Hypogonadism is a condition in which the sexual glands (gonads) — the testes in males and the ovaries in females — produce little or no hormones.

Although hypogonadism can affect both sexes, “Most of the time, when people talk about hypogonadism, they’re specifically referring to male hypogonadism,” says Barbara Chubak, MD, an assistant professor of urology at the Icahn School of Medicine at Mount Sinai in New York City.

Male hypogonadism is also known as low testosterone or low T because the testes (aka the testicles) produce insufficient levels of the hormone testosterone. Testosterone drives and supports the physical changes that take place in males during puberty; helps regulate sex drive and sperm production; and promotes bone development, heart health, and red blood cell count, among other functions.

Female hypogonadism is a condition in which the ovaries produce little to no estrogen or progesterone. Progesterone prepares the body for pregnancy and regulates the monthly menstrual cycle, while estrogen spurs and supports the physical changes that begin in females during puberty and plays an important role in heart health, bone development, brain function, skin aging, and more.

While menopause is by definition a type of hypogonadism, Caroline Nguyen, MD, an endocrinologist (a specialist in glands that secrete hormones) with Keck Medicine at the University of Southern California in Pasadena says that female hypogonadism is often viewed as a condition that happens separately from menopause.

There are many possible causes of hypogonadism, including genetics, environmental influences, and certain health issues.

Many people with hypogonadism may not realize they have the condition. A study in the International Journal of Clinical Practice stated that hypogonadism in adult men is often overlooked, even in the presence of symptoms, because it’s easy to ignore the signs or ascribe them to something else.

Male Hypogonadism

The Cleveland Clinic lists the following symptoms of low testosterone:

• Reduced sex drive

• Erectile dysfunction

• Loss of armpit or pubic hair

• Shrinking testicles

• Hot flashes (when testosterone is very low)

• Low or zero sperm count

• Depressed mood

• Difficulties with concentration and memory

• Increased body fat

• Enlarged male breast tissue

• Decrease in muscle strength and mass

• Decrease in endurance

Female Hypogonadism

The Cleveland Clinic lists the following symptoms of low estrogen:

• Tender breasts

• Dry skin

• Weak or brittle bones

• Trouble concentrating

• Moodiness and irritability

• Vagina dryness or atrophy

• Hot flashes and night sweats

• Irregular periods or no periods (amenorrhea)

• Weight gain, especially in the belly

• Headaches before or during a period

• Diminished sex drive and painful intercourse (dyspareunia)

• Fatigue and trouble sleeping

In adolescents, hypogonadism can delay or prevent puberty and the sexual development that typically occurs during that stage of life.

Medical experts classify hypogonadism as either secondary or primary.

Secondary hypogonadism This form of hypogonadism results from abnormalities in the pituitary gland or a hormone-producing area of the brain called the hypothalamus gland.

In people without hypogonadism, the hypothalamus produces hormones that stimulate the release of hormones from the pituitary; the pituitary hormones, in turn, instruct the testes to produce testosterone or the ovaries to produce estrogen and progesterone.

“Secondary hypogonadism is when the signal from the pituitary is deficient,” says Dr. Chubak. “So your gonads could conceivably make hormones in a normal quantity, but they’re not getting the instruction to do so, and so your hormones are low.”

Causes of secondary hypogonadism include the aging process, pituitary gland disorders (such as a pituitary tumor or tumor treatment), certain inflammatory diseases, HIV/AIDS, and some medications (such as certain opiates). A genetic condition, Kallmann syndrome, can also lead to secondary hypogonadism.

Primary hypogonadism Primary hypogonadism doesn’t involve the hypothalamus or pituitary but can be traced directly to abnormalities in the testes or ovaries.

Primary hypogonadism may begin when a child is in the womb. A mother’s diet, lifestyle, and exposure to drugs and chemicals may have an impact on the fetus. For example, a maternal zinc deficiency has been associated with male hypogonadism. Other research has shown that exposure to pesticides, radiation, air pollution, heavy metals, or other endocrine-disrupting chemicals may create oxidative stress, which may lead to reproductive disorders that begin in the fetal stage.

In the fetal stage, a lack of hormones can impede the growth of the sexual organs. In very rare cases, a child who is genetically male or female may be born with genitals of the opposite sex, or sexual organs that are neither clearly male nor clearly female (ambiguous genitals), or underdeveloped genitals.

Primary hypogonadism can also be genetic. Disorders that cause primary male hypogonadism include Klinefelter syndrome, the result of an extra X chromosome. (Males normally have one X and one Y chromosome, while females have two X chromosomes.)

In some women, a completely or partially missing X chromosome can cause Turner syndrome, a condition characterized by low estrogen. Fragile X syndrome is another genetic condition that can cause a host of reproductive issues, including low estrogen and early menopause.

Cancer treatment — radiation and chemotherapy — can cause primary or secondary hypogonadism depending on the exact therapies and types of cancer.

Other causes of primary hypogonadism include complications from the mumps and physical injury to the testicles or ovaries.

Risk Factors for Hypogonadism

Aging As males age, their testosterone levels may naturally decrease by about 1 percent a year after age 40. One study from the Boston University School of Medicine found that more than 6 out of 10 men over age 65 have testosterone levels that are below the average levels of men ages 30 to 35.

Obesity This condition is a risk factor for male hypogonadism. Body fat contains an enzyme called aromatase that converts testosterone into estrogen, causing hormonal imbalance. (Both male and female bodies produce estrogen and testosterone, albeit in different amounts.)

“Men who are carrying more fat are more vulnerable to extra conversion of testosterone to estrogen because that conversion occurs more in fatty tissue than in other kinds of body parts,” says Chubak.

Obesity does not appear to be a risk factor for female hypogonadism, Dr. Nguyen says.

Lack of body fat or disordered eating These are risk factors for female hypogonadism. The ovaries can stop producing estrogen prior to menopause when women are too thin, have an eating disorder, or work out excessively.

Type 2 diabetes is a risk factor for hypogonadism. Chubak says, “Diabetes can do a number on a lot of different organs,” including causing fibrosis, a type of scarring. “So one potential explanation [for hypogonadism] is that the sexual organs have a little bit of fibrosis due to diabetes.”

Some research has specifically pointed to a link between low estrogen and diabetes. A study led by Texas A&M University and published in Science Daily in February 2019 found that estrogen deficiency or impaired estrogen signaling is associated with the development of type 2 diabetes as well as obesity.

If a person suspects they have hypogonadism, a doctor can make a diagnosis by asking about medical history, conducting a physical exam, and ordering blood tests.

“Typically, the first step for a person who is worried they might have hypogonadism is to go to a primary care doctor and discuss their concerns,” says Nguyen. “Then if the primary care doctor feels that this is appropriate to do further workup, a patient may be referred to an endocrinologist.”

An inexpensive and reliable screening test for male hypogonadism can measure total and “free” testosterone levels in the blood. This test is typically done in the morning (testosterone levels typically peak between 8 and 10 a.m.). As the Cleveland Clinic explains, these tests may also measure hormones produced by the pituitary gland, such as follicle-stimulating hormone and luteinizing hormone.

For females, a simple blood test can measure blood level of estrogen, primarily a type called estradiol. This is typically paired with a test for the pituitary hormone FSH (follicle-stimulating hormone) to determine the cause of lower estrogen levels.

While there is no cure for hypogonadism, doctor-prescribed hormone replacement therapy can improve some symptoms.

Male Hypogonadism

Testosterone replacement may not only increase testosterone levels but also improve bone health, muscle development, and anemia (low red cells in the blood). The Endocrine Society says that the treatment is safe and can be effective.

To treat hypogonadism, millions of American males now turn to prescription testosterone injection, gels, patches, pellets (implanted under the skin), or buccal tablets (sticky pills applied to the gums).

Harvard Medical School points out that testosterone therapy has risks. A relatively small number of men experience immediate side effects such as acne, disturbed breathing while sleeping, breast swelling or tenderness, or ankle swelling. Red blood cell counts can also increase to abnormally high levels, which could increase the risk of clotting.

Testosterone therapy can also cause hormonal changes that lower the amount of testosterone that the testes are making, decreasing sperm production and fertility, according to the American Society for Reproductive Medicine. In most cases the infertility caused by testosterone treatment is reversible.

As Harvard Medical School points out, before starting testosterone, it's best to have a frank discussion with your doctor to get an evaluation and check in about other potential causes and contributors to the condition, such as stress, lack of exercise, poor sleep, and cardiovascular disease.

Make sure you get accurate and properly interpreted test results from reputable labs, which require testing testosterone in the morning and which may require multiple measurements plus additional tests with an endocrinologist.

Be sure to tell your doctor if you are at high risk for prostate cancer; have severe urinary symptoms from prostate enlargement; or have diagnosed heart disease, a previous heart attack, or multiple risk factors for heart problems.

If your doctor does start you on supplemental testosterone, it's very important to have periodic testing to make sure your testosterone levels are okay and to evaluate prostate and blood chemistry.

Female Hypogonadism

Women may be prescribed hormone replacement in the form of estrogen, progestin (another hormone), or estrogen with progestin. These products come in the form of patches, pills, gels, creams, sprays, and injections.

The U.S. Food and Drug Administration (FDA) cautions that hormone replacement therapy may increase the risk of blood clots, heart attacks, strokes, breast cancer, and gallbladder disease. Estrogen also raises the odds of endometrial cancer (cancer of the uterine lining), but adding progestin lowers this risk.

Do Supplements Work?

The market is flooded with testosterone-boosting supplements, but consumers should know that some may not be effective. A 2020 evaluation of 50 such supplements in the World Journal of Men’s Health discovered that 90 percent of “T booster” supplements claimed to boost T, but only a quarter had data to support these claims, and 10 percent contained components that might have a negative effect on testosterone.

“I don’t personally prescribe supplements,” says Nguyen. “But if you're talking about long-term risks in patients who have hypogonadism, it would make sense to optimize their vitamin D levels, because that would help with their bone health.”

The U.S. Department of Veterans Affairs provides a list of nonpharmaceutical approaches for optimizing testosterone levels, including maintaining ideal body weight, taking steps to avoid diabetes, exercise, good sleeping, good nutrition, stress reduction, and avoiding tobacco, opiate pain medications, and excessive alcohol.

These same habits can help women maintain healthy levels of estrogen as well, although health authorities warn that excessive exercise can deplete the body of estrogen.

While hypogonadism is often a lifelong condition, requiring ongoing treatment, people who take hormone replacement therapy and make positive lifestyle changes may improve quality of life, sense of well-being, sexual function, and muscle and bone strength.

According to information from Piedmont, a not-for-profit community health system, a combination of cardio and strength training can boost hormone levels.

Male Hypogonadism

University of Rochester Medical Center notes that male hypogonadism may contribute to the onset or worsening of conditions including:

• Cardiovascular disease

• Metabolic syndrome (high blood pressure, elevated insulin levels, excess belly fat, and abnormal cholesterol levels)

• Diabetes

• Atherosclerosis (plaque buildup inside the arteries that causes them to narrow over time)

• Prostate cancer or other more aggressive forms of cancer

• Osteoporosis

Female Hypogonadism

University of Rochester Medical Center warns that female hypogonadism raises the risk of:

• Osteoporosis

• Heart disease

An estimated 35 percent of men older than 45 and an estimated 30 to 50 percent of men with obesity or type 2 diabetes have hypogonadism, according to the Endocrine Society.

Female hypogonadism in premenopausal age groups (younger than 45) occurs in an estimated 1 percent of the population, with an estimated 5 percent experiencing early menopause, according to a report in the October 2019 Frontiers in Endocrinology.