Exercise-Hypogonadal Male Condition

Discussion in 'Men's Health Forum' started by Michael Scally MD, May 5, 2017.

  1. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Hooper DR, Kraemer WJ, Saenz C, et al. The presence of symptoms of testosterone deficiency in the exercise-hypogonadal male condition and the role of nutrition. Eur J Appl Physiol. https://link.springer.com/article/10.1007%2Fs00421-017-3623-z

    PURPOSE: High volumes of aerobic exercise have been associated with reduced testosterone (T), known as the exercise-hypogonadal male condition (EHMC). Although the presence of low T has been identified, few studies have assessed the presence of androgen-deficient symptoms. The purpose of this investigation is to assess men exhibiting EHMC and evaluate their hypothalamic-pituitary-gonadal axis, the presence of hypogonadal symptoms, and also investigate a possible contribution of inadequate nutrition to the condition.

    METHODS: A cross-sectional design compared 9 long-distance runners exhibiting EHMC to 8 non-active controls. Comparisons included serum T, luteinizing hormone (LH), follicle-stimulating hormone, and cortisol, the Aging Male Symptoms (AMS) questionnaire score, bone mineral density (BMD), and a food frequency questionnaire.

    RESULTS: Mean T was significantly reduced in the EHMC group (EHMC 9.2 nmol L-1 vs. CONT 16.2 nmol L-1). The EHMC group demonstrated significantly higher AMS scores (EHMC 27.1 +/- 7.3 vs. CONT 19.7 +/- 2.5). There were no differences in bone density, although 3 cases of osteopenia were noted for EHMC in the lumbar spine, 1 in the right femur, and 1 in the radius. Energy availability was significantly reduced in EHMC (EHMC 27.2 +/- 12.7 vs. CONT 45.4 +/- 18.2 kcal d FFM-1).

    CONCLUSIONS: Men exhibiting EHMC do appear to present with symptoms associated with androgen deficiency. For the most part, these symptoms are limited to those reported on the AMS questionnaire, although there are also some cases of clinically low BMD. It is possible that inadequate energy intake is contributing to this condition.
     
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  2. virginian

    virginian Member

    In other words, heavy exercise burns up your testosterone thereby reducing its level?
     
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  3. BBC3

    BBC3 Member

    What was the title again...?? DOES Girly work equal girly body...?!:D

    L.............. O................. L.................:confused::confused::confused::eek::eek::eek::eek:

    ** The position of my argument would be that in fact this kind of training CAUSES LESS TT PRODUCTION and POSSIBLY LESS ANDROGEN CONVERSION (It should be noted that the author makes reference to "Androgens", however, does not appear to consider for study... I.E. DHT, Etc...).

    TANGENT EPIPHANY ALERT -
    Does supplementing testosterone WHILE engaging in Aerobic Type Exercise CAUSE EXTENDED/EXACERBATED HPTA SHUTDOWN POST TESTOSTERONE SUPPLEMENTATION.!?!?

    AS GIVEN by AUTHOR... The abstract cites AEROBIC Exercise. Which will/should encompass exercise methods consisting of a low intensity REPEATED type muscular work load...

    DISCLAIMER... I have not reviewed "AMS Questionnairre"...


    "PURPOSE: High volumes of aerobic exercise have been associated with reduced testosterone (T), known as the exercise-hypogonadal male condition (EHMC). Although the presence of low T has been identified, few studies have assessed the presence of androgen-deficient symptoms. The purpose of this investigation is to assess men exhibiting EHMC and evaluate their hypothalamic-pituitary-gonadal axis, the presence of hypogonadal symptoms, and also investigate a possible contribution of inadequate nutrition to the condition."


    1. In my younger "experimental days", I seem to recall that I experienced a "threshold dose" of Synthetic T-Cyp Dosing about 250-300mgs/week at which point the muscular TYPE activity (PUMP) began to interfere with my ability to continue aerobic type exercise for long at all. Meaning, I could not fast-walk ONE single mile without my calves getting so pumped that I would just about stove up below the knees and fall over.. LOL but serious...

    2. I WOULD Agree that the condition exists, but most likely not for the reasons "medical science" would expect. My thoughts are that this would appear to be a proper & NORMAL RE-SPONCE, to a given set of conditions. As, it would APPEAR that the presence of high testosterone IN COMBINATION with continued REPEATED TYPE physical activity is CONTRA-TO....

    3. I DO observed and recognize that the study ALSO makes reference to "Androgens", which in the read of the ABSTRACT would appear to give away their get out of jail card on this one.... As "testosterone" and androgens DO NOT necessarily correlate.. So, it APPEARS to be a POOR article anywayz, whether GENERATED or ALLOWED - they are one in the same... But Perfect..!

    4. NO..! Running a mile or going to an aerobics class never blew my nutz up...

    5. Could it be possible that the body senses and understands what current biological DEMANDS are, and compensates??:confused:

    6. While YES, testosterone and other hormones ARE INDEED "BURNED" - A.K.A. METABOLIZED... We certainly won't ever hear science say that different conditions could indeed change metabolic production and elimination rates ON A DIME and AS MUCH AS 100% PLUS..:eek: Oh but forget about NOTIONS LIKE histamine response, Hunger signalling, BODY TEMP,
    and DIARRHEA...!:confused::eek::confused:

    7. One might also SUSPECT that when a person is involved in an aerobic activity, which happens to REQUIRE a considerable amount of DRIVE and DEVOTION to a cause, that they JUST MIGHT ALSO be dieting and the same time (free-jail card #2)... I ALSO HEAR that this type of physical activity tends to cut down on PERCEIVED CALORIC DEMANDS...:rolleyes: Then again, lets give the author his due, and perhaps he's trying to make a POINT...? However, somehow I don't suspect mature skeletal bone as just gobbling up androgens as compared to striated muscle, and you don't see HOBOz out for a jog to improve the shape of their ass...:confused:;)

    8. I WILL STATE that BEYOND A DOUBT OF CERTAINTY.. My nutz NEVER shrank so much as that time I was supping supra-physiological doses of Test Cyp and conducted considerable aerobic type exercise workload at the same time...

    9.
    It might even be REASONABLE to SUSPECT that the HPTA REVERSE FEEDBACK LOOP is POTENTIALLY magnified many-fold, when a human animal supplements testosterone and exercises at an aerobic capacity simultaneously...!!!! Thus POSSIBLY GREATLY compounding and complicating the effects of the post AAS conditions inclusive of prolonged low TT in serum count measurements as a general. AND THE POTENTIAL MAGNITUDE POSSIBLY EVEN DIRECTLY RELATED TO THE AMOUNT OF TESTOSTERONE OR TYPE OF AAS SUPPLEMENTATION INCLUDED DURING SAID AEROBIC TRAINING PERIOD...??! As well as the degree and extent of aerobic type workload.!


    10. (BBC'S Gathering from topic) -
    (a) Perhaps the effect of AEROBIC TYPE WORKLOAD on a testosterone supplemented male are GREATLY UNDERSTATED and UNKNOWN EVEN, as pertaining to the DEGREE and EXTENT of "EXPECTED"/Resulting HPTA shutdown...?!
    (b) Is this indeed simple proof and reflection of the possible point that muscle tissue in males metabolizes testosterone much more efficiently than Adipose tissue..?!
    (c) Smaller requirements ='s smaller NUTz...
    (d) Is there a such a thing as a "Horny Runner", or more like just an EXTRA- FRUSTRATED MALE...:eek::confused::(?!?!?!?
    (e) Why not review Hormones in Female runners as included.?
    (f) Were Estrogen levels in these males reviewed/considered.?
    (g) I'd like to see the Cortisol data and how it was considered with educational primer for me.
    (h) DID YOU just say "A food FREQUENCY questionnaire"!?!?!?!?!? Yea thought so, because to consider the QUALITY AKA the WHAT they ate would indeed be interesting. Or course that kind a study would be REAL WORK now wouldn't it...:confused::p:D
    (i) CAN aerobic type work be maximized in natural or unnatural conditions of LOW T..???

    (j) Chicken OR Egg is clearly in play here. AND ON MANY LEVELS... But aint that what makes it such a fine "target".. LOL:p
    :)
     
    Last edited: May 8, 2017
  4. themud

    themud Junior Member

    Marshall Unger (something to that name) ran across America. He is ultra runner. After a couple of days in his T levels went up. Same with Dean Karnazas who did 50 marathons in 50 states in 50 days with NO catabolism.

    I do believe moderate endurance (I use to do ultras and ironmans) do lower T.

    My TRT dr will not prescribe AI or hcg. Only DIM. She wants E2 at 5% ratio. Is that normal?
     
  5. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    [OA] Chronic Low testosterone Levels in Endurance Trained Men: The Exercise-Hypogonadal Male Condition

    Sportsmen and women who participate in endurance events perform a tremendous amount of exercise training [1]. For instance, it is not uncommon for a marathon or ultra-distance runner to perform 150 to 200 kilometers of intensive running per week as part of their regular training. Chronic exercise training to this extent results in positive physiological adaptations that are highly advantageous to the human body.

    For example, there is an enhancement of the maximal cardiac stroke volume, maximal cardiac output, maximal arterial-venous oxygen differential, increased erythrocyte number, decreased levels of stored adiposity and increased skeletal muscle mitochondrial density [1,2].

    Such physiological changes result in an increased human performance capacity. Yet exercise training to this extent can also place an incredible amount of stress and strain on the athlete’s body and result in unwanted physiological responses and health problems.

    Some of the common unwanted consequences of high volume training include development of the “Overtraining Syndrome” condition, which can completely compromise the ability of an athlete to perform, or lead to musculo-skeletal trauma and injury (i.e., “pulled muscles”) [3].



    The terminology to refer to these endurance-trained men with low resting testosterone had not been universally standardized, but in 2005 researchers from our laboratory group proposed the use of the phrase the “exercise-hypogonadal male” as a name to refer to this condition [6]. This is the terminology we and other investigators have chosen to use in our research discussions on the topic [5-8]. Men with this condition have certain characteristics and traits in common.

    Hackney AC, Aggon E. Chronic Low Testosterone Levels in Endurance Trained Men: The Exercise-Hypogonadal Male Condition. J Biochem Physiol 2018;1. https://www.scitechnol.com/peer-rev...-exercise-hypogonadal-male-condition-7DNx.pdf
     
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  6. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Hackney AC, Lane AR. Low testosterone in male endurance-trained distance runners: impact of years in training. Hormones 2018. Low testosterone in male endurance-trained distance runners: impact of years in training

    There has recently been renewed interest in the effect of exercise on the reproductive system of men. Meanwhile, the IOC Medical Committee has released a report proposing an overarching terminology for sportsmen and women having reproductive-endocrine disruptions and alterations, namely “Relative Energy Deficiency in Sports” (RED-S) [3].

    One of the central tenets of this report suggests that the reproductive changes seen in men, as well as in women, who do athletics are related to the development of low energy availability (LEA) [4]. In women, this relationship is strongly supported by research findings; however, in men, the assumption has yet to be fully substantiated [5].

    More research is therefore necessary before determination of whether LEA is universal and similar in its effect on men and women and on their reproductive function.

    One of the common practical questions concerning men engaged in endurance training and at risk for EHMC is as follows: To what degree of magnitude are their testosterone levels lowered? Typically, research reports demonstrate that testosterone is statistically significantly less than a given reference value. However, how much of a reduction from expected hormonal reference values or as compared to individuals who are healthy but are non-exercisers is not clearly addressed in the literature.

    Thus, we chose to examine and review archived data from studies within our research group which looked at men engaged in endurance exercise training in order to assess the magnitude of change in resting testosterone levels. In particular, anecdotal observations suggested that years of training was a critical factor in influencing testosterone levels of endurance-trained men; hence, we stratified by this factor.



    To our knowledge, these findings represent the largest published sample on the influence of chronic endurance training and the resulting effects on resting testosterone in men. The finding of lower testosterone in such men is not novel, but the training “dosage by years” impact is unique [5, 6].

    Our intent was not to assess why the occurrence of low testosterone exists in these men; hence, we will not speculate on this issue. However, in the case of EHMC, it is reported that endurance exercise training may result in an adaptive response in men such that their HPG axis regulation is re-set to facilitate lower overall testosterone production [6]. This latter issue is an area in which more research is needed.

    The current findings point to the necessity for both clinicians and researchers to be mindful of the fact that male patients and research subjects who have extensive endurance exercise training backgrounds will show potential alterations in their resting testosterone levels.

    Thus, standard clinical reference norms and/or expected ranges of hormonal assessment may be inappropriate for these individuals. Future research is required in this area of reproductive endocrinology as low testosterone has critical implications for infertility, bone health, and energy metabolism in men
     

    Attached Files:

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  7. Apexvallen

    Apexvallen Member AnabolicLab.com Supporter

    Thats my favourite quote in that whole post. Imagine the medical community saying 'oh wait, our reference ranges might not actually be the most perfect golden standard we pretend they are'.

    I had the test levels of an 85 year old man and was told 'you're within range, you're fine' while suffering every single symptom of low test. Stubborn as fuck medical boards and doctors potentially ruin lives.
     
  8. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Negative Consequences of Low Energy Availability in Natural Male Bodybuilding: A Review

    Energy availability (EA) is a scientific concept describing how much energy is available for basic metabolic functions such as reproduction, immunity, and skeletal homeostasis. Carefully controlled studies on women have shown pathological effects of EA < 30 kcal/kg fat-free mass (FFM), and this state has been labeled low EA (LEA).

    Bodybuilding is a sport in which athletes compete to show muscular definition, symmetry, and low body fat (BF). The process of contest preparation in bodybuilding includes months of underfeeding, thus increasing the risk of LEA and its negative health consequences. As no well-controlled studies have been conducted in natural male bodybuilders on effects of LEA, the aim of this review was to summarize what can be extrapolated from previous relevant research findings in which EA can be calculated.

    The reviewed literature indicates that a prolonged EA < 25 kcal/kg FFM results in muscle loss, hormonal imbalances, psychological problems, and negatively affects the cardiovascular system when approaching the lower limits of BF (∼4%–5%) among males. Case studies on natural male bodybuilders who prepare for contest show muscle loss (>40% of total weight loss) with EA < 20 kcal/kg FFM, and in the study with the lowest observed BF (∼4 kg), major mood disturbance and hormonal imbalances co-occurred. Studies also underline the problem of BF overshoot during refeeding after extremes of LEA among males. A more tempered approach (EA > 25 kcal/kg FFM) might result in less muscle loss among natural male bodybuilders who prepare for contest, but more research is needed.

    Fagerberg P. Negative Consequences of Low Energy Availability in Natural Male Bodybuilding: A Review. International journal of sport nutrition and exercise metabolism 2018:1-18. https://doi.org/10.1123/ijsnem.2016-0332
     
  9. barneys

    barneys Member

    Ditto, the range of "normal test levels" is way too broad
     
  10. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    I think many would prefer not to be treated by their levels. They are pointing to the fact that a low testosterone was "normal."

    I would point more to the following study/post, which you have noted. https://thinksteroids.com/community...edicine-and-big-data-who-is-normal.134392172/
     
  11. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Evidence of the Exercise Hypogonadal Male Condition at the 2011 Kona Ironman World Championships

    PURPOSE: Prior research has illustrated that high volumes of aerobic exercise result in a reduction in basal concentrations of testosterone in men. These prior studies have mostly been conducted on recreational runners and identified reduced testosterone, but not concentrations low enough to be considered pathological. Therefore, the purpose of this study is to assess the basal concentrations of testosterone and cortisol in elite triathletes, as well as assess the impact of a World Championship race on the acute responses of these hormones.

    METHODS: 22 men (Age: 40.6 +/- 11.5 yrs; Height: 179 +/- 6 cm; Weight: 77.0 +/- 7.0 kg) who participated in the 2011 Ironman World Championships served as subjects. Resting blood samples were taken 2-4 days prior (BL), as well as immediately (IP), 1 day (D1) and 2 days (D2) following the event, and were later analyzed for total testosterone and cortisol concentrations.

    RESULTS: At BL, of the 22 subjects, 9 men had a normal testosterone concentration, while 9 men fell within a 'grey zone' and 4 other men demonstrated concentrations suggestive of deficiency. Testosterone was significantly lower than BL at D1 (95% CI=0.10-0.34, P<0.001, ES=0.53) and D2 (95% CI=0.01-0.21, P=0.034, ES=0.35). Cortisol was significantly different from baseline at IP (95% CI=1.07-0.83, P<0.001, ES=8.0). There were significant correlations between time and age (R = 0.68, P=0.001) as well as baseline testosterone and cortisol (R=0.51, P=0.015).

    CONCLUSIONS: Elite ultra-endurance athletes may demonstrate not only reduced testosterone, but sometimes clinically low concentrations that could be indicative of androgen deficiency.

    Hooper DR, Kraemer WJ, Stearns RL, et al. Evidence of the Exercise Hypogonadal Male Condition at the 2011 Kona Ironman World Championships. International journal of sports physiology and performance 2018:1-22. https://journals.humankinetics.com/doi/10.1123/ijspp.2017-0476
     
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  12. virginian

    virginian Member

    I normally am quite active, but if I measure my test levels after an inactive period, they are unexpected high. This explains it. Intense exercise burns up test.
     
  13. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Case Study: Extreme Weight Making Causes Relative Energy Deficiency, Dehydration and Acute Kidney Injury in a Male Mixed Martial Arts Athlete

    The aim of the present case study was to quantify the physiological and metabolic impact of extreme weight cutting by an elite male MMA athlete. Throughout an 8-week period, we obtained regular assessments of body composition, resting metabolic rate (RMR), VO2peak and blood clinical chemistry to assess endocrine status, lipid profiles, hydration and kidney function.

    The athlete adhered to a "phased" weight loss plan consisting of 7 weeks of reduced energy (ranging from 1300 - 1900 kcal.d(-1)) intake (phase 1), 5 days of water loading with 8 L per day for 4 days followed by 250 ml on day 5 (phase 2), 20 h fasting and dehydration (phase 3) and 32 h of rehydration and refuelling prior to competition (phase 4). Body mass declined by 18.1 % (80.2 to 65.7 kg) corresponding to changes of 4.4, 2.8 and 7.3 kg in phase 1, 2 and 3, respectively.

    We observed clear indices of relative energy deficiency, as evidenced by reduced RMR (-331 kcal), inability to complete performance tests, alterations to endocrine hormones (testosterone: <3 nmol.L(-1)) and hypercholesterolemia (>6 mmol.L(-1)). Moreover, severe dehydration (reducing body mass by 9.3%) in the final 24 hours prior to weigh-in induced hypernatremia (plasma sodium: 148 mmol.L(-1)) and acute kidney injury (serum creatinine: 177 mumol.L(-1)).

    These data therefore support publicised reports of the harmful (and potentially fatal) effects of extreme weight cutting in MMA athletes and represent a call for action to governing bodies to safeguard the welfare of MMA athletes.

    Kasper AM, Crighton B, Langan-Evans C, et al. Case Study: Extreme Weight Making Causes Relative Energy Deficiency, Dehydration and Acute Kidney Injury in a Male Mixed Martial Arts Athlete. International journal of sport nutrition and exercise metabolism 2018:1-20. https://journals.humankinetics.com/doi/10.1123/ijsnem.2018-0029
     
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  14. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Neuromuscular Performance and Hormonal Profile During Military Training and Subsequent Recovery Period

    Introduction: Military training loads may induce different physiological responses in garrison and field training and only a little is known about how short-time recovery, lasting a few days, affects neuromuscular fitness and hormonal profile.

    This study aimed to investigate the effects of garrison and field military service on neuromuscular performance and hormonal profile and to evaluate the effects of a 3-day recovery on those factors.

    Methods: Twenty healthy male soldiers (20 +/- 1 years) participated in the study, which consisted of 4 days of garrison training [days (D) 1-4] and 7 days of military field training (Days 5-12) followed by a 3-day recovery period (Day 15).

    Serum hormone concentrations [testosterone (TES), cortisol (COR), sex-hormone binding globulin (SHBG), free thyroxine (T4)] were assessed at D1, D5, D8-12, and D15.

    Handgrip strength was measured in 10 participants at D1, D5, D8, D12, and D15. Maximal isometric force, electromyography, and rate of force development (RFD) of the knee extensors and arm flexors were also measured at D5, D12, and D15.

    Results: The maximal force of both the arm flexors and knee extensors was not affected by the garrison or field training, whereas the RFD of the knee extensors was decreased during the field training (D5: 383 +/- 130 vs. D12: 321 +/- 120 N/s, p < 0.05). In addition, handgrip strength was mostly no affected, although a significant difference was observed between D8 and D12 (531 +/- 53 vs. 507 +/- 43 N, p < 0.05) during the field training.

    TES decreased already during the garrison training (D1: 18.2 +/- 3.9 vs. D5: 16.2 +/- 4.0 nmol/L, p < 0.05) and decreased further during the field training compared to baseline (D8: 10.2 +/- 3.6 - D11: 11.4 +/- 5.4 nmol/L, p < 0.05) exceeding the lowest concentration in the end of the field training (D12: 7.1 +/- 4.1 nmol/L, p < 0.05). Similar changes were observed in free TES (D1: 72.2 +/- 31.4 vs. D12: 35.1 +/- 21.5 nmol/L, p < 0.001). The TES concentration recovered back to the baseline level and free TES increased after the recovery period compared with the baseline values (D15: 19.9 +/- 5.3 nmol/L, D15: 99.7 +/- 41.1 nmol/L, respectively).

    No changes were observed in the COR or SHBG concentrations during the garrison period. COR was decreased in the end of the field training (D12: 388 +/- 109 nmol/L) compared with baseline (D1: 536 +/- 113 nmol/L) (p < 0.05-0.001) but recovered back to the baseline levels after the recovery period (D15: 495 +/- 58 nmol/L), whereas SHBG linearly increased towards the end of the field training (p < 0.05-0.001).

    Conclusions: The present findings demonstrate that neuromuscular performance can be relatively well maintained during short-term garrison and field training even when a clear decrease in hormonal profile is evident. In addition, hormonal responses during field training seem to be greater compared to garrison training, however, the recovery of 3-day in free-living conditions seems to be sufficient for hormonal recovery. Therefore, a short-term recovery period lasting few days after the military field training may be required to maintain operational readiness after the field training.

    Salonen M, Huovinen J, Kyrolainen H, Piirainen JM, Vaara JP. Neuromuscular Performance and Hormonal Profile During Military Training and Subsequent Recovery Period. Mil Med 2018. Neuromuscular Performance and Hormonal Profile During Military Training and Subsequent Recovery Period | Military Medicine | Oxford Academic
     
  15. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Hooper D, Tenforde A, Hackney A. Treating exercise-associated low testosterone and its related symptoms. The Physician and Sportsmedicine 2018 https://doi.org/10.1080/00913847.2018.1507234

    The Exercise-hypogonadal Male Condition (EHMC) has been described to occur in athletes who experience low serum testosterone and associated symptoms. While high volumes of endurance exercise can lead to reduced testosterone concentrations in men, similar changes may occur in other sports including anaerobic and power sports such as American football, and weight class sports such as wrestling.

    A reduced testosterone concentration alone does not necessarily warrant treatment, but when it is accompanied by symptoms of hypogonadism, such as fatigue, sexual dysfunction and/or low bone mineral density (BMD), an athlete’s performance and/or health may suffer.

    While pharmacological treatments such as testosterone or clomiphene citrate have been shown to be effective in treating hypogonadism, these options are not available to athletes competing in sports governed by the World Anti-Doping Agency.

    We recommend treatment of EHMC in athletes should include nutritional intervention and modification of training. Recognizing EHMC‘s existence in male athletes is important to optimize their health.
     
  16. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Zekarias K, Shrestha RT. Role of Relative Malnutrition in Exercise-Hypogonadal Male Condition. Medicine and science in sports and exercise 2018. Role of Relative Malnutrition in Exercise-Hypogonadal Male... : Medicine & Science in Sports & Exercise

    OBJECTIVE: Exercise Hypogonadal Male Condition (EHMC) is a well-recognized condition in women but much less understood in men. The aim of this case report is to highlight exercise induced hypogonadotropic hypogonadism in a male who recovered with lifestyle modifications.

    METHODS: We report a case of an adolescent male who developed hypogonadotropic hypogonadism secondary to excessive exercise and malnutrition that was followed up for a year without exogenous testosterone supplementation. Informed consent was obtained from the patient for his information to be used in a manuscript submitted to a journal.

    RESULTS: 18-year-old adolescent male presented to the clinic with symptoms of fatigue and low endurance, low libido and lack of morning erections. At the time of his presentation, he was running about 60 miles per week for school cross-country team in addition to cross training with kick-boxing. Physical examination was remarkable for low BMI (Body mass index) of 19 but was otherwise normal.

    Biochemical work up confirmed hypogonadotropic hypogonadism and a mild pancytopenia. Other pituitary laboratory values and MRI of the brain were unremarkable. Bone marrow biopsy performed for anemia showed features consistent with malnutrition. With a working diagnosis of EHMC, he was advised to reduce the frequency and intensity of his exercise and increase calorie intake. Cell counts and testosterone levels normalized and his symptoms resolved without any further interventions.

    CONCLUSION: Significant reversible hypogonadism can develop after intensive and prolonged exercise. One of the mechanisms of hypogonadism in endurance athletes performing intensive exercise could be relative malnutrition. Further studies to evaluate the role of nutrition and BMI in male endurance athletes presenting with hypogonadism are needed to identify the underlying mechanism of this condition.
     
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