Compensated primary hypogonadism - what do?

Medical Q&A [Moderated]
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Hi BBM Drs,

First time posting here, but I’ve been following your work for some time and have read/listened to everything that you have put out on this topic, which has been immensely helpful. The trigger for finally posting something here was the opening to your recent email titled “Is Low T Holding You Back?”, where the symptoms of low T were presented.

I’m a 35 y/o male, who recently got tested for hypogonadism, in part thanks to your resources on the topic.

The diagnosis from endo was “compensated primary hypogonadism”, i.e. total T in the normal range, but very high LH and FSH. I have a bunch, but not all of the specific, suggestive, and non-specific syptoms listed in your email, the key one being small testes and infertility, but also less-than-normal body hair, gynecomastia, and some seemingly unshakeable body fat. I’ve also had periods of sleep disturbance and fatigue through periods of my life.

I’m currently in a weird limbo where my body is making a “normal” amount of T, and I’ve been able to naturally cope with the symptoms through aerobic and resistance exercise, eating well, etc. The question I have is whether I would see some benefit by going on T replacement therapy when my levels are in the normal range.

The health system where I am doesn’t seem very well set up for people in my situation and I can’t find any good resources for compensated primary hypogonadism specifically. Drs here also seem hesitant to recommend/prescribe T replacement, saying that it could irrecoverably supress my normal T production meaning a lifetime of injections if I start down that track. In my mind this could be worthwhile if it means I am healthier and happier overall.

I appreciate this is verging on consultation territory, but I’m really just lookign for a sense-check and the impetus to take that next step.

Thanks,
Sam

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Hey there – glad you’ve found the resources helpful.

I agree with a reluctance to initiate T therapy at this point, but not for the reasons your doctors are mentioning.

Instead, if we’re in a situation of primary testosterone deficiency/hypogonadism, that requires further workup and determination of an underlying diagnosis of why, exactly, the testes are failing. You may have undiagnosed Klinefelter’s syndrome, for example. Be sure you’re seeing a board-certified endocrinologist.

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Hi Austin, thanks for the reply.

Apologies but for brevity I didn’t include all details in the first post. I’m 46XY. Checked twice. Reason for failure is still unexplained, but possibly late-descension. Seems like a trip back to the endo is the next move.

Thanks again,
Sam

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Got it. Beyond that additional evaluation to determine an underlying cause, given the set of signs and symptoms you describe, I’d be curious to know the specific numbers on your lab results, and what all has been measured so far.

We know that symptoms tend to track more closely with free testosterone levels than with total, so while Total T remains a great preliminary screening test, if that level falls in an equivocal range with specific/suggestive symptoms, the free level can often serve as a “tiebreaker” in that situation for decision making regarding treatment.

You don’t necessarily need to share any of the data here, but just mentioning some of the other things I’d be looking at in the setting of a one-on-one consultation.

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