Additional testing may be necessary to confirm a diagnosis of hypogonadism. For accuracy, the blood test should be drawn between the hours of 7.00 and 11.00 in the morning on at least two occasions. After puberty, a wide range of factors can lead to hypogonadism, including tumors, eating disorders, genetic problems, and surgery, such as a hysterectomy. Symptoms include delayed puberty and a lack of menstruation or irregular menstruation. It is normally given as a topical gel, transdermal patch, or by injection. Adolescents and young adults who have not yet completed puberty appear younger than their chronological age. The signs and symptoms depend on when it starts, how severe the deficiency is, and whether or not there is a decrease in the major functions of the testes. It is recommended to perform a baseline digital rectal examinations (DRE) and a baseline PSA level measurement before starting testosterone therapy for any man, whatever his age (2,89). Although it is an effective oral androgen formulation, it is not recommended as a testosterone therapy for hypogonadism because of its hepatotoxic side effects and its association with long-term development of liver tumours. These are applied in the night and provide a good approximation of normal circadian plasma testosterone levels. A number of studies have shown that testosterone therapy can improve lean body mass and BMD and strength in hypogonadal men with COPD (17). There have been some studies that suggest that COPD patients have a higher incidence of hypogonadism than the general population and that glucocorticoid treatment is only part of the reason. Interventional studies have shown that testosterone replacement therapy in hypogonadal males increased spine BMD and trabecular connectivity (61,67). A recent study showed that supervised diet and exercise increased testosterone levels in hypogonadal men with metabolic syndrome and newly diagnosed type 2 diabetes. Adipose tissue affects testosterone levels by increasing the aromatisation of testosterone to estradiol, because the aromatase enzyme is concentrated in adipocytes. Low testosterone levels increase fat mass and decrease lean muscle, resulting in increased adipose tissue (52). Low testosterone levels are correlated with insulin resistance in both epidemiological and interventional studies, and this may be attributable to the effect of testosterone on adiposity. In particular, research has questioned the validity of commonly administered assays of free testosterone by radioimmunoassay. A position statement by the Endocrine Society expressed dissatisfaction with most assays for total, free, and bioavailable testosterone. Hypogonadism is often discovered during the evaluation of delayed puberty, but ordinary delay, which eventually results in normal pubertal development, wherein reproductive function is termed constitutional delay. Contrast with a young woman or teen, who would have hypogonadism rather than menopause. The signs and symptoms depend on the stage at which the patient presents with hypogonadism in relation to sexual maturity. It is also known as hypogonadotrophic hypogonadism due to low levels of LH and FSH resulting in decreased testosterone production. Secondary hypogonadism occurs when signalling to the testis is unable to stimulate sufficient testosterone production and is caused by conditions affecting the function of the hypothalamus and/or pituitary gland.
