Male hypogonadism: Causes, symptoms and treatment

Hypogonadism or testosterone deficiency is also one of the most debated areas in modern hormonal healthcare. Partly because the symptoms overlap with stress, depression and metabolic problems, and partly because many men end up in a gray area where the testosterone level is not clear or, more accurately, low enough for treatment but where the symptoms are still noticeable. This means that testosterone deficiency risks being both underdiagnosed and undertreated.

What exactly does hypogonadism mean?

Hypogonadism means that the body has insufficient testosterone production or a lack of hormonal signaling that leads to significantly lower testosterone levels. Testosterone is produced primarily in the testicles and is controlled via a hormone axis between the brain and the testicles. When this signaling functions less well or when the testicles no longer produce enough, testosterone levels drop. The process occurs naturally with increasing age but varies greatly individually for several reasons and in many cases the process causes symptoms.

Testosterone affects much more than sex drive. The hormone is important for muscle mass, bone strength, fat distribution, blood formation, energy, motivation and general well-being. Therefore, testosterone deficiency can be noticed in several different ways and is often perceived as “non-specific” before taking a testosterone test.

How common is testosterone deficiency in men

How common hypogonadism is depends largely on how the condition is defined and which age group is studied. Testosterone levels fall on average by about 1–2% per year after the age of 30–40, but not all men develop symptoms or clinically relevant testosterone deficiency.

Population studies show that about 2–5% of younger and middle-aged men meet criteria for hypogonadism, while the proportion increases significantly with increasing age. In men over 60 years of age, approximately 15–20% are estimated to have testosterone levels below established reference limits, and in men over 70 years of age, the figure may be even higher.

Testosterone deficiency is also significantly more common in men with certain risk factors. Studies show that low testosterone levels occur in up to 30–40% of men with type 2 diabetes, metabolic syndrome or severe obesity. Abdominal obesity, insulin resistance and chronic low-grade inflammation affect hormone balance and can both contribute to and exacerbate testosterone deficiency.

In practice, there is also a large group of men who do not have clearly low laboratory values, but who still experience symptoms consistent with hypogonadism. These men often find themselves in a so-called gray zone, where S-testosterone is just above traditional limit values, but where the biologically active proportion of testosterone may be low or where the individual's previous levels have been significantly higher.

It is often in this gray zone that the issue of underdiagnosis and treatment levels becomes most relevant. Because both symptoms and laboratory values ​​need to be weighed together, there is a risk that testosterone deficiency is overlooked, especially in men where symptoms have developed slowly and normalized as part of aging or lifestyle.

Who is affected and why?

Hypogonadism can affect both younger and older men, but it is more often seen in men with certain risk factors. Overweight and abdominal obesity are strongly linked to lower testosterone levels, partly because adipose tissue affects hormone balance and increases the conversion of testosterone to estrogen. Type 2 diabetes and insulin resistance are also common with low testosterone levels.

Other factors that may contribute include chronic stress, prolonged sleep deprivation, certain medications (such as opioids and long-term cortisone treatment), previous testicular damage, genetic conditions or effects on the pituitary gland. In some men, the cause is clear, in others it is a combination of lifestyle, age and other medical conditions.

When can you get a diagnosis in Sweden?

In Swedish healthcare, the diagnosis of hypogonadism is usually made only when both symptoms and laboratory findings are seen. A frequently used guideline is that S-testosterone below approximately 12 nmol/L in combination with typical symptoms can indicate testosterone deficiency. At the same time, it is important that the sample is taken correctly, since testosterone varies throughout the day and is affected by sleep, infections, stress and energy balance.

To assess testosterone deficiency in a more accurate way, it is often necessary to take a sample in the morning and sometimes repeat the sample. In case of borderline values, it may also be relevant to supplement with SHBG and calculated free testosterone, since some men may have “normal” total testosterone but still low biologically active testosterone.

What symptoms may indicate hypogonadism?

Testosterone deficiency often causes symptoms that develop gradually. Many people first notice a combination of decreased sex drive and lower energy. Others describe poorer motivation, increased fatigue, difficulty building or maintaining muscle, and a changed body composition with more abdominal fat. Some also experience depression, irritability, or cognitive “fog,” where focus and mental acuity are affected.

It is important to remember that symptoms are not specific to testosterone deficiency. This is why blood tests and a comprehensive assessment are crucial, especially if you have risk factors such as obesity, diabetes, or long-term stress.

Can testosterone deficiency be avoided?

Some causes of hypogonadism cannot be influenced, such as genetic conditions or testicular damage. But for many men, testosterone levels are strongly linked to lifestyle and metabolic health. Weight loss if overweight, regular strength training, better sleep, and reduced alcohol consumption can in some cases raise testosterone levels and improve symptoms.

This does not mean that lifestyle is always enough, but it does mean that testosterone deficiency is often related to the big picture: stress levels, recovery, body composition, and long-term health.

Is hypogonadism linked to other conditions?

Yes, low testosterone is often linked to other medical conditions, especially those that affect metabolism and cardiovascular risk. Testosterone deficiency is often seen along with insulin resistance, type 2 diabetes, high blood pressure, and abdominal obesity. It can also be linked to osteoporosis and an increased risk of low bone mass over time.

That's why testosterone deficiency is not just a question of sex drive, but can be part of a larger overall picture of male health.

When should you get tested for testosterone deficiency?

You should consider testing testosterone if you have a combination of typical symptoms, especially if they affect your quality of life and have been going on for a long time. It may also be relevant if you have risk factors such as obesity, diabetes or metabolic problems, or if you notice a clear change in energy, libido and recovery compared to before.

A good rule of thumb is to test when symptoms are recurring and difficult to explain with lifestyle or stress alone, or when you want to get an objective picture of your hormonal status as part of a health check.

Testosterone, PSA and prostate cancer - is there a connection?

The question of testosterone and the prostate is one of the most common reasons why men hesitate before investigation or treatment. PSA is a prostate marker test that is used as part of follow-up, and during testosterone treatment, PSA and prostate status are often monitored over time.

It is important to distinguish between two things: testosterone can affect the activity of the prostate, which can sometimes affect PSA levels, but this does not automatically mean that testosterone causes prostate cancer. Modern research has not shown that testosterone treatment itself causes prostate cancer in men without a previous disease, but prostate checks and medical follow-up are always a central part of safe treatment.

Why are more men in the gray area not being treated?

This is where the debate arises that many men recognize. Some have testosterone levels just above 12 nmol/L, but still experience clear symptoms. They are often told that the value is “normal” and that there is therefore no clear reason for further investigation. The problem is that a reference range does not always indicate what is optimal for the individual, especially when symptoms are clear.

At the same time, there is a legitimate reason for caution. Testosterone treatment is not a “vitamin injection” but a hormonal treatment that may require long-term follow-up. It must be used with the right indication and followed up with checks of blood values, PSA, symptom development and possible side effects. The debate is therefore rarely about whether treatment is “good or bad”, but about where the limit should be drawn, for whom and on what grounds.

Is testosterone treatment dangerous?

For the right patient and with correct follow-up, testosterone treatment is often safe and can provide a clear improvement in quality of life. At the same time, there are potential disadvantages. Treatment can affect blood concentration (hematocrit), affect fertility and require regular follow-up. Some may experience acne, fluid retention or mood effects, especially if the dosage is not individually adjusted.

It is also important to be clear: testosterone treatment should not be used as a shortcut to performance, but as a medical treatment for suspected or confirmed testosterone deficiency where benefits and risks are weighed together. If you suspect testosterone deficiency, a natural first step is to test your hormone levels properly and then interpret them in a medical context, along with your symptom picture and risk profile.