Andrology · KIMS Secunderabad
Low Testosterone (Hypogonadism) — Symptoms, Testing, and Treatment
Testosterone is the primary male sex hormone — produced by the Leydig cells of the testes under stimulation from luteinising hormone (LH), released from the pituitary gland. It is responsible for the development and maintenance of male characteristics: libido, erectile function, sperm production, muscle mass, bone density, body hair, red blood cell production, and mood regulation. When testosterone production falls below the normal range — a condition called hypogonadism — these functions are impaired, producing a recognisable but often overlooked clinical syndrome.
Low testosterone is significantly under-diagnosed in India. The symptoms — fatigue, low libido, reduced exercise tolerance, mood changes, and difficulty concentrating — are non-specific and are frequently attributed to stress, age, or overwork without a testosterone level being checked. A simple fasting morning blood test identifies low testosterone definitively and, where treatment is appropriate, testosterone replacement therapy (TRT) produces a significant and often dramatic improvement in quality of life.
Symptoms of low testosterone
Reduced libido — diminished sexual desire is the most specific symptom of testosterone deficiency.
Erectile dysfunction — testosterone is required for libido and for maintaining the sensitivity of erectile tissue, though it is not directly responsible for the vascular mechanism of erection.
Fatigue and low energy — profound, persistent fatigue that does not improve with rest.
Reduced muscle mass and strength — testosterone is anabolic; its deficiency causes sarcopenia.
Increased body fat — particularly visceral (abdominal) fat deposition.
Mood changes — depression, irritability, poor concentration, and reduced motivation.
Reduced bone density — testosterone maintains bone mineral density; deficiency causes osteoporosis risk.
Reduced body and facial hair — in established hypogonadism.
Testicular atrophy — reduced testicular volume in primary hypogonadism.
Hot flushes — in severe or rapid-onset hypogonadism (analogous to menopausal symptoms in women).
Causes — primary vs secondary hypogonadism
Primary hypogonadism (testicular failure)
The testes fail to produce adequate testosterone despite normal or elevated LH from the pituitary. Causes: Klinefelter syndrome (47,XXY — the most common genetic cause), orchitis (from mumps in post-pubertal men — historically important in India), bilateral undescended testes, testicular trauma or torsion, chemotherapy or radiation to the testes, and age-related decline (late-onset hypogonadism — testosterone falls approximately 1 to 2% per year after age 30). Blood tests: low testosterone + high LH and FSH.
Secondary hypogonadism (hypothalamic-pituitary failure)
The testes are normal but receive insufficient LH stimulation. Causes: pituitary tumours (prolactinoma — the most common — hyperprolactinaemia suppresses GnRH), obesity (excess oestrogen from adipose tissue conversion of androgens suppresses the HPG axis), opioid use (opioids suppress GnRH), systemic illness, anabolic steroid use (exogenous testosterone suppresses the HPG axis — a common reversible cause in younger men). Blood tests: low testosterone + low or inappropriately normal LH and FSH.
Diagnosis at KIMS
Fasting morning testosterone (2 samples)
Fasting morning testosterone measured on 2 separate samples on different days — testosterone peaks in the early morning. Below 8 nmol/L (231 ng/dL) confirms hypogonadism. 8 to 12 nmol/L is borderline — symptomatic patients in this range may benefit from treatment. Above 12 nmol/L is generally normal.
LH and FSH
Distinguishes primary (high LH/FSH — testicular failure) from secondary (low/normal LH/FSH — hypothalamic-pituitary failure) hypogonadism. This is the key step in determining the underlying cause and choosing the right treatment pathway.
Prolactin
Elevated prolactin from a pituitary adenoma suppresses testosterone. Prolactin measurement is mandatory in secondary hypogonadism to rule out prolactinoma as the cause.
Metabolic and baseline screening
Full blood count, lipids, HbA1c — testosterone deficiency is associated with metabolic syndrome and diabetes. PSA (in men above 45) and haematocrit — baseline before TRT (testosterone stimulates red cell production and prostate).
Treatment — testosterone replacement therapy (TRT)
TRT is indicated when testosterone is confirmed low on two separate tests and symptoms are present. The KIMS andrology team selects the formulation based on patient preference, fertility goals, and monitoring requirements.
Testosterone undecanoate injection (Nebido)
1000mg IM — the most convenient option — given every 10 to 14 weeks. Provides stable testosterone levels without the peaks and troughs of shorter-acting esters.
Testosterone enanthate / cypionate injection
200–250mg IM every 2 to 4 weeks. Less expensive than long-acting undecanoate; requires more frequent administration.
Testosterone gel (AndroGel, Testogel)
Applied to shoulders or upper arms daily. Good for patients who prefer to avoid injections — daily topical application gives steady absorption.
Clomiphene citrate (off-label, fertility-preserving)
Stimulates endogenous testosterone production by blocking oestrogen feedback at the pituitary. Preserves fertility (unlike exogenous TRT which suppresses spermatogenesis). Useful for younger men with secondary hypogonadism who wish to maintain fertility.
Contraindications to TRT
TRT is contraindicated in: prostate cancer (testosterone drives prostate cancer growth), breast cancer, haematocrit above 54% (polycythaemia risk), severe untreated sleep apnoea, and active desire for fertility (exogenous testosterone suppresses sperm production).
Monitoring on TRT
PSA monitoring every 6 to 12 months and haematocrit monitoring every 3 to 6 months are required on TRT. At KIMS, TRT patients are reviewed every 3 to 6 months with testosterone, haematocrit, PSA, and clinical assessment.
TRT is contraindicated in: prostate cancer (testosterone drives prostate cancer growth), breast cancer, haematocrit above 54% (polycythaemia risk), severe untreated sleep apnoea, active desire for fertility (exogenous testosterone suppresses sperm production). PSA monitoring every 6 to 12 months and haematocrit monitoring every 3 to 6 months are required on TRT.
Book a Testosterone Assessment at KIMS — Confidential Consultation
Frequently Asked Questions — Low Testosterone
Normal total testosterone in adult men is generally 10 to 35 nmol/L (300 to 1000 ng/dL). Hypogonadism is confirmed when fasting morning total testosterone is below 8 nmol/L (231 ng/dL) on two separate measurements. The borderline range of 8 to 12 nmol/L requires clinical judgement — a symptomatic man in this range may benefit from treatment. Testosterone varies significantly during the day (peaks in the early morning) and between days — which is why two fasting morning samples are required before making a treatment decision.
Yes — weight loss in obese men normalises testosterone substantially (adipose tissue converts testosterone to oestrogen via aromatase, suppressing the HPG axis). Resistance exercise (weight training) acutely raises testosterone and improves long-term testosterone sensitivity. Sleep optimisation — testosterone production is predominantly nocturnal, during deep sleep stages. Stopping anabolic steroids allows the HPG axis to recover over 3 to 12 months. For men in the borderline range with modifiable lifestyle factors, a 3-month lifestyle programme before initiating TRT is a reasonable approach.
Yes — exogenous testosterone suppresses LH production, which in turn stops FSH stimulation of sperm production (spermatogenesis). Men who want to maintain fertility should not use standard injectable or topical TRT. Alternatives that preserve or restore fertility: clomiphene citrate (stimulates endogenous LH and FSH) or human chorionic gonadotrophin (hCG) injections (directly stimulates testosterone production without suppressing FSH). Spermatogenesis typically recovers within 3 to 12 months of stopping TRT — sperm banking before starting TRT is advisable for any man considering future fatherhood.
TRT is safe for most men when properly monitored. The main risks requiring monitoring: polycythaemia (raised haematocrit from erythropoietic stimulation — managed by phlebotomy or dose reduction), cardiovascular events (the evidence on cardiovascular risk is complex — recent data from the TRAVERSE trial shows TRT does not increase major cardiovascular events in men with hypogonadism and high cardiovascular risk), prostate growth (TRT can cause a modest increase in PSA — it does not cause prostate cancer but must be avoided in established prostate cancer), and testicular atrophy (from LH suppression). At KIMS, TRT patients are reviewed every 3 to 6 months with testosterone, haematocrit, PSA, and clinical assessment.
KIMS Secunderabad — Dr. Neil Narendra Trivedi (MCh Urology KEM Mumbai, Member SIU, andrologist), fasting morning testosterone measurement, full hormonal workup (LH, FSH, prolactin), TRT in all available formulations (injection, gel), clomiphene/hCG for fertility preservation, PSA and haematocrit monitoring. Confidential consultation. Call 040-4488-5000.