Hypogonadism: real diagnosis vs marketing

A real diagnosis with a marketing problem

Male hypogonadism is a genuine clinical condition: the testes fail to produce adequate testosterone, sperm, or both. It has identifiable causes, agreed diagnostic criteria, and treatment that helps the men who have it.

It has also become the commercial engine of an entire clinic sector, and the gap between the diagnosis and the marketing is where the harm sits.

What the diagnosis actually requires

Professional guidelines — the Endocrine Society's among them — are consistent, and the requirements are stricter than most advertising implies. All of the following:

• Symptoms and signs consistent with testosterone deficiency
• Two low morning total testosterone measurements, drawn fasting, on separate days
• A reliable assay, with free testosterone calculated rather than measured by direct immunoassay where SHBG is likely to be abnormal
• LH and FSH, to distinguish a testicular cause from a pituitary one
• Reversible causes excluded before treatment is considered

A single afternoon blood test followed by a prescription meets none of this.

The two kinds, and why the distinction matters

Primary hypogonadism is a testicular problem — low testosterone with high LH and FSH, because the pituitary is shouting and nothing is answering.

Secondary is a pituitary or hypothalamic problem — low testosterone with low or inappropriately normal LH and FSH.

That second pattern matters because it can indicate something that needs finding: a pituitary tumour, haemochromatosis, significant illness. Treating the testosterone without asking why it is low can mean treating a symptom of something else entirely. Measuring LH and FSH costs little and is how that is avoided.

The reversible causes, which are common

This is the heart of it. In men seen by metabolic clinics, low testosterone is frequently a consequence rather than a cause:

• Obesity. Adipose tissue converts testosterone to oestradiol and lowers SHBG. Weight loss raises testosterone, in a dose‑dependent way across multiple studies.
• Obstructive sleep apnoea, through disrupted sleep architecture.
• Opioids, which suppress the axis strongly and are easily forgotten in a medicines history.
• Glucocorticoids, acute illness, severe stress, extreme training loads.
• Alcohol, at sustained high intake.

Each of these is treatable, and treating it may raise testosterone without any hormone being prescribed. A work‑up that does not look for them will find low testosterone and stop there — which is convenient for a clinic that sells testosterone.

What "low T" marketing gets wrong

Four recurring moves, all identifiable from the outside:

• Symptom lists so broad they include everyone. Tiredness, low mood, poor concentration, reduced libido, less muscle — also the symptoms of apnoea, depression, anaemia, thyroid disease, and insufficient sleep.
• Treating within the reference range. Offering treatment to men whose results are normal, on the argument that they are "not optimal". That is not a diagnosis; it is a redefinition.
• Age-related decline presented as disease. Testosterone declines gradually with age in most men. Whether that decline should be treated in the absence of a specific cause is genuinely unsettled, and guidelines are cautious about it.
• No mention of fertility. Exogenous testosterone suppresses sperm production, often substantially, and sometimes slowly to reverse. A man who may want children must be told this before the first injection, not after.

What should be said about risk

Treatment raises haematocrit, which is why a baseline full blood count is required and why it is monitored. It affects the prostate, which is why PSA is checked in older men.

On cardiovascular risk, the picture improved with the TRAVERSE trial, which did not find an excess of major cardiac events in men with hypogonadism and cardiovascular risk. It did report more cases of atrial fibrillation and pulmonary embolism. "Reassuring but not without signals" is the fair summary, and a clinic claiming it is proven safe is overstating a real result.

The boundary

Men who genuinely have this condition benefit from treatment, and under‑diagnosis is a real problem too. The argument here is only for the work‑up: two morning samples, the full panel around them, reversible causes excluded, and a conversation about fertility — before anything is prescribed.