Hypogonadism Workup

Updated: Aug 03, 2022
  • Author: Maria G Vogiatzi, MD; Chief Editor: George T Griffing, MD  more...
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Approach Considerations

Careful history taking, including of family and medication history, along with a physical examination, can guide the differential diagnosis and appropriate workup in hypogonadism. In postpubertal males, measurement of morning serum testosterone concentrations can establish the diagnosis of hypogonadism.

LH and FSH can be used to distinguish between hypogonadotropic and hypergonadotropic hypogonadism and guide further evaluation and management in both males and females. Hypergonadotropic hypogonadism indicates a primary gonadal defect (congenital or acquired), while hypogonadotropic hypogonadism suggests a hypothalamic/pituitary process (congenital or acquired).

Further hormonal testing (ie, measurement of serum prolactin or thyroid function tests) can be ordered based on presentation and history. Obtaining a karyotype can be considered in certain cases.

In the absence of specific symptoms or signs to direct the workup, evaluation for chronic illness includes a complete white blood count, a sedimentation rate, a comprehensive metabolic panel, a celiac screening, thyroid function tests, and a urinalysis.


Laboratory Studies


For males after puberty, the guidelines of the Endocrine Society [3] require that the diagnosis of hypogonadism be based on symptoms and signs of hypogonadism plus the presence of a low testosterone level measured on at least two occasions. Because of the diurnal variation in testosterone levels, a morning sample is recommended.

For postpubertal males with total testosterone concentrations near the lower limit of the normal range, measurement of free or bioavailable testosterone using a reliable assay is suggested if there is suspicion of sex hormone binding globulin (SHBG) changes. [3]

Obesity decreases serum SHBG concentrations to a degree that is proportionate to the severity of the obesity, thereby decreasing total testosterone values without usually affecting free testosterone. However, morbid obesity (BMI >40 kg/m2) may be associated with a low free testosterone concentration because of hypothalamic hypogonadism. Decreased SHBG concentrations are also seen in insulin resistance, type II diabetes mellitus, hypothyroidism, glucocorticoid use, and nephrotic syndrome. Increased SHBG concentrations can occur with aging, hyperthyroidism, liver disease, and anticonvulsant use.  

Examination of seminal fluid, karyotyping, and testicular biopsy may be helpful.


Karyotyping may be helpful. In females with normal karyotype and elevated gonadotropin levels, measure antiovarian antibody levels to rule out autoimmune disease.

In postpubertal females with signs of acne, hirsutism, and/or amenorrhea or irregular menses, measurement of total and free testosterone and 17-hydroxyprogesterone concentrations is indicated.


Imaging Studies

Magnetic resonance imaging (MRI) of the brain should be considered in cases of anosmia and suspected hypogonadotropic hypogonadism. Absence of the olfactory bulbs is associated with Kallmann syndrome.

Moreover, brain MRI should be ordered in cases of hypogonadotropic hypogonadism that are either isolated or occurring in combination with pituitary defects.

MRI of the pelvis is usually performed in DSD cases, such as androgen insensitivity or ovotesticular DSD, to help delineate the anatomy of internal genitalia. Uterine aplasia in a pubertal girl with normal gonadal function and amenorrhea can be seen in Mayer-Rokitansky-Küster-Hauser syndrome.

Pelvic ultrasonography may be helpful in females.

Bone age may be helpful in the evaluation of adolescents with delayed puberty and provides insight into their growth potential.


Other Tests

Adrenocorticotropic hormone (ACTH) stimulation testing: In patients in whom a form of congenital adrenal hyperplasia is suspected, adrenal steroid synthesis is best evaluated by performing a cosyntropin (ACTH 1-24) stimulation test. Baseline serum adrenocortical hormone levels are measured, then 0.25 mg of cosyntropin is intravenously injected, and serum hormone levels are remeasured after 60 minutes. Precursor product ratios are compared with those in age-matched control subjects to determine whether a steroidogenic defect is involved in sex hormone synthesis.

Luteinizing-hormone releasing hormone (LHRH) stimulation testing: To distinguish between true hypogonadotropic hypogonadism and constitutional delay in growth and maturation, performing a stimulation test with LHRH may be helpful.

  • LHRH is intravenously injected, and LH and FSH levels are determined at 15-minute intervals following LHRH administration.

  • A shortened version of the study has been used, in which LHRH is subcutaneously injected, and the specimen for LH and FSH levels is taken at 30-40 minutes.

  • Obtaining LHRH for testing over the past several years has been difficult. Some centers have substituted testing LH response to aqueous leuprolide.

Testicular tissue testing: If testes are not palpable and whether any testicular tissue is present is unclear, administering human chorionic gonadotropin (hCG) and measuring testosterone response may be helpful.



In prepubertal males with delayed puberty, priming with testosterone (usually testosterone enanthate 50 mg IM monthly for a total of 3 months) may lead to puberty initiation and help in the differential diagnosis of hypogonadotropic hypogonadism.

In postpubertal females with amenorrhea, withdrawal bleeding after a 5-10 day course of progestin (such as medroxyprogesterone 10mg hs) indicates adequate estrogen secretion and implies intact gonadal function.

Occasionally, testicular biopsy findings are helpful, particularly if azoospermia or oligospermia is present.