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Androgen deficiency
What is androgen deficiency?
Androgen deficiency, or male hypogonadism, is defined as the underproduction of testosterone
by the testes. Starting at puberty the pituitary gland releases hormones which stimulate the testes
to produce testosterone, the hormone responsible for male physical characteristics. The action of
testosterone in the testes is also important for the production of sperm.
What are the signs and symptoms of androgen deficiency?
There are many symptoms and signs suggestive of low testosterone in adult men, although many
of them are non-specific:

Incomplete sexual development

Reduced libido (sexual desire) and activity

Decreased spontaneous morning erections

Breast discomfort or enlargement

Loss of body hair or reduced need to shave

Small testes

Inability to father children (low sperm count)

Reduced muscle bulk and strength

Hot flushes, sweats

Fatigue
How is androgen deficiency diagnosed?
A thorough medical history and examination is important, followed by measurement of
testosterone levels in the blood. It is important that this measurement is made first thing in the
morning when plasma testosterone levels are highest. Since testosterone levels can fluctuate it is
important that more than one level is assessed to confirm the diagnosis.
What are the causes of androgen deficiency?
Androgen deficiency can be primary (resulting from a problem with the testes) or secondary
(resulting from a problem with the pituitary gland and hypothalamus in the brain). With primary
hypogonadism, testosterone is low but LH and FSH (the pituitary hormones) are high. With
secondary hypogonadism, testosterone is low and LH and FSH levels are normal or low (often
called hypogonadotrophic hypogonadism).
Thus, low testosterone can be caused by a testicular problem (such as trauma, infection, radiation, a
congenital abnormality) or a pituitary cause. Of note, acute illness and chronic medical conditions
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Androgen deficiency
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such as obesity, type 2 diabetes, obstructive sleep apnoea (long pauses in breathing during sleep),
liver and kidney disease can also affect testosterone levels, as well as some medications such as
chronic morphine therapy. It is important that the cause of testosterone deficiency is identified as it
may represent an important problem with the pituitary gland.
Treatment of male hypogonadism/androgen deficiency
Treatment with testosterone replacement therapy is recommended for men with repeatedly low
testosterone levels and symptoms or signs of androgen deficiency. Not only is testosterone
important for sexual functioning but also for the maintenance of muscle strength, as well as
preserving bone density. The goal of treatment is to increase testosterone levels into the normal
range. Treatment goals may vary between patients but include improving or maintaining the
signs of masculinity (such as deep voice, growth of beard and pubic hair), improving sexual
functioning, energy, muscle and bone strength. Options for treatment include the following:

Oral testosterone undecanoate 40 mg capsules – these are best taken with food and can be
useful to induce puberty or for older men when lower levels of testosterone are frequently
adequate. The usual adult replacement dose is 80 twice daily.

Testosterone patches (Androderm 2.5 mg) – two patches are required daily, and for many
patients skin irritation is a significant concern.

Injectable testosterone esters (Sustanon 250 mg, testosterone cypionate 200 mg) – these
injections require intra-muscular administration every two to four weeks, the aim of treatment
being a trough testosterone (prior to injection) in the lower half of the normal range.

Depo-Testosterone preparations including long-acting testosterone decanoate (Reandron) –
this is given as a 4 ml intra-muscular injection with maintenance doses approximately threemonthly.

Testosterone implant therapy can also be used under the direction of an endocrinologist or
other specialist.

Testosterone gels are not currently available in New Zealand.
The particular form of testosterone prescribed depends on the patient preference, tolerance and
cost.
Are there adverse effects of treatment?
Testosterone therapy is usually well tolerated and improves overall wellbeing. Occasionally it can
cause an increase in the number of red blood cells (haemoglobin level), and it is important that a
blood count is checked each year. Testosterone replacement therapy does not cause prostate
cancer but may promote the growth of pre-existing prostate cancer. It is important that all men
are screened for this prior to commencing therapy, and that they then undergo surveillance for
prostate disease, similar to that recommended for men with normal testosterone levels. Men who
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have prostate cancer must not receive testosterone therapy. Testosterone therapy may also
worsen untreated obstructive sleep apnoea, severe untreated enlargement of the prostate or
severe heart failure.
Erectile dysfunction, or impotence, is the inability to maintain an erection (hard penis) for enough
time to achieve satisfactory sexual intercourse. Any physical condition that interferes with sexual
desire, blood flow or nerve signals to the penis can cause erectile dysfunction. The most common
causes are conditions affecting blood vessels and blood flow such as hardening of the arteries
(atherosclerosis) that is linked to diabetes, obesity, smoking, high blood pressure and high
cholesterol. Medications such as anti-depressants, drugs for high blood pressure, alcohol, etc.
also commonly cause erectile dysfunction. Erectile dysfunction can also occur with androgen
deficiency, and be corrected or improved by testosterone replacement, but it is important to
remember that there are numerous other causes, as described above.
More information
If you require further information you may wish to visit:
National Institutes of Health (www.nlm.nih.gov/medlineplus)
The Endocrine Society (www.endocrine.org)
The Hormone Foundation (www.hormone.org)
Written by the Department of Endocrinology, Christchurch Hospital.Endorsed by HealthInfo clinical advisers.
June 2013.
70631
HealthInfo reference: 70631
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Issued: 22 July 2014
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