriate sex hormone replacement therapy is now positioned as part of an overall health strategy for men, which also includes advice on lifestyle, diet, exercise, smoking cessation, cognitive training and safe levels of alcohol consumption.
List of sources
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