Skip to main content

Etiology of low testosterone levels in male patients with severe sepsis requiring mechanical ventilation


Low testosterone levels are frequently found in critically ill male patients. The etiology and clinical significance is still poorly understood. In the present study we have investigated the kinetics and pathophysiology of altered gonadal hormone synthesis in male patients with severe sepsis and respiratory failure.


All male patients with severe sepsis and respiratory failure who were admitted to the ICU of a large teaching hospital in the Netherlands between September 2011 and June 2012 were included. Steroid hormone levels were measured on days 1, 3 and 7


In total, 18 patients were included. The mean age was 69 ± 2 years, mean weight 76 ± 2 kg, APACHE II score 23 ± 2 and most patients suffered from pneumosepsis. On the first days of intubation, total and free testosterone levels were extremely low in most patients and remained low during the first week (Figure 1). 17β-Estradiol levels were elevated on day 1 and decreased during the first week. LH and FSH levels were inappropriately low. All lipoprotein fractions and their apo-proteins were reduced as well as 17-OH-progesterone, DHEA and DHEAS. In contrast, androstenedione (adione) levels were elevated. This suggests preferential and stimulated synthesis of androstenedione (Figure 2). The high 17β-estradiol levels indicate that androstenedione is shunted into the estrogen pathway, a process that requires high aromatase activity. The high estradiol/total testosterone ratio supports this conclusion

Figure 1


Figure 2



Hyperestrogenic hypotestosteronemia is a frequent finding in the acute phase of severe sepsis in male patients with respiratory failure. It is suggested to be caused by decreased androgen production and shunting of androgen to estrogen synthesis as a result of increased aromatase activity. The clinical relevance of gonadal hormone substitution needs further study.

Author information



Corresponding author

Correspondence to A Bech.

Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Cite this article

Bech, A., Van Leeuwen, H. & De Boer, H. Etiology of low testosterone levels in male patients with severe sepsis requiring mechanical ventilation. Crit Care 17, P448 (2013).

Download citation


  • Respiratory Failure
  • Severe Sepsis
  • DHEA
  • Androstenedione