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a low testosterone level in the bloodstream might result from 2 factors. Most of the testosterone in men is produced by the Leydig cells situated in the testes. This process takes place using the luteinizing hormone (LH) from the pituitary gland. The LH is also strictly linked to the gonadotropin-releasing hormone (GnRH) which is produced by the hypothalamus. The GnRH is released in a pulsatile manner and a disruption in this process can lead to low testosterone levels over time.

To sum it up, men can suffer from primary hypogonadism (the testosterone is not produced in the testes), from secondary hypogonadism (the production of LH or GnRH is disrupted in the pituitary or hypothalamus) or both.

If a patient has primary hypogonadism, the LH and FSH levels will be elevated as these hormones are produced by the pituitary and hypothalamus, but not properly converted into testosterone. Most specialists recommend karyotype analysis for further investigation.

The causes of primary hypogonadism can be multiple and they include HIV, toxins gathered in the body, acquired anorchia, orchitis, and more. On the other hand, if the LH and FSH levels are low then additional investigations must be done to determine the nature of the secondary hypogonadism. It basically means that the testes are perfectly capable of making testosterone, but they don’t have the primary resource (LH) to do so.

The pituitary gland and problems associated with it

Secondary hypogonadism is a more complicated medical issue and it involves looking at the characteristics of the pituitary gland. There are numerous factors which might cause secondary hypogonadism such as certain types of tumors, untreated sleep apnea, infiltrative diseases, use of certain drugs such as marijuana, opiates, and heroin, etc.

Approximately 5% of secondary hypogonadism can be caused by hyperprolactinemia. This means that a prolactin adenoma can put pressure on the pituitary gland and cause damage. There are also different types of medications which can affect prolactin secretion such as metoclopramide and others.

In some cases, secondary hypogonadism can be caused by GnRH deficiency which happens as a result of damage to the hypothalamus. This part of the brain can become injured as a result of toxins accumulation, trauma, taking certain types of medication as well as systemic disease. If a patient is suspected of having secondary hypogonadism, he will receive a full pituitary workup to determine prolactin levels and to see if its secretion is disrupted or not.

It is paramount to differentiate between secondary hypogonadism originating in the pituitary and the one originating in the hypothalamus. Men who have fertility goals and want to have children in the near future need a different type of treatment than those who don’t have any fertility goals.

For example, if the hypogonadism originates in the hypothalamus, treatment with pulsatile GnRH should be considered as well as gonadotropin therapy. This approach promotes a healthy testosterone production which dramatically increases the chances of having children. On the other hand, if there are no fertility goals, testosterone replacement therapy can be prescribed in this case.

There are rare instances when men suffer from a combination of primary and secondary hypogonadism. This might happen as a result of alcohol abuse, sickle cell disease, and more. There are several treatment options available in this case such as spermatogenesis and others.

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