Benefits and Health Implications of Testosterone Therapy in Men With Testosterone Deficiency

The dichotomy between health and drug abuse in bodybuilding

Aim: The aim of the present study was to investigate the expansion and prevalence of anabolic steroid use by examining the divergent effects between health and drug abuse and to create more awareness around the harmful consequences of these drugs when administered at abusive levels. Methods: A focused and concise literature search was conducted, and 101 high-quality articles were included in the review. Results: The findings underscore the adverse health risks of steroid abuse, emphasizing the stark contrast between health and drug abuse. Conclusions: While steroids and other performance-enhancing drugs can yield muscle growth, strength and even fat loss, abusing these substances can lead to adverse health outcomes. Furthermore, within the fitness subculture, particularly in the realm of bodybuilding, steroid abuse fosters an atmosphere of cheating and deception, frequently downplaying or ignoring the negative and sometimes deadly consequences it brings.

Hyperestrogenism is associated with sexual function impairment in men-findings from a cross-sectional, real-life study

BACKGROUND

Hyperestrogenism is believed to be harmful to male sexuality. We aimed to investigate the prevalence of and the impact of hyperestrogenism on sexual functioning in a cohort of men seeking medical attention for new-onset erectile dysfunction.

MATERIALS AND METHODS

Data from 547 men seeking first medical help for new-onset erectile dysfunction at a single andrology center were analyzed. Patients were assessed with a thorough medical and sexual history. Comorbidities were scored with the Charlson comorbidity index. All patients completed the International index of erectile function; the International index of erectile function-erectile function domain was categorized according to Cappelleri's criteria. Circulating hormones were measured in every patient. Hyperestrogenism was defined as estradiol levels >42.6 pg/mL (Tan et al., 2015). Descriptive statistics and logistic/linear regression models tested the association between hyperestrogenism and International index of erectile function domains score.

RESULTS

Overall, 96 (17.6%) participants had serum estrogen levels suggestive of hyperestrogenism. Men with hyperestrogenism were older (median [interquartile range]: 46 [35-59] vs. 44 [31-56] years; p < 0.001), had a higher rate of comorbidities (Charlson comorbidity index ≥1: 26.0% vs. 7.4%; p < 0.001), and higher serum total testosterone values (5.4 [5.2-8.0] vs. 4.3 [4.1-5.7] ng/mL; p = 0.01) than those with normal estradiol values. A higher prevalence of severe erectile dysfunction (135 [29.9%] vs. 47 [48.9%] men; p = 0.01) and of hypogonadism (22 [4.8%] vs. 6 [6.3%] men; p = 0.004) were found in men with hyperestrogenism. Serum estradiol levels were positively correlated with total testosterone levels (β = 0.26, p < 0.001) but negatively correlated with International index of erectile function-orgasmic function (β = -0.24, p = 0.002) and International index of erectile function-erectile function scores (β = -0.03, p < 0.001). When International index of erectile function scores was used to stratify erectile dysfunction patients, hyperestrogenism (odds ratio 2.44, p = 0.02) was associated with severe erectile dysfunction.

CONCLUSIONS

One out of five men seeking first medical help for erectile dysfunction showed elevated serum estradiol values suggestive of hyperestrogenism. Hyperestrogenism was associated with health-significant comorbidities, orgasmic function impairment, and erectile dysfunction severity.

Cardiovascular Impact of Androgen Deprivation Therapy: from Basic Biology to Clinical Practice

PURPOSE OF THE REVIEW

There have been increasing reports of cardiovascular complications of androgen deprivation therapy (ADT) leading to worse outcomes among patients with prostate cancer. While this may result from the direct effects of androgen suppression in the cardiovascular systems, there are ADT-type-specific distinct cardiovascular complications suggestive of mechanisms beyond androgen-mediated. Thus, it is critical to understand the biological and clinical impact of ADT on the cardiovascular system.

RECENT FINDINGS

Gonadotropin-releasing hormone (GnRH) agonists cause increased cardiovascular events compared to GnRH antagonists. Androgen receptor antagonists are linked to an increased risk of long QT syndrome, torsades de pointes, and sudden cardiac death. Androgen synthesis inhibitors are associated with increased rates of hypertension, atrial tachyarrhythmia, and, in rare incidences, heart failure. ADT increases the risk of cardiovascular disease. The risk among ADT drugs differs and must be evaluated to develop a medically optimal plan for prostate cancer patients.

Predictive Values of Nocturia and Its Voiding Frequency on the Aging Males' Symptoms

BACKGROUND

The link between nocturia and aging male symptoms (AMS) has not been scientifically established. This study aimed to measure the degree of severity of AMS that impacts health-related quality of life (HRQoL) in adult males living with nocturia and to determine the predictive values of nocturnal factors on AMS.

METHODS

This is an extended analysis of new data collected by using the Hong Kong Traditional AMS (HK-AMS) scale and the Cantonese version of the Pittsburgh Sleep Quality Index (PSQI) in a recently published cross-sectional population-based survey.

RESULTS

Of the 781 respondents that completed the set of questionnaires, 68% and 61% of men living with nocturia reported clinically significant (at moderate-to-severe levels) somato-vegetative and sexual AMS; the prevalence and severity were increased with advancing nighttime voiding frequency. Age, the Global PSQI score, certain metabolic diseases, the nocturia-specific QoL (NQoL) score and bedtime voiding frequency were found to be significant predictive factors for composite somato-vegetative and sexual AMS.

CONCLUSIONS

The current findings suggested the inclusion of nocturia when measuring male-specific HRQoL related to aging.

A new oral testosterone (TLANDO ® ) treatment regimen without dose titration requirement for male hypogonadism

Background

Male hypogonadism (testosterone level < 300 ng/dl) is a clinical syndrome that results from failure of the testis to produce physiological levels of testosterone. Most marketed testosterone replacement therapy products often require multiple dose adjustment clinic visits to achieve the desired, eugonadal testosterone levels.

Objective

To evaluate the efficacy and safety of a novel oral testosterone undecanoate therapy for the treatment of hypogonadism.

Material and methods

Ninety‐five (N = 95) hypogonadal men were enrolled in this open‐label, single‐arm, multicenter study in the United States (NCT03242590). Subjects received 225 mg of oral testosterone undecanoate (TLANDO) twice a day for 24 days without dose adjustment. Primary efficacy was percentages of subjects who achieved mean 24‐h testosterone levels within the eugonadal range and secondary efficacies were evaluated based on the upper limit of lab normal range of testosterone concentration.

Results

Subjects enrolled were on average age of 56 years, with about 17% of subjects older than 65 years. The mean body mass index was 32.8 kg/m². The baseline mean total testosterone values were below the normal range (202 ± 74 ng/dl). Post‐treatment with 450 mg testosterone undecanoate daily dose without dose adjustment, 80% of subjects (95% confidence interval of 72%–88%) achieved a testosterone Cavg in the normal range and restored testosterone levels to mean testosterone Cavg of 476 ± 184 ng/dl at steady state. Testosterone restoration was comparable to other approved testosterone replacement therapy products. TLANDO was well tolerated with no deaths, no drug‐related serious adverse events, and no hepatic adverse events.

Discussion and conclusions

TLANDO restored testosterone levels to the normal range in the majority of hypogonadal males. This new oral testosterone replacement therapy can provide an option for no‐titration oral testosterone replacement therapy. This therapy has the potential to improve patient compliance in testosterone replacement therapy.

Clomiphene Citrate for Men with Hypogonadism - A Systematic Review & Meta-analysis

BACKGROUND

Male hypogonadism is a clinical and biochemical androgen insufficiency syndrome, becoming more prevalent with age. Exogenous testosterone is first choice therapy, with several side-effects, including negative feedback of the hypothalamic-pituitary-gonadal axis, resulting in suppression of intratesticular testosterone production and spermatogenesis. To preserve these testicular functions while treating male hypogonadism clomiphene citrate (CC) is used as off-label therapy. This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of CC therapy for men with hypogonadism.

METHODS

The EMBASE, PubMed, Cochrane databases were searched in May 2021, for effectiveness studies of men with hypogonadism treated with CC. Both intervention and observational studies were included. The Effective Public Health Practice Project Quality Assessment Tool, a validated instrument was used to assess methodological study quality. The primary outcome measure was the evaluation of serum hormone concentration. Secondary outcomes were symptoms of hypogonadism, metabolic- and lipid profile, side-effects, safety aspects.

RESULTS

We included 19 studies, comprising four randomized controlled trials and 15 observational studies, resulting in 1642 patients. Seventeen studies were included in the meta-analysis, with a total of 1279 patients. Therapy and follow-up duration varied between one and a half and 52 months. Total testosterone (TT) increased with 2.60 (95% CI 1.82 - 3.38) during CC treatment. An increase was also seen in free testosterone, luteinizing hormone, follicle stimulating hormone, sex hormone-binding globulin and estradiol. Different symptom scoring methods were used in the included studies. The most frequently used instrument was the Androgen Deficiency in Aging Males-questionnaire, which score improved during treatment. Reported side-effects were only prevalent in less than 10% of the study populations and no serious adverse events were reported.

CONCLUSION

CC is an effective therapy for improving both biochemical as well as clinical symptoms of males suffering from hypogonadism. CC has few reported side-effects and good safety aspects. This article is protected by copyright. All rights reserved.

Barriers to receiving testosterone replacement therapy in the community during COVID-19 pandemic

Background

While the etiology for the upsurge in testosterone testing and prescriptions is likely multifactorial, increased direct-to-consumer marketing and the expansion of clinical care centers devoted to testosterone treatment likely play a role. Many of these centers require patients to report, in-person, on a regular basis for their injectable therapy and/or lab studies. The purpose of our study was to investigate barriers of care that patients receiving treatment for testosterone deficiency may be experiencing in the setting of COVID-19.

Methods

Our survey was posted on a closed Facebook support page for males currently receiving testosterone treatment and members of the group were invited to participate. The survey asked participants several questions related to how they received their injections, if they've experienced difficulties obtaining their injections due to COVID-19 restrictions, and about their interest in telemedicine services for their care.

Results

The majority of patients were able to receive their treatment despite barriers enforced by the pandemic. Of the 104 participants, almost half received their testosterone prescriptions from an outpatient clinic dedicated to testosterone replacement, while the other half received their therapy from a PCP, endocrinologist, or urologist. Only 5 patients (4.8%) noted difficulties obtaining their injections during this pandemic, 4 of which received their prescriptions from dedicated testosterone clinics, and the other from a PCP. Nearly 90% of respondents self-administered their testosterone therapy. With regards to telemedicine, 57.8% of patients have utilized the technology in some capacity, however 74.4% said that they would prefer to use telemedicine video services with a urologist or APP with expertise in andrology over in-person services.

Conclusions

In our survey, the majority of the respondents have been able to receive their injectable testosterone therapy despite the ongoing pandemic. The majority of respondents self-administer their treatments, which may explain the lack of barriers. This study is the first of its kind to investigate the effect of a pandemic on the receipt of care for those being treated for testosterone deficiency with injectable testosterone.

The association between testosterone, estradiol and their ratio and mortality among US men

While studies have suggested that testosterone is associated with a man's health, the relationship with other sex steroids remains uncertain. The current study aimed to investigate the association between sex steroids (i.e. testosterone, estradiol and the testosterone:estradiol ratio) and mortality in a representative sample of 1,109 US men. Three NHANES continuous cycles (1999-2000, 2001-2002, 2003-2004) were included in our study. Serum testosterone and estradiol levels were evaluated along with sociodemographic, lifestyle and health factors. Cox proportional hazards models were used. The adjusted risk of death for men with low testosterone levels was 1.66 (95% CI = 1.00-2.74, p = .05). The adjusted risk of death for men with abnormal estradiol levels was 0.96 (95% CI = 0.48-1.91, p = .91). The adjusted risk of death for men with low testosterone to estradiol ratio was 1.27 (95% CI = 0.82-1.97, p = .88). Relevant lifestyle and health factors significantly attenuated the associations. The adjusted risk of CVD-related death for men with low testosterone levels was 2.43 (95% CI = 1.07-5.50, p = .03). In conclusion, a significant association between testosterone and mortality and testosterone to estradiol ratio and CVD-related mortality was identified.

Case Report: Low Bone and Normal Lean Mass in Adolescents With Complete Androgen Insensitivity Syndrome

INTRODUCTION

Osteopenia and osteoporosis have been reported in adults with Complete Androgen Insensitivity Syndrome (CAIS). Little is known about changes in bone mineral density (BMD) in adolescents with CAIS and whether it is affected by early gonadectomy. Body composition data have not been reported.

METHODS

Single-center, retrospective study of CAIS adolescents who underwent dual-energy x-ray absorptiometry (DXA) (Hologic, Horizon A). Body composition is presented as lean and fat mass indices (LMI, FMI). Z-scores for lumbar spine areal BMD (LBMD), total body less head (TBLH), bone mineral content (BMC), LMI, and FMI were calculated using female normative data. Results are expressed as median and min, max.

RESULTS

Six females with genetically confirmed CAIS were identified-one with intact gonads and five with history of gonadectomy at 2-11 months. In the subject with intact gonads, LBMD-Z and TBLH BMC-Z were -1.56 and -1.26, respectively, at age 16 years. Among those with gonadectomy, LBMD-Z was -1.8 (-3.59 to 0.49) at age 15.6 years (12-16.8) and decreased in all three subjects who had longitudinal follow-up despite hormone replacement therapy (HRT). Adherence to HRT was intermittent. LMI-Z and FMI-Z were 0.1 (-1.39 to 0.7) and 1.0 (0.22 to 1.49), respectively.

CONCLUSIONS

These limited data indicate that adolescents with CAIS have bone mass deficit. Further studies are needed to understand the extent of BMD abnormalities and the effect of gonadectomy, especially early in childhood, and to establish the optimal HRT regimen for bone accrual. Data on lean mass are reassuring.

Remission of type 2 diabetes following long-term treatment with injectable testosterone undecanoate in patients with hypogonadism and type 2 diabetes: 11-year data from a real-world registry study

AIMS

To investigate whether testosterone therapy (TTh) in men with hypogonadism and type 2 diabetes mellitus (T2DM) improves glycaemic control and insulin sensitivity, and results in remission of T2DM.

MATERIAL AND METHODS

A total of 356 men who had total testosterone levels ≤12.1 nmol/L (350 ng/dL) and symptoms of hypogonadism were included in the study and followed up for 11 years. All patients received standard diabetes treatment and 178 patients additionally received parenteral testosterone undecanoate 1000 mg every 12 weeks following an initial 6-week interval. A control group comprised 178 hypogonadal patients who opted not to receive TTh.

RESULTS

Patients with hypogonadism and T2DM treated with testosterone had significant progressive and sustained reductions in fasting glucose, glycated haemoglobin (HbA1c) and fasting insulin over the treatment period. In the control group, fasting glucose, HbA1c and fasting insulin increased. Among the patients treated with testosterone 34.3% achieved remission of their diabetes and 46.6% of patients achieved normal glucose regulation. Of the testosterone-treated group, 83.1% reached the HbA1c target of 47.5 mmol/mol (6.5%) and 90% achieved the HbA1c target of 53.0 mmol/mol (7%). In contrast, no remission of diabetes or reductions in glucose or HbA1c levels were noted in the control group. There were fewer deaths, myocardial infarctions, strokes and diabetic complications in the testosterone-treated group.

CONCLUSIONS

Long-term TTh in men with T2DM and hypogonadism improves glycaemic control and insulin resistance. Remission of diabetes occurred in one-third of the patients. TTh is potentially a novel additional therapy for men with T2DM and hypogonadism.

Oncological safety and functional outcomes of testosterone replacement therapy in symptomatic adult-onset hypogonadal prostate cancer patients following robot-assisted radical prostatectomy

PURPOSE

Testosterone replacement therapy (TRT) remains controversial in men with treated prostate cancer. We assessed its safety and functional impacts in patients after definitive surgical treatment with robotic-assisted radical prostatectomy (RARP).

METHODS

We performed a retrospective analysis of 1303 patients who underwent RARP during the years 2006-2019. We identified men with symptoms of andropause and low serum testosterone who received TRT post-RARP; then we divided the cohort into two groups accordingly for comparison. Biochemical recurrence (BCR) was the primary endpoint. Secondary endpoints included functional outcomes. Predictors of BCR, including the effect of TRT on BCR, were evaluated using univariable and multivariable logistic regression.

RESULTS

Among the forty-seven men who received TRT, the mean age was 60.83 years with a median follow-up of 48 months. Three (6.4%) and 157 (12.56%) patients experienced BCR in TRT and non-TRT groups, respectively. Baseline characteristics were similar between both groups except for higher mean BMI in the TRT group (p = 0.03). In the multivariate analysis (MVA), higher pre-RARP prostate-specific antigen (PSA) (p = 0.043), higher International Society of Urological Pathology score (p < 0.001), seminal vesical invasion (p = 0.018) and positive surgical margin (p < 0.001) were predictors of BCR. However, TRT was not (p = 0.389). In addition, there was a significant change in the Sexual Health Inventory for Men (p = 0.022), and serum testosterone level (p < 0.001) before and 6 months after initiation of TRT.

CONCLUSION

Our findings suggest that TRT, in well-selected, closely followed, symptomatic men post-RARP is an oncologically safe and functionally effective treatment in prostate cancer patients post-RARP.

Pathophysiological effects of androgens on the female vascular system

Sex hormones and their respective receptors affect vascular function differently in men and women, so it is reasonable to assume they play a role in the sex differences in cardiovascular disease states. This review focuses on how the effects of testosterone on arterial vessels impact the female vasculature. In women with androgen-excess polycystic ovary syndrome, and in transgender men, testosterone exposure is associated with high blood pressure, endothelial dysfunction, and dyslipidemia. These relationships suggest that androgens may exert pathophysiological effects on the female vasculature, and these effects on the female vasculature appear to be independent from other co-morbidities of cardiovascular disease. There is evidence that the engagement of androgens with androgen receptor induces detrimental outcomes in the female cardiovascular system, thereby representing a potential causative link with sex differences and cardiovascular regulation. Gender affirming hormone therapy is the primary medical intervention sought by transgender people to reduce the characteristics of their natal sex and induce those of their desired sex. Transgender men, and women with androgen-excess polycystic ovary syndrome both represent patient groups that experience chronic hyperandrogenism and thus lifelong exposure to significant medical risk. The study of testosterone effects on the female vasculature is relatively new, and a complex picture has begun to emerge. Long-term research in this area is needed for the development of more consistent models and controlled experimental designs that will provide insights into the impact of endogenous androgen concentrations, testosterone doses for hormone therapy, and specific hormone types on function of the female cardiovascular system.

The Effects of Androgens on Cardiometabolic Syndrome: Current Therapeutic Concepts

INTRODUCTION

Cardiometabolic syndrome (CMS), as a bunch of metabolic disorders mainly characterized by type 2 diabetes mellitus (T2DM), hypertension, atherosclerosis, central adiposity, and abdominal obesity triggering androgen deficiency, is one of the most critical threats to men. Although many significant preclinical and clinical findings explain CMS, new approaches toward common pathophysiological mechanisms and reasonable therapeutic targets are lacking.

AIM

To gain a further understanding of the role of androgen levels in various facets of CMS such as the constellation of cardiometabolic risk factors including central adiposity, dyslipidemia, insulin resistance, diabetes, and arterial hypertension and to define future directions for development of effective therapeutic modalities.

METHODS

Clinical and experimental data were searched through scientific literature databases (PubMed) from 2009 to October 2019.

MAIN OUTCOME MEASURE

Evidence from basic and clinical research was gathered with regard to the causal impact and therapeutic roles of androgens on CMS.

RESULTS

There are important mechanisms implicated in androgen levels and the risk of CMS. Low testosterone levels have many signs and symptoms on cardiometabolic and glycometabolic risks as well as abdominal obesity in men.

CLINICAL IMPLICATIONS

The implications of the findings can shed light on future improvements in androgen levels and add potentially predictive risk for CMS, as well as T2DM, abdominal obesity to guide clinical management in the early stage.

STRENGTHS & LIMITATIONS

This comprehensive review refers to the association between androgens and cardiovascular health. A limitation of this study is the lack of large, prospective population-based studies that analyze the effects of testosterone treatment on CMS or mortality.

CONCLUSION

Low testosterone levels have several common features with metabolic syndrome. Thus, testosterone may have preventive role in the progress of metabolic syndrome and subsequent T2DM, abdominal obesity, and cardiovascular disease and likely affect aging men's health mainly through endocrine and vascular mechanisms. Further studies are necessary to evaluate the therapeutic interventions directed at preventing CMS in men. Kirlangic OF, Yilmaz-Oral D, Kaya-Sezginer E, et al. The Effects of Androgens on Cardiometabolic Syndrome: Current Therapeutic Concepts. Sex Med 2020;8:132-155.

Baseline Gonadotropin Levels and Testosterone Response in Hypogonadal Men Treated With Clomiphene Citrate

OBJECTIVE

To investigate the role of baseline gonadotropins in predicting the biochemical response to clomiphene citrate (CC) treatment.

METHODS

We conducted a retrospective review of data from hypogonadal men treated with CC in 2 high-volume fertility centers between 2013 and 2018. Patient age, body mass index, and baseline hormones (follicle stimulating hormone [FSH], luteinizing hormone [LH], and total testosterone [TT]) were obtained. Response to treatment was measured as changes in TT levels within 6 months of initiating CC treatment. Linear regression models adjusted for age, body mass index, and time on CC therapy were fitted to assess the associations between baseline LH and FSH levels with treatment response.

RESULTS

A total of 332 men with mean ± standard deviation age of 36.2 ± 8.2 years were included. Median time to initial follow-up was 6 weeks (25th-75th interquartile range [IQR]: 4-9 weeks). TT levels increased significantly on CC treatment (mean change: 329.2 ng/dL, 95% CI: 307.4-351.0) with 73% of men having at least 200 ng/dL increase over baseline TT levels. In univariable linear regression models, only age was significantly associated with TT response. Neither the baseline LH nor FSH significantly predicted TT response in linear regression models.

CONCLUSION

CC treatment results in significant increases in testosterone levels in most men. Baseline gonadotropins are not strong predictors for treatment response to CC. Adequate biochemical response with CC trial can be expected in most patients with normal or slightly elevated baseline gonadotropin levels.

Sexual motivation: problem solved and new problems introduced

Background During the past 50 years, motivational studies have evolved from the logical inference of logically required "intervening variables" to explain behavioral change, to electrophysiological and molecular analyses of the mechanisms causing such changes. Aim The purpose of this review article is two-fold: first to describe the logic of sexual motivation in a way that applies to laboratory animals as well as humans, and the second is to address some of the problems of sexual motivation experienced by men. Results When problems of motivational mechanisms are stripped down to their essentials, as performed in the laboratory animal models and are available for reductionistic studies, then the problems can be solved with certainty, as illustrated in the first part of this review. However, with respect to human sexual motivation, the various determinants which include so many behavioral routes and so many brain states come into play, that definite conclusions are harder to come by, as illustrated in the second part of this review. Conclusions This review highlights a number of key questions that merit further investigation. These include (a) What mechanisms do cultural and experiential influences interact with androgenic hormone influences on human sexual motivation? (b) How would epigenetic effects in the human brain related to changes in motivation be investigated? (c) What are the effects of unpredictable traumatic and stressful human experiences on sexual motivation; (d) How such mechanisms are activated upon unpredictable traumatic and stressful insults? (e) What are the outstanding differences between sexual motivational drive and motivations driven by homeostatic systems such as hunger and thirst?

Lifestyle modifications and pharmacological approaches to improve sexual function and satisfaction in men with spinal cord injury: a narrative review

STUDY DESIGN

A narrative review describing various components of sexual dysfunction in men with spinal cord injury (SCI), as well as addressing potential therapeutic approaches.

OBJECTIVES

Restoration of sexual function is considered one of the most important health priorities for individuals with SCI. The purpose of this review is to provide information regarding the factors that are less appreciated when considering changes to sexual function in men with SCI. We also propose therapeutic approaches, with a focus on lifestyle modifications, which have been shown to improve sexual function.

METHODS

A literature search was performed and limited evidence for therapeutic approaches in individuals with SCI was supplemented by consistent findings from the able-bodied population.

RESULTS

We evaluated the less addressed factors known to contribute to sexual dysfunction in men with SCI, including hormonal influences (i.e., testosterone deficiency, thyroid hormone, and cortisol), psychological factors (i.e., pain, fatigue, depression, and body image), and secondary SCI complications (i.e., urinary tract infection, pressure sores, and autonomic dysreflexia). To address these factors beyond standard medical treatments for sexual dysfunction, options include physical activity/exercise, diet, and specific medications for symptom relief (i.e., testosterone replacement therapy and selective serotonin reuptake inhibitors for depression).

CONCLUSIONS

Physical activity's potential application, efficacy across multiple aspects of sexuality, and the lack of side effects, suggests that long-term exercise is a viable solution to directly or indirectly improve sexual function in males with SCI. Diet and supplemental medications may further promote body composition changes, which more broadly affect sexuality.

The effect of Trigonella foenum-graecum extract on prostate-specific antigen, and prostate function in otherwise healthy men with benign prostate hyperplasia

The aim of this trial was to evaluate the effect of a standardised Trigonella foenum-graecum (Fenugreek) extract on the symptoms of benign prostate hyperplasia (BPH) using a double-blind randomised placebo controlled design. The study recruited 100 healthy males aged between 45 and 80 years with symptoms of BPH who recorded a minimum score of eight on the International Prostate Symptom Score. Participants were randomised to an oral dose of either 600mg Trigonella foenum-graceum per day or placebo for 12 weeks. The primary outcome measure was the International Prostate Symptom Score total and subdomain scores. The secondary outcomes were serum levels of the hormones (testosterone, free testosterone, and sex hormone binding globulin) prostate-specific antigen, and safety markers. The results indicated that Trigonella foenum-graceum did not have an effect on improving the symptoms of BPH. Hormone levels, safety markers, and prostate-specific antigen remained unchanged and within normal limits after 12 weeks, which adds to the safety profile of this specialised extract.

Identification and functional characterization of microRNAs in rat Leydig cells during development from the progenitor to the adult stage

The aim of the present study was to identify microRNAs (miRNAs) that regulate the proliferation and differentiation of Leydig cells (LCs) of rat. Three small RNA libraries derived from progenitor LCs (PLCs), immature LCs (ILCs) and adult LCs (ALCs) were analyzed by microarrays. In total, 68 differentially expressed miRNAs (DEMs) were identified. Based on the trend of DEM expression from PLCs to ALCs, primary LCs were transfected with miRNA mimics or inhibitors. Five miRNAs (miR-30a-5p, miR-3585-5p, miR-212-3p, miR-369-5p and miR-434-3p) promoted PLC proliferation, and 3 miRNAs (miR-17-5p, miR-532-3p and miR-329-3p) activated caspase-3, which triggered LC apoptosis. For steroidogenesis, 18 miRNAs could elevate or inhibit androsterone release at the PLC stage. Eleven and 9 miRNAs inhibited the production of 5α-androstane-3α,17β-diol in ILCs and testosterone in ALCs, respectively. miR-17-5p, miR-29a-3p and miR-299a-5p decreased androgen production by LCs at all developmental stages. Furthermore, the miR-299a-5p-mediated decrease in androgen production by the LC lineage was primarily achieved by downregulating the expression of luteinizing hormone/choriogonadotropin receptor (LHCGR) and 3β-hydroxysteroid dehydrogenase 1 (HSD3B1). These findings provide insights into the regulatory roles of miRNAs during the postnatal development of LCs and suggest potential strategies for the treatment of steroid-related disorders.

Testosterone Recovery Profiles After Cessation of Androgen Deprivation Therapy for Prostate Cancer

INTRODUCTION

Androgen deprivation therapy (ADT) is frequently used in the treatment of prostate cancer worldwide. Variable testosterone (T) recovery profiles after ADT cessation have been cited.

AIM

To evaluate T recovery after cessation of ADT.

METHODS

We reviewed our institutional prospectively maintained database of patients with prostate cancer who received ADT. Serum early morning total T (TT) levels, collected at baseline and periodically after ADT cessation, were analyzed. Patient age, baseline T level, duration of ADT, and presence of diabetes and sleep apnea were selected as potential predictors of T recovery. 3 metrics of T recovery after 24 months of ADT cessation were analyzed: return to non-castrate level (TT > 50 ng/dL), return to normal (T > 300 ng/dL), and return back to baseline level (BTB). Multivariable time-to-event analysis (Cox proportional hazards), χ² test, logistic regression model, and Kaplan-Meier curve were performed to define impact of the above predictors on time and chance of T recovery.

MAIN OUTCOME MEASURES

Time and chance of T recovery to non-castrate level (TT > 50 ng/dL), return to normal (T > 300 ng/dL), and return BTB.

RESULTS

307 men with a mean age of 65 ± 8 years were included. Mean duration of ADT was 17 ± 25 months, and median follow-up was 31 ± 35 months. Mean TT values were 379 ng/dL at baseline and 321 ng/dL at >24 months. At 24 months after cessation of ADT, 8% of men remained at castrate level, 76% returned to TT >300 ng/dL, and 51% had returned BTB. Lower baseline T levels (TT < 400 ng/dL) and ADT duration >6 months were associated with a lower likelihood of recovery to normal TT at 24 months. Age >65 years and receiving ADT for >6 months were significantly associated with a slower T recovery.

CLINICAL IMPLICATIONS

T recovery after ADT is not certain and may take longer than expected. Considering the range of side effects of low T, we believe that these findings must be discussed with patients before initiating such therapies.

STRENGTHS & LIMITATIONS

Our strengths consisted of a relatively large database, long follow-up, and clinically meaningful endpoints. Limitations included the retrospective design of the study.

CONCLUSION

T recovery rates after ADT cessation vary according to patient age, ADT duration, and baseline T levels. Approximately one-quarter of patients failed to normalize their TT level, and one-tenth of men remained at castrate levels 24 months after ADT cessation. Nascimento B, Miranda EP, Jenkins LC, et al. Testosterone Recovery Profiles After Cessation of Androgen Deprivation Therapy for Prostate Cancer. J Sex Med 2019;16:872-879.

Testosterone and Benign Prostatic Hyperplasia

INTRODUCTION

Benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) are frequent in aging. Nonetheless, their pathogenesis is largely unknown. The androgen dependence of the first phases of prostate development have inspired the historical view that higher testosterone (T) may be involved in BPH occurrence; however, recent evidence suggests a different scenario.

AIM

To review the available knowledge on the pathogenesis of BPH particularly concerning the role of T and the possible connections with metabolic impairments.

METHODS

Relevant records were retrieved by an extensive search in Medline, including the following keywords ("testosterone"[MeSH Terms] OR "testosterone"[All Fields]) AND ("prostatic hyperplasia"[MeSH Terms] OR ("prostatic"[All Fields] AND "hyperplasia"[All Fields]) OR "prostatic hyperplasia"[All Fields] OR ("benign"[All Fields] AND "prostatic"[All Fields] AND "hyperplasia"[All Fields]) OR "benign prostatic hyperplasia"[All Fields]). There were no limitations in terms of publication date or study design.

MAIN OUTCOME MEASURES

Preclinical and clinical studies have been reported, with special emphasis on our contribution and interpretation.

RESULTS

Inflammation is a key aspect of BPH development. Along with infectious agents, prostate inflammation can be triggered by metabolic stimuli, such as dyslipidemia, an important component of metabolic syndrome (MetS). Low T and hyperestrogenism frequently occur in MetS. Mounting evidence shows that low, rather than high, T and hyperestrogenism may favor prostate inflammation. Considering these data as a whole, we postulate that BPH is the result of the action of multiple factors, which reinforce their mutual detrimental effects.

CONCLUSION

T is not detrimental for the prostate, and treating hypogonadism could even produce relief from LUTS and limit prostatic inflammation, which generates and maintains the process leading to BPH. Rastrelli G, Vignozzi L, Corona G, et al. Testosterone and Benign Prostatic Hyperplasia. Sex Med Rev 2019;7:259-271.

Male and Female Hypogonadism

Hypogonadism is a clinical syndrome that results in hormone deficiency in men and women. Primary hypogonadism is caused by gonadal (testicular or ovarian) failure. Secondary hypogonadism is the result of a dysfunction within the hypothalamus and/or pituitary. Diagnosis of hypogonadism requires a comprehensive health history, evaluation of the signs and symptoms, complete physical examination, as well as laboratory and diagnostic testing for both sexes. Hormone replacement is the hallmark of hypogonadism treatment. Restoring and/or maintaining quality of life is a major consideration in the management of patients with hypogonadism.

The Testosterone Effect on Metabolic and Urologic Outcomes in Patients with Nonfunctioning Pituitary Macroadenomas and Hypogonadotropic Hypogonadism

OBJECTIVE

To evaluate cardiovascular risk, metabolic profile, low urinary tract symptoms (LUTS), and sexual function in patients with nonfunctional pituitary macroadenoma (NFPMA) and hypogonadotropic hypogonadism with testosterone therapy (TTh).

METHODS

A retrospective clinical study at a tertiary care center was performed in 101 men with NFPMA, HH, and TTh; metabolic profile, cardiovascular risk, International Prostate Symptoms Score (IPSS), and International Index of Erectile Function 5 (IIEF-5) scores were evaluated before initiation of TTh and at the last checkup with TTh.

RESULTS

Age was 49.3 ± 8.8 years; T before TTh was 195 ng/mL (101-259) vs. 574 (423-774) at the last checkup. The time of TTh administration was 34 months (12-72). An increase in triglyceride levels (200 (153-294) vs. 174 (134-233) mg/dL; p=0.03), dyslipidemia (40% vs. 52%; p=0.03), and MetS (25% vs. 34%; p=0.05) was corroborated. A statistical difference in the Globorisk score and cardiovascular (CV) risk stratification was not found. IIEF-5 score was 15.5 ± 6.5 vs. 17.8 ± 5.3 (p=0.11). An improvement in penetration quality (2.0 ± 1.5 vs. 2.6 ± 1.3; p=0.05), erection after penetration (1.8 ± 1.2 vs. 2.5 ± 1.6; p=0.02), completion of intercourse (1.8 ± 1.2 vs. 2.4 ± 1.3; p=0.03), and satisfaction of sexual intercourse (1.8 ± 1.3 vs. 2.5 ± 1.5; p=0.01) was evidenced. IPSS score was 6 (IQR 2-10) vs. 7 (IQR 4-12); p=0.30. A lower rate of intermittency (14% vs. 3%; p=0.02), urgency (39% vs. 16%; p=0.01), and episodes of nocturia (18% vs. 4%; p=0.02) was found. An increase of hematocrit (44.1 ± 4.4 vs. 47.3 ± 4.4%; p=0.001), hemoglobin (14.9 ± 1.4 vs. 15.9 ± 1.4 g/dL; p=0.001), and prostatic specific antigen (0.59 (0.43-1.19) vs. 0.82 (0.45-1.4) ng/mL; p=0.02) was evidenced during TTh.

CONCLUSION

TTh in young men with NFPMA improves LUTS, sexual function, and some metabolic parameters, and it is relatively safe in the prostatic context.

The complex association between metabolic syndrome and male hypogonadism

BACKGROUND

The complex association between metabolic syndrome (MetS) and male hypogonadism is well established. A number of observational studies show that low testosterone is associated with insulin resistance and an increased risk for diabetes mellitus and MetS in men.

AIMS

To elucidate the association between MetS and male hypogonadism, present epidemiological data on the co-existence of the two comorbidities, enlighten the underlying pathophysiology and appraise the effects of testosterone supplementation therapy (TTh) and lifestyle modifications on MetS and body composition in men.

MATERIALS AND METHODS

Systematic search to PubMed and Medline databases for publications reporting data on association between MetS and male hypogonadism.

RESULTS

Both MetS and male hypogonadism have a high prevalence in the general population and are frequently co-existing e.g. in males with diabetes. Accumulating evidence from animal and human studies suggests that MetS is involved in the pathogenesis of hypogonadism in males as well as the other way around. On the other hand, there is evidence for a favorable effect of testosterone supplementation in testosterone deficient men with MetS and/or diabetes mellitus.

CONCLUSIONS

Studies with superior methodological characteristics are needed in order to establish a role for testosterone supplementation in men with MetS and/or diabetes mellitus.