Hypogonadism is when the sex glands (gonads) produce little or no sex hormones. Low sex hormone levels (testosterone and estrogen) lead to low energy, decreased sex drive, and conditions like irregular periods and erectile dysfunction.

The causes of hypogonadism may be primary (related to the testes in males or ovaries in females) or secondary (related to the pituitary gland and hypothalamus in the brain). The treatment typically involves hormone replacement therapy.

Causes of Hypogonadism in Males and Females

Males and females can experience hypogonadism for many of the same reasons as well as for reasons specific to their sex.

Normal aging can also cause hypogonadism. Menopause, is characterized by a steep drop in sex hormones in females after age 50 that coincides with the ending of menstrual cycles. Men can also experience a steep decline after age 50, which some describe as “male menopause.”

Primary Hypogonadism

Primary hypogonadism is when the gonads do not function properly, leading to a decline in male sex hormones (hypoandrogenism) and female sex hormones (hypoestrogenism).

The possible causes of primary hypogonadism include:

Secondary Hypogonadism

Secondary hypogonadism is when the hypothalamus (located in the center of the brain) and pituitary gland (situated just below the hypothalamus) do not function properly. These organs regulate the production of estrogen and testosterone.

The hypothalamus directs the pituitary gland to release follicle-stimulating hormone (FSH) and luteinizing hormone (LH) into the bloodstream. FSH and LH act on the ovaries and testes and trigger the release of estrogen and testosterone.

If either the hypothalamus or pituitary gland is damaged or defective, estrogen and testosterone levels will drop.

Causes of secondary hypogonadism include:

• Genetic disorders such as Kallmann syndrome, which affects the normal development of the hypothalamus
• Pituitary tumors, such as prolactinomas which secrete excessive amounts of prolactin (a hormone that interferes with the production of estrogen and testosterone)
• Chronic infections like human immunodeficiency virus (HIV), which exposes the hypothalamus and pituitary gland to damaging inflammation
• Inflammatory diseases like sarcoidosis and tuberculosis that directly damage the hypothalamus and pituitary gland
• Traumatic brain injuries (TBIs) that injure the hypothalamus and pituitary gland
• Brain surgery or radiation
• Diabetes, which can affect the hypothalamus and pituitary due to insulin resistance (when cells do not respond well to the hormone insulin, which regulates blood sugar, and cannot take up enough glucose to use for energy)
• Pituitary disorders, including Cushing’s syndrome and diabetes insipidus
• Obstructive sleep apnea, in which decreased blood oxygen from breathing gaps impairs hypothalamus function
• Nutritional deficiencies, such as vitamin C, D, B1, and B12, which aid in nerve signaling and the normal function of the hypothalamus
• Eating disorders like anorexia nervosa that cause malnutrition
• Obesity, in which fatty tissues release excessive amounts of the enzyme aromatase that converts testosterone into estrogen
• Medications like opioids and anabolic steroids that disrupt communications between the hypothalamus and pituitary gland
• Hemochromatosis (iron overload) which overwhelms the hypothalamus and pituitary gland with iron deposits

Effects of Hypogonadism and Associated Symptoms

Hypogonadism can cause different symptoms based on your age and sex. The severity of symptoms corresponds to how low estrogen or testosterone levels are.

In children and adolescents, low estrogen or testosterone levels can affect physical and sexual development, sometimes irreversibly.

In Males 

Male hypogonadism is characterized by low testosterone, also known as “low T.”

In boys, low T can delay the onset of puberty, affecting normal physical development and the development of secondary male characteristics (such as facial hair and an Adam’s apple). Boys with hypogonadism might experience:

• Decreased stature and bone mass
• Decreased penis or testicle size
• Gynecomastia (abnormal breast enlargement)
• Little or no deepening of the voice
• Slowed muscle growth and decreased muscle mas
• Sparse body, facial, and pubic hair

In adult males, hypogonadism is associated with a cascade of physical, sexual, and psychological symptoms, including:

• Decreased body and facial hair
• Decreased muscle mass
• Depression
• Erectile dysfunction
• Gynecomastia
• Infertility
• Low libido (sex drive)
• Osteoporosis (loss of bone mineral density and bone mass)
• Reduced energy

In Females

In girls, low estrogen can lead to delayed puberty and interfere with normal physical and sexual development, causing symptoms like:

• Delayed breast development
• Delayed menarche (first period)
• Smaller breast size
• Smaller stature

In adult females, hypogonadism can cause different symptoms based on the person’s age and degree of hormonal impairment. Symptoms may include:

Treatment Effectiveness and Curability

Hypogonadism treatment in both males and females involves hormone replacement therapy. These therapies can help minimize or eliminate the symptoms. While certain causes of hypogonadism can be cured, many others cannot and require long-term treatment.

In Males

Testosterone replacement therapy (TRT) treats male hypogonadism. TRT is available in the following forms:

• Intramuscular (into the muscle) injection
• Long-lasting testosterone implants
• Oral tablets
• Rectal suppositories
• Subcutaneous (under the skin) injection
• Sublingual (under the tongue) pills or drops
• Topical (on the skin) gels
• Transdermal patches (applied to the skin)

In male hypogonadism, TRT can:

• Improve erectile dysfunction
• Improve overall quality of life
• Increase libido and sexual satisfaction
• Significantly increase lean body mass

However, most studies have not shown significant mood or energy level changes in hypogonadal men on TRT.

Adolescent boys may be prescribed TRT to initiate puberty, achieve their target height, body composition, and bone mass, and enhance sexual function during and after puberty. TRT in boys typically starts between the ages of 12 and 14 and, for some, may continue for a lifetime.

In Females

Estrogen replacement therapy (ERT) is the primary treatment for female hypogonadism. It is available in many forms, including:

• Intramuscular injection
• Intravaginal ring
• Oral pills
• Sublingual tablet
• Topical gel
• Transdermal patch

The primary aim of ERT is to prevent long-term complications of a deficiency of estrogen (hypoestrogenemia), including osteoporosis and heart disease. ERT also helps eases symptoms such as hot flashes, mood swings, and vaginal dryness.

In younger women with hypoestrogenemia, ERT has been showed to:

After menopause, progesterone may be added to reduce the risk of uterine cancer.

Girls with hypogonadism require ERT to initiate and sustain puberty. This generally starts between the ages of 11 and 12. Estrogen is started at lower doses to initiate puberty and is gradually increased every few months. Progesterone may then be added to stimulate the first period.

Other Treatment Options to Consider

Other prescription drugs are used on their own or in combination with hormone replacement therapy in people with hypogonadism, including:

• Clomid (clomiphene): Oral low-dose clomiphene increases the production of LH, which, in turn, stimulates the production of testosterone in the testes and ovaries.
• Human chorionic gonadotropin (HCG): Delivered by injection, HCG stimulates cells in the testicles, called Leydig cells, that produce testosterone. It may not be effective for primary hypogonadism if Leydig cells are damaged, defective, or dysfunctional.

No over-the-counter or alternative remedies have proven effective in treating hypogonadism. While many supplements and herbal remedies are marketed as “testosterone boosters” (including those with fenugreek, zinc, Tribulus, and Ashwagandha), none have shown any significant effect, and some have even decreased testosterone levels.

Self-Care to Manage Symptoms 

Hypogonadism tends to be a long-term condition that needs to be managed not only with medications but also with lifestyle changes and self-care practices. Some of these changes may even help increase testosterone by mitigating the risk factors that contribute to hypogonadism.

Six simple lifestyle “fixes” that may help are:

• Maintain a healthy weight: By achieving and sustaining a healthy weight (defined as a body mass index between 18.5 and 24.5), you may boost testosterone levels by as much as 30%.
• Exercise regularly: Exercise can help by burning fat, decreasing aromatase levels, and increasing insulin levels. Aim for at least 150 minutes of moderate-intensity physical activity per week.
• Eat a healthy diet: Eat plenty of fruits, vegetables, whole grains, fiber, and lean protein. Cut back on sugar, alcohol, caffeine, and animal fat.
• Get plenty of sleep. Lack of sleep disrupts the normal testosterone production cycle. Aim for 7 to 8 hours of interrupted sleep a night. If you have trouble sleeping, take steps to improve your sleep hygiene.
• Change medications: Opioids and anabolic steroids can produce low testosterone. Ask a healthcare provider about alternatives.
• Manage stress: Stress triggers the release of the hormone cortisol, which decreases testosterone levels over time. Use stress reduction techniques.

When to See a Healthcare Provider 

Hypogonadism can cause symptoms that are nonspecific, meaning they could be caused by and easily attributed to other conditions, including aging. See a healthcare provider for persistent symptoms that occur for no known cause. This is especially true if you have risk factors for hypogonadism, such as:

• Anabolic steroid use
• Autoimmune diseases like lupus or rheumatoid arthritis
• Chronic diseases like diabetes, HIV, liver disease, or kidney disease
• Excessive alcohol use
• Obesity
• Previous chemotherapy or radiation therapy
• Sleep disorders

Though hypogonadism can be diagnosed by a healthcare provider (based on blood test results), you may be referred to a specialist known as an endocrinologist for ongoing care.

Summary

Hypogonadism occurs when the ovaries or testes produce little or no sex hormones, leading to low testosterone in males and low estrogen in females. Primary hypogonadism occurs when the testes or ovaries do not function properly, and secondary hypogonadism occurs when the hypothalamus or pituitary gland does not work properly.

Symptoms of hypogonadism include erectile dysfunction, enlarged breasts, and a loss of muscle mass in males. In females, vaginal dryness, night sweats, and irregular periods are common. Hormone replacement therapy is the first-line treatment (testosterone for males, estrogen for females).