In men with secondary hypogonadism, decreased libido, impotence, and infertility are common. The patient may note that he shaves less frequently and that there is a decline in the rate of progression of male pattern hair loss. With long-standing hypogo-nadism, fatigue and a loss of muscularity may be noted. A history of hyposmia or anosmia may be elicited from patients with Kallmann syndrome. If symptoms begin before or during puberty, the patient may demonstrate lack of deepening of the voice, no need for deodorant, and concerns about social acceptance. In some cases, it may be difficult to differentiate hypogonadotropic hypogonadism from delayed puberty (see Chap. 7, Chap. 91 and Chap. 92).31