Diagnosis and Treatment of Testosterone Deficiency: Updated Recommendations From the Lisbon 2018 International Consultation for Sexual Medicine

Clinical factors impacting microdissection testicular sperm extraction success in hypogonadal men with nonobstructive azoospermia

OBJECTIVE

To explore factors influencing microdissection testicular sperm extraction (micro-TESE) success in hypogonadal men with nonobstructive azoospermia (NOA).

DESIGN

A cohort study.

SETTING

University-affiliated male reproductive health center.

PATIENT(S)

A total of 616 consecutive patients with NOA and hypogonadism (total testosterone [T] levels <350 ng/dL) underwent micro-TESE between 2014 and 2021. All patients had no prior sperm retrieval (SR) history.

INTERVENTION(S)

Patients aged 23-55 years underwent comprehensive clinical, laboratory, and histopathological diagnostic evaluation for NOA and were further categorized into two cohorts on the basis of pre-SR hormonal stimulation.

MAIN OUTCOME MEASURE(S)

A multivariable logistic regression analysis explored the associations between patient variables and micro-TESE success, defined as the presence of viable spermatozoa in extracted specimens. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were computed to assess the relationship between SR success and relevant predictors. Sperm retrieval rates were compared between patients receiving or not hormonal stimulation, and logistic regression analysis evaluated the effect of baseline follicle-stimulating hormone levels (i.e., normogonadotropic vs. hypergonadotropic classes) on SR success.

RESULT(S)

The overall micro-TESE success rate was 56.6%. Baseline follicle-stimulating hormone levels (aOR, 0.97; 95% CI, 0.94-0.99), pre-SR hormonal stimulation (aOR, 2.54; 95% CI, 1.64-3.93), presence of clinical varicocele (aOR, 0.05; 95% CI, 0.01-0.51), history of previous varicocelectomy (aOR, 2.55; 95% CI, 1.26-5.16), and testicular histopathology were independent predictors of SR success. Among hormone-pretreated patients, pre-micro-TESE T levels and delta T (an absolute increase in T levels from baseline) were associated with SR success. A pre-micro-TESE T level of 418.5 ng/dL (area under the curve value: 0.78) and a delta T of 258 ng/dL (area under the value: 0.76) distinguished patients with positive and negative SR outcomes. Subgroup analysis showed that pre-SR hormonal stimulation yielded a greater benefit for normogonadotropic patients than for those who were hypergonadotropic.

CONCLUSION(S)

This study underscores the association between clinical factors and micro-TESE success in hypogonadal men with NOA. Although causality is not established, our findings suggest that these patients may benefit from pre-SR interventions, particularly hormonal stimulation and varicocele repair.

CLINICAL TRIAL REGISTRATION NUMBER

NCT05110391.

Endocrine health in survivors of adult-onset cancer

Long-term survivors of cancer (ie, the patient who is considered cured or for whom the disease is under long-term control and unlikely to recur) are at an increased risk of developing endocrine complications such as hypothalamic-pituitary dysfunctions, hypogonadisms, osteoporosis, or metabolic disorders, particularly when intensive tumour-directed therapies are applied. Symptom severity associated with these conditions ranges from mild and subclinical to highly detrimental, affecting individual health and quality of life. Although they are usually manageable, many of these endocrine pathologies remain underdiagnosed and untreated for years. To address this challenge, a higher degree of awareness, standardised screening tools, comprehensible treatment algorithms, and a close collaborative effort between endocrinologists and oncologists are essential to early identify patients who are at risk, and to implement appropriate treatment protocols. This Review highlights common symptoms and conditions related to endocrine disorders among survivors of adult-onset cancer, provides a summary of the currently available practice guidelines, and proposes a practical approach to diagnose affected patients among this group.

Are they functional hypogonadal men? Testosterone serum levels unravel male idiopathic infertility subgroups

PURPOSE

To evaluate total testosterone distribution in male idiopathic infertility.

METHODS

A retrospective, real-world case-control clinical study was conducted. Cases consisted of men evaluated for couple infertility, specifically those with alterations in semen parameters and normal gonadotropin levels, and after excluding all known causes of male infertility. Controls were male subjects who underwent semen analysis for screening purposes, without any abnormality detected. The total testosterone distribution was evaluated in cases and controls. Further analyses were performed subgrouping cases according to total testosterone reference threshold suggested by scientific societies (i.e., 3.5 ng/mL).

RESULTS

Cases included 214 idiopathic infertile men (mean age 38.2 ± 6.2 years) and controls 224 subjects with normozoospermia (mean age 33.7 ± 7.5 years). Total testosterone was not-normally distributed in both cases and controls, with positive asymmetric distribution slightly shifted on the left in cases. The rate of subjects with testosterone lower than 3.5 ng/mL was higher in cases (23.8%) than controls (4.5%) (p < 0.001). In cases with testosterone lower than 3.5 ng/mL, a significant direct correlation between testosterone and the percentage of normal morphology sperms was highlighted, also applying multivariate stepwise linear regression analysis (R = 0.430, standard error = 0.3, p = 0.020).

CONCLUSION

Although idiopathic infertile men show by definition altered semen analysis and gonadotropins within reference ranges, testosterone serum levels are widely variable in this population. Approximately a quarter of these patients present some sort of functional hypogonadism. Our data support the need to better classify idiopathic male infertility and total testosterone serum levels could be a supportive parameter in tracing the patient's therapeutic profile.

APHRODITE criteria: addressing male patients with hypogonadism and/or infertility owing to altered idiopathic testicular function

RESEARCH QUESTION

Can a novel classification system of the infertile male - 'APHRODITE' (Addressing male Patients with Hypogonadism and/or infeRtility Owing to altereD, Idiopathic TEsticular function) - stratify different subgroups of male infertility to help scientists to design clinical trials on the hormonal treatment of male infertility, and clinicians to counsel and treat the endocrinological imbalances in men and, ultimately, increase the chances of natural and assisted conception?

DESIGN

A collaboration between andrologists, reproductive urologists and gynaecologists, with specialization in reproductive medicine and expertise in male infertility, led to the development of the APHRODITE criteria through an iterative consensus process based on clinical patient descriptions and the results of routine laboratory tests, including semen analysis and hormonal testing.

RESULTS

Five patient groups were delineated according to the APHRODITE criteria; (1) Hypogonadotrophic hypogonadism (acquired and congenital); (2) Idiopathic male infertility with lowered semen analysis parameters, normal serum FSH and normal serum total testosterone concentrations; (3) A hypogonadal state with lowered semen analysis parameters, normal FSH and reduced total testosterone concentrations; (4) Lowered semen analysis parameters, elevated FSH concentrations and reduced or normal total testosterone concentrations; and (5) Unexplained male infertility in the context of unexplained couple infertility.

CONCLUSION

The APHRODITE criteria offer a novel and standardized patient stratification system for male infertility independent of aetiology and/or altered spermatogenesis, facilitating communication among clinicians, researchers and patients to improve reproductive outcomes following hormonal therapy. APHRODITE is proposed as a basis for future trials of the hormonal treatment of male infertility.

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.

Association between genetically proxied HMGCR inhibition and male reproductive health: A Mendelian randomization study

BACKGROUND

The causal associations between statin use and male sex hormone levels and related disorders have not been fully understood. In this study, we employed Mendelian randomization for the first time to investigate these associations.

METHODS

In two-sample Mendelian randomization framework, genetic proxies for hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) inhibition were identified as variants in the HMGCR gene that were associated with both levels of gene expression and low density lipoprotein cholesterol (LDL-C). We assessed the causal relationship between HMGCR inhibitor and 5 sex hormone levels/2 male-related diseases. Additionally, we investigated the association between 4 circulating lipid traits and outcomes. The "inverse variance weighting" method was used as the primary approach, and we assessed for potential heterogeneity and pleiotropy. In a secondary analysis, we revalidated the impact of HMGCR on 7 major outcomes using the summary-data-based Mendelian randomization method.

RESULTS

Our study found a significant causal association between genetic proxies for HMGCR inhibitor and decreased levels of total testosterone (TT) (LDL-C per standard deviation = 38.7mg/dL, effect = -0.20, 95% confidence interval [CI] = -0.25 to -0.15) and bioavailable testosterone (BT) (effect = -0.15, 95% CI = -0.21 to -0.10). Obesity-related factors were found to mediate this association. Furthermore, the inhibitor were found to mediate a reduced risk of prostate cancer (odds ratio = 0.81, 95%CI = 0.7-0.93) by lowering bioavailable testosterone levels, without increasing the risk of erectile dysfunction (P = .17). On the other hand, there was a causal association between increased levels of LDL-C, total cholesterol, triglycerides (TG) and decreased levels of TT, sex hormone-binding globulin, and estradiol.

CONCLUSIONS

The use of HMGCR inhibitor will reduce testosterone levels and the risk of prostate cancer without the side effect of erectile dysfunction. LDL-C, total cholesterol, and TG levels were protective factors for TT, sex hormone-binding globulin, and estradiol.

Genetic regulation of testosterone level in overweight males from the Kazakh population and its association with hypogonadism

Male hypogonadism and erectile dysfunction in different populations are associated with excess body weight. A key aspect in most studies is the metabolism of sexual hormones, primarily testosterone. At the same time, the binding protein sex hormone binding globulin (SHBG) can play a large role, as it determines the ratio of total and bioavailable testosterone in blood, i.e. both the hormone content and level of its production. Recent research has identified common mutations that affect SHBG levels, such as the rs727428 polymorphic locus, which is associated with alterations in histone protein function, affecting the regulation of ribonucleic acid (RNA) protein SHBG synthesis. Similar relationships have been observed for prevalent mutations, including rs5934505 and rs10822184, in diverse populations. This study involved 300 individuals of Kazakh nationality from the Eastern Kazakhstan region, examining three polymorphic variants of the SHBG gene (rs727428, rs5934505, and rs10822184). The participants were categorized into three groups: individuals with hypogonadism and obesity (group 1, n=85), those with excess body weight but no hypogonadism (group 2, n=70), and individuals with neither excess body weight nor hypogonadism (group 3, n=145). The frequency of mutant gene alleles impacting GPS (SHBG) synthesis in the Kazakh population was notably high, comparable to European and South-East Asian populations. However, the association between excess body weight and these mutations exhibited varying patterns. Hypogonadism was linked to decreased GPS levels, strongly correlating with total testosterone but not bioavailable testosterone. The retention of sexual functions in overweight men was not always directly related to BMI levels and GPS concentrations.

Association of blood metals with serum sex hormones in adults: A cross-sectional study

Heavy metals such as lead, mercury, and cadmium have been identified to have negative impacts on human health. Although the individual effects of these metals have been extensively researched, the present study aims to explore their combined effects and their association with serum sex hormones among adults. Data for this study were obtained from the general adult population of the 2013-2016 National Health and Nutrition Survey (NHANES) and included five metal (mercury, cadmium, manganese, lead, and selenium) exposures and three sex hormones (total testosterone [TT], estradiol [E2], and sex hormone-binding globulin [SHBG]) levels. The free androgen index (FAI) and TT/E2 ratio were also calculated. The relationships between blood metals and serum sex hormones were analysed using linear regression and restricted cubic spline regression. The effect of blood metal mixtures on sex hormone levels was examined using the quantile g-computation (qgcomp) model. There were 3,499 participants in this study, including 1,940 males and 1,559 females. In males, positive relationships between blood cadmium and serum SHBG (β=0.049 [0.006, 0.093]), lead and SHBG (β=0.040 [0.002, 0.079]), manganese and FAI (β=0.080 [0.016, 0.144]), and selenium and FAI (β=0.278 [0.054, 0.502]) were observed. In contrast, manganese and SHBG (β=-0.137 [-0.237, -0.037]), selenium and SHBG (β=-0.281 [-0.533, -0.028]), and manganese and TT/E2 ratio (β=-0.094 [-0.158, -0.029]) were negative associations. In females, blood cadmium and serum TT (β=0.082 [0.023, 0.141]), manganese and E2 (β=0.282 [0.072, 0.493]), cadmium and SHBG (β=0.146 [0.089, 0.203]), lead and SHBG (β=0.163 [0.095, 0.231]), and lead and TT/E2 ratio (β=0.174 [0.056, 0.292]) were positive relationships, while lead and E2 (β=-0.168 [-0.315, -0.021]) and FAI (β=-0.157 [-0.228, -0.086]) were negative associations. This correlation was stronger among elderly women (>50 years old). The qgcomp analysis revealed that the positive effect of mixed metals on SHBG was mainly driven by cadmium, while the negative effect of mixed metals on FAI was mainly driven by lead. Our findings indicate that exposure to heavy metals may disrupt hormonal homeostasis in adults, particularly in older women.

Diagnosis of hypogonadism in ageing men

To make the diagnosis of hypogonadism in an ageing man, in absence of rare organic cause often referred to as functional or late onset hypogonadism (LOH), he should present with a clinical syndrome suggestive of androgen deficiency and have consistently low serum testosterone (T) levels. This does not differ from the diagnosis of any other form of hypogonadism. Particular to LOH diagnostic are uncertainties surrounding this entity: signs and symptoms of androgen deficiency (including sexual symptoms) are nonspecific in older men; clinical significance of only moderately low T levels is uncertain; comorbidity plays a substantial role with potential for reversibility; the place of T therapy in these men is debatable. This context demands for a pragmatic, but appropriately conservative approach to diagnosis. Evaluation should be stepwise with clinical evaluation, if suggestive for androgen deficiency, followed by measurement of a fasting morning serum T, if unequivocally low to be confirmed in a separate morning sample by a second low T or, if initial T borderline low or in presence of factors known to affect SHBG, by a low calculated free T level. All other (free) T results make hypogonadism an unlikely cause of the patient's symptoms. In the absence of consensus cut-off levels for total and free T in the published clinical guidelines for diagnosis of hypogonadism, it seems appropriate in the context of LOH to use stringent criteria indicating a convincingly low serum T. The approach to the diagnosis of LOH is not fundamentally different from that of other forms of hypogonadism but should put extra weight on prioritizing the shunning of overdiagnosis above the risk of underdiagnosis.

A Proposal of a New Nomogram to Predict the Need for Testosterone ReplACEment (TRACE): A Simple Tool for Everyday Clinical Practice

International guidelines suggest to use testosterone therapy (TTh) in hypogonadal men presenting symptoms of testosterone deficiency (TD), even if there is no fixed threshold level of T at which TTh should be started. We aimed to develop and validate a nomogram named TRACE (Testosterone ReplACEment) for predicting the need of TTh in patients with "low-normal" total testosterone levels. The following nomogram variables were used: serum T level; serum LH level; BMI; state of nocturnal erections; metabolic comorbidities; and IPSS total score. The nomogram has been tested by calculating concordance probabilities, as well as assaying the calibration of predicted probability of clinical testosterone deficiency and need for TTh, together with the clinical outcome of the TTh. A cohort of 141 patients was used for the development of the nomogram, while a cohort of 123 patients attending another institution was used to externally validate and calibrate it. Sixty-four patients (45.3%) received TTh. Among them, sixty patients (93.7%) reported a significant clinical improvement after TTh. The nomogram had a concordance index of 0.83 [area under the ROC curve 0.81 (95% CI 0.71-0.83)]. In conclusion, the TRACE nomogram accurately predicted the probability of clinical impairment related to TD, and resulted in a simple and reliable method to use to select hypogonadal patients with not clearly pathological testosterone values who will benefit from TTh.

Effect of High Testosterone Levels on Endothelial Function in Aorta and Erectile Function in Rats

BACKGROUND

Testosterone is an important hormone for the physical and mental health of men; however testosterone administration has also been suggested to adversely affect the cardiovascular system.

AIM

To investigate the effects of excessive testosterone administration on vascular endothelial and erectile function in rats.

METHODS

A total of seventy-five 12-week-old rats were divided into the following groups: Sham, castrated (Cast), castrated with subcutaneous administration of 100 mg/kg/month testosterone (Cast + T1), and castrated with subcutaneous administration of 100 mg/kg/week testosterone (Cast + T4). To observe the changes in testosterone level after the administration, rats were further divided into the following groups: control; T(6.25), wherein the rats were subcutaneously injected with 6.25 mg/kg testosterone; T(25) per week, wherein the rats were subcutaneously injected with 25 mg/kg testosterone per week; and T(100), wherein the rats were subcutaneously injected with 100 mg/kg testosterone per week. The relaxation responses of aorta were measured in these rats using standardized methods, and their erectile function was also evaluated. Statistical analysis of the obtained data was performed using two-way analysis of variance (ANOVA), Tukey-Kramer's multiple comparison test, or Student's t-test.

OUTCOMES

At the end of the study period, endothelial function was evaluated through measurement of isometric tension, while erectile function was assessed using intracavernosal pressure (ICP), mean arterial pressure (MAP), and the expression of endothelial nitric oxide synthase (eNOS), inducible nitric oxide synthase (iNOS), sirtuin 1 (Sirt1) and vascular endothelial growth factor A.

RESULTS

The ICP/MAP ratio in the Cast group (0.42 ± 0.04) was significantly lower than that in the Sham group (0.79 ± 0.07). The ICP/MAP ratio in the Cast + T1 group (0.73 ± 0.06) was significantly higher than that in the Cast group (P < .01) and that of the Cast + T4 (0.38 ± 0.01) group was unchanged (P > .05). The T(25) and T(100) groups exhibited significantly lower responses to ACh than the control group at 4 weeks (P < .01). Meanwhile, the ICP/MAP ratios in the T(25) group (0.44 ± 0.07) and T(100) group (0.47 ± 0.03) were significantly lower than that in the control group (0.67 ± 0.05) at stimulation frequencies of 16 Hz (P < .05). The expression of androgen receptor, Sirt1, and eNOS were significantly lower while that of iNOS was higher in the T(25) group compared with the control group (P < .05).

CLINICAL TRANSLATION

The results based on this animal model indicate that extremely high testosterone levels may affect endothelial and erectile function.

STRENGTHS AND LIMITATIONS

We found that high-dose testosterone administration decreased endothelial function in aorta and erectile function in rats. A major limitation of this study is that the blood concentration may not be representative of that in humans, and further research is needed.

CONCLUSION

The findings suggest that high doses of testosterone may cause endothelial dysfunction in the aorta and erectile dysfunction in rats and that the blood concentration should be monitored after testosterone administration. Kataoka T, Fukamoto A, Hotta Y, et al. Effect of High Testosterone Levels on Endothelial Function in Aorta and Erectile Function in Rats. Sex Med 2022;10:100550.

Effect of SHBG Polymorphism on the Levels of Bioavailable Testosterone and Lipid Metabolism in Older Men of the Kazakh Population

This study is aimed at investigating the effect of SHBG (rs727428; rs10822184) and LPL (rs754493647) single nucleotide polymorphisms on the concentration of the bioavailable fraction of testosterone in older men. Materials and methods To study gene mutations, 417 residents of the East Kazakhstan region of Kazakh nationality were examined. The main group included 135 men with signs of hypogonadism (AMS 37-49), and the control group consisted of 282 healthy men (AMS 17-26) of the corresponding age (p = 0.5). Single nucleotide polymorphisms rs 727428 [C / T]; rs10822184 [T / C]; rs754493647 [T / C], was determined by the TaqMan method. Results Analysis of the rs727428 polymorphism has revealed that the TT allele (rs727428) has a lower level of albumin (p = 0.03), bioavailable testosterone (p = 0.04), and free testosterone (p = 0.6) than in carriers of the CC and CT genotypes. Also, it has shown a decrease in total testosterone (p = 0.001) and an increase in SHBG levels (p = 0.07) in men with the TT genotype of the rs727428 gene polymorphism. The rs10822184 polymorphism demonstrated an increase in triglyceride and LDL levels in TT genotype (p ≤ 0.04), in comparison with CC and CT genotypes. Conclusion It has been proven that rs727428 (p = 0.001) is associated with testosterone levels and therefore can determine the concentration of bioavailable testosterone. Decreased levels of bioavailable testosterone are a sign of male hypogonadism. This study confirms the effect of rs10822184 on LDL (p = 0.01) and triglyceride (p = 0.04) levels, but its association with androgen levels has not been proven. Our results may be of interest for understanding the etiology of early development of hypogonadism and lipid metabolism disorders in men. To confirm the conclusions, a more detailed study with a large sample of men from the Kazakh population may be required.

Good Clinical Practice of the Italian Society of Thalassemia and Haemoglobinopathies (SITE) for the Management of Endocrine Complications in Patients with Haemoglobinopathies

Background: The treatment of endocrinopathies in haemoglobinopathies is a continually expanding research area; therefore, recommendations supporting the appropriateness of treatments are a pressing need for the medical community. Methods: The Management Committee of SITE selected and gathered a multidisciplinary and multi-professional team, including experts in haemoglobinopathies and experts in endocrinopathies, who have been flanked by experts with methodological and organizational expertise, in order to formulate recommendations based on the available scientific evidence integrated by personal clinical experience. The project followed the systematic approach for the production of clinical practice guidelines according to the methodology suggested by the National Center for Clinical Excellence, Quality and Safety of Care (CNEC). Results: Out of 14 topics, 100 clinical questions were addressed, and 206 recommendations were elaborated on. The strength of recommendations, panel agreement, a short general description of the topic, and the interpretation of evidence were reported. Conclusions: Good Practice Recommendations are the final outcome of translational research and allow one to transfer to the daily clinical practice of endocrine complications in haemoglobinopathies.

Reverse intermittent androgen deprivation therapy: Prostate cancer and hypopituitarism

Testosterone replacement in the context of untreated prostate cancer is a controversial topic, where the symptomatic benefits of testosterone therapy contrast with the risk of disease progression. We report the case of a 76-year-old gentleman, under watchful waiting for known prostate cancer, who underwent a transsphenoidal resection of a pituitary macroadenoma. The adenoma and subsequent surgical treatment resulted in secondary testosterone deficiency, effectively ‘self-commencing’ endogenous androgen deprivation therapy. After discussion with the endocrine team, careful intermittent testosterone supplementation was undertaken to address his symptoms, with the patient undergoing prostate-specific antigen surveillance. This was felt to be similar to intermittent androgen deprivation therapy in reverse. Here, we review current evidence regarding testosterone therapy in the context of prostate cancer.

Level of Evidence: 5

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.

Common Pitfalls in the Interpretation of Endocrine Tests

Endocrine tests are the cornerstone of diagnosing multiple diseases that primary care physicians are frequently faced with. Some of these tests can be affected by situations that affect the proper interpretation, leading to incorrect diagnoses and unnecessary treatment, such as the interference of biotin with thyroid function test, falsely elevated prolactin values in presence of macroprolactinemia or falsely normal due to the "hook effect" in macroprolactinomas. Recognizing these situations is essential for the clinician to make an adequate interpretation of these tests as well as an accurate diagnosis that guarantees the best outcomes for the patient.

Effects of Testosterone Treatment on Quality of Life in Patients With Chronic Kidney Disease

Testosterone deficiency (TD) is common and impairs quality of life (QoL) in patients with chronic kidney disease (CKD). However, there are no studies about whether testosterone replacement therapy (TRT) can improve QoL in patients with CKD. Therefore, we investigated the effect of TRT on the QoL of patients with CKD and confirmed the safety of TRT. Twenty-five male patients with stages III–IV CKD whose serum testosterone levels were <350 ng/dl (TD) were enrolled and treated with testosterone gel for 3 months (group II). Age-matched controls with stages III–IV CKD and TD (group I) were recommended to exercise for the same period. Before and after the treatment, the BMI and handgrip strength were checked, serological tests were performed, and questionnaires were administered in both groups. Compared to baseline, there was no significant difference in serum testosterone levels, scores of the 36-Item Short Form Health Survey (SF-36), Aging Males’ Symptoms Scale (AMS), and International Prostate Symptom Score (IPSS), and grip strength in group I after 3 months. In group II, a significant increase in testosterone, hemoglobin (Hb), and hematocrit (Hct) was observed, and grip strength significantly increased after TRT. Significant improvement in scores of SF-36, AMS, and IPSS was also confirmed after TRT in group II. There was a significant difference in testosterone, Hb, Hct, grip strength, and scores of SF-36, AMS, and IPSS between the two groups after 3 months. The patients in group II showed positive results and continued with TRT. Therefore, we conclude that TRT safely improves the QoL and TD symptoms in patients with moderate-to-severe CKD.

[Practical recommendations for the management of testosterone deficiency]

OBJECTIVES

The Francophone Society of Sexual Medicine (SFMS) and the Andrology and Sexual Medicine Committee (CAMS) of the French Association of Urology (AFU) have brought together a panel of experts to develop French recommendations for the management of testosterone deficiency (TD).

METHODS

Systematic review of the literature between 01/2000 and 07/2019. Use of the method of recommendations for clinical practice (RPC) and the AGREE II grid.

RESULTS

TD is defined as the association of clinical signs and symptoms suggestive of TD with a decrease in testosterone levels or serum androgen activity. Diagnosis requires a T lower than the reference values in young men on 2 successive assays. Sexual disorders are often at the forefront, and concern the whole male sexual function (desire, arousal, pleasure and orgasm). The most evocative symptoms are: decrease in sexual desire, disappearance of nocturnal erections, fatigue, loss of muscle strength. Overweight, depressed mood, anxiety, irritability and malaise are also frequently found. TD is more common in cases of metabolic, cardiovascular, chronic, andrological diseases, and in cases of corticosteroid, opioid, antipsychotic, anticonvulsant, antiretroviral, or cancer treatment. Since SHBG is frequently abnormal, we recommend that free or bioavailable T is preferred over total T. The treatment of TD requires a prior clinical (DRE, breast examination) and biological (PSA, CBC) assessment. Contraindications to T treatment are: progressive prostate or breast cancer, severe heart failure or recent cardiovascular event, polycytemia, complicated BPH, paternity project. It is possible in cases of sleep apnea syndrome, psychiatric history, stable heart disease, prostate cancer under active surveillance and after one year of complete remission of a low or intermediate risk localized prostate cancer treated in a curative manner. It includes long-term testosterone supplementation and life-style counseling. Treatment is monitored at 3, 6, 12 months and annually thereafter. It is clinical (annual DRE) and biological (total T, PSA, CBC), the most frequent side effect being polyglobulia.

CONCLUSION

These recommendations should help improve the management of TD.

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.

Testosterone Therapy After Prostate Cancer Treatment: A Review of Literature

INTRODUCTION

Although testosterone therapy (TTh) is the standard practice in otherwise healthy hypogonadal men, this therapy has historically been contraindicated in men with a history of prostate cancer. Recent evidence suggests that there is minimal or no prostate cancer growth in the setting of TTh administration in men definitively treated for non-metastatic prostate cancer.

OBJECTIVE

To review the evidence supporting the safety and efficacy of TTh in patients previously treated for localized prostate cancer.

METHODS

A literature review of the PubMed database was performed to identify studies evaluating the safety and efficacy of TTh in patients with a history of prostate cancer. Search terms included Testosterone Therapy, Testosterone Replacement Therapy and Radical Prostatectomy, Radiotherapy, External Beam Radiation Therapy, EBRT, Brachytherapy; Prostate Cancer and Hypogonadism, Low Testosterone; Bipolar Androgen Therapy.

RESULTS

Available literature provides evidence for the safe application of TTh in patients previously treated for prostate cancer with either radical prostatectomy or radiotherapy. Furthermore, there exists evidence that severely hypogonadal levels of testosterone may lead to worse oncological outcomes. More recent research has begun to elucidate the effectiveness of bipolar androgen deprivation therapy in the treatment of prostate cancer. This mechanism of action increases the level of evidence indicating that the traditional management of maintaining testosterone levels at low levels may no longer be standard of care. TTh likely has a role in improved erectile function and other quality-of-life concerns in patients developing testosterone deficiency after being treated for prostate cancer.

CONCLUSIONS

TTh should be offered to select hypogonadal patients who have a history of definitively treated prostate cancer. Adequately designed randomized controlled trials are necessary to confirm the safety and efficacy of TTh in this population. Natale C, Carlos C, Hong J, et al. Testosterone Replacement Therapy After Prostate Cancer Treatment: A Review of Literature. Sex Med Rev 2021;9:393-405.

Treating the primary in low burden metastatic prostate cancer: Where do we stand?

ABSTRACT

On the basis of endocrine therapy for patients with low burden metastatic prostate cancer (LBMP), the clinical efficacy and quality of life were compared between prostate-only directed radiotherapy (PODT) and prostate and metastasis radiotherapy (PMRT).From November 2009 to November 2015, total 91 patients newly diagnosed with LBMP were retrospectively analyzed, of which 52 patients received PODT and 39 patients received PMRT. The biochemical failure free interval (IBF), prostate specific survival (PCSS), and overall survival (OS) time were compared between the 2 groups, and expanded prostate cancer index composite (EPIC) scale was used to evaluate the difference in quality of life between the 2 groups.The median IBF of the PODT group was 31 months, which was significantly lower than the 39 months of the PMRT group (P < .05); the 5-year OS and PCSS were 58.9%, 65.3% in PODT group, and 58.9%, 71.79% in PMRT group, respectively. There was no significant between the 2 groups (P > .05); the side effects of acute radiotherapy in PMRT group were significantly higher than PODT group (P < .05), especially in bone marrow suppression and gastrointestinal reactions; The scores of urinary system function and intestinal system function in PMRT group were significantly higher than PODT group at the end of radiotherapy, 3 months after radiotherapy, and 6 months after radiotherapy (P < .05). The score of sexual function in PMRT group was significantly lower than that in PODT group after radiotherapy (P < .05), and higher than that in PORT group at other follow-up time points (P < .05). The hormone function was decreased at each follow-up time point in 2 groups, and there was no significant difference between the 2 groups (P > .05).Patients with LBMP receiving PMRT can improve IBF, but cannot increase PCSS and OS, and increase the incidence of acute radiation injury.

[AFU and SALF recommendations for the evaluation of male infertility]

BACKGROUND

The aim of these Association Française d'Urologie (AFU) and Société d'Andrologie de Langue Française (SALF) common recommendations are to provide practice guidelines for the French Urological and Andrological community regarding the evaluation of infertile men.

MATERIAL AND METHODS

Literature search in PubMed using the keywords "male infertility", "diagnosis", "management" and "evaluation" limited to clinical articles in English and French prior to 1/01/2020. To inform the level of evidence, the HAS grading system (2013) was applied.

RESULTS

Concerning the evaluation of infertile men, the AFU and the SALF recommend : (1) a systematic interview exploring the family history, the fertility history of the man outside the couple, the patient's personal history that may have an impact on his fertility, lifestyle habits, treatments, symptoms and possible sexual difficulties of the couple; (2) a general physical examination to assess signs of hypogonadism and secondary sexual characters; (3) a scrotal physical examination performed by an urologist or andrologist to assess (i) the testes for volume and consistency, (ii) vas deferens and epididymes for total or partial absence or nodules, and (iii) presence of varicoceles; (4) Performing two semen analyses, according to World Health Organization guidelines, if the first one has at least one abnormaly; (5) a scrotal ultrasound as part of routine investigation, that can be completed with an endorectal pelvic ultrasound according to the clinic; (6) an endocrine evaluation with at least a Testosterone and FSH serum determination; (7) Karyotype analysis in infertile men with a sperm concentration ≤10 10⁶/mL; (8) assessment of Yq microdeletions in infertile men with a sperm concentration ≤1 10⁶/mL; (9) Cystic fibrosis transmembrane conductance regulator gene evaluation in case of suspicion for bilateral or unilateral congenital agenesis of vas deferens and seminal vesicles. The interest of tests analyzing DNA fragmentation (TUNEL, SCSA) is still under investigation.

CONCLUSION

These guidelines can be applied in routine clinical practice in all infertile men.

Andropause symptoms and sickness absence in Japanese male workers: a prospective study

OBJECTIVE

The purpose of the study was to investigate the association between andropause symptoms and sickness absence in Japanese male workers over 2 years.

METHODS

A baseline survey asking about andropause symptoms, along with blood sampling for testosterone level, was conducted in June 2009. A total of 418 men (mean age = 52.4 years, SD = 8.6) participated and were followed through 2011. Hazard ratios (HRs) and 95% confidence intervals (CIs) for sickness absence were calculated using Cox proportional hazard models.

RESULTS

During the follow-up period, 31 of 35 participants who took sickness absences had physical illnesses. A higher andropause symptom score was associated with an increased risk of sickness absence. Testosterone deficiency (<350 ng/dL) was not associated with sickness absence. Among the subscales of andropause symptoms, the somatic symptom score was positively associated with sickness absence, whereas testosterone deficiency combined with high sexual symptoms was not associated with sickness absence. Results were similar when limited to sickness absence because of physical illness. No significant interaction between andropause symptoms and testosterone deficiency was found.

CONCLUSIONS

Non-specific andropause symptoms unrelated to testosterone deficiency were positively associated with sickness absence.

Subclinical male hypogonadism

INTRODUCTION

The concept of subclinical or compensated male hypogonadism (SHG), characterized by increased gonadotropins and normal testosterone levels is emerging. However, its real clinical significance is still conflicting. The aim of the present study was to summarize and discuss the available evidence related to the possible definition of SHG and the possible advantages of testosterone replacement therapy (TRT).

EVIDENCE ACQUISITION

A comprehensive systematic Medline, Embase and Cochrane search was performed. Publications from January 1, 1969 up to February 29, 2020 were included. The search was restricted to English-language articles and studies of human participants.

EVIDENCE SYNTHESIS

Two main clinical forms of SHG can be described. The first identifies young patients who have a positive medical history for testis damage occurring before puberty onset. The second form can occur as a consequence of an age-dependent decline of T. Whereas the former can be the consequence of several congenital or acquired diseases, also possible causes of primary hypogonadism, the real significance of the latter is still debatable. Available evidence indicates that age-related SHG is quite a common phenomenon, occurring in 9.4% of aging men from the general population. Cross-sectional and longitudinal data have documented that it is associated with poor health and can be a sign of forthcoming increased cardiovascular mortality and morbidity.

CONCLUSIONS

Although available evidence suggests that in aging populations SHG can be considered a particular condition associated with an increased CV risk, it is still unknown if treatment with T can improve any outcomes in these subjects. Hence, further interventional studies are advisable to better understand the characteristics of SHG and the possible advantages of an early TRT.

The Effect of Longer-Acting vs Shorter-Acting Testosterone Therapy on Follicle Stimulating Hormone and Luteinizing Hormone

INTRODUCTION

Testosterone (T) replacement therapy causes suppression of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) that can lead to decrease in semen parameters and possible infertility. Different T formulations may have varying suppression on FSH and LH.

OBJECTIVE

To study whether shorter-acting T (multiple daily dosing) has less suppression on FSH and LH serum levels compared with longer-acting T (transdermal gel, injectable).

METHODS

A systematic literature search was conducted by following the protocol based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocols. We comprehensively reviewed the literature by systematically searching manuscripts indexed in PubMed from 1995 to March 13, 2019 to identify studies reporting changes in FSH and LH in hypogonadal men treated with exogenous T which evaluated the effect of exogenous T on FSH and LH.

RESULTS

A total of 8 studies reported the effect of T on FSH and LH in 793 hypogonadal men: 2 used long-acting injectables (enanthate or undecanoate) in a total of 16 men, 5 used intermediate-acting daily topical gels or patches in a total of 471 men, and 1 used short-acting intranasal T (125 μL/nostril, twice a day or three times a day) in 306 men. Long-acting injectables decreased FSH by 86.3%, intermediate-acting daily gels/patches decreased FSH by 60.2%, and short-acting intranasal gel decreased FSH by 37.8%. Long-acting injectables decreased LH by 71.8%, intermediate-acting daily gels/patches decreased LH by 59.2%, and short-acting intranasal gel decreased LH by 47.3%.

CONCLUSIONS

Our findings suggest that short-acting T preparations do not decrease serum FSH or LH to the same extent as longer-acting transdermal gels and injectables. However, further clinical trial data are necessary to determine whether the effect of short-acting TRT on gonadotropins translates into similar changes in semen parameters and fertility. Masterson TA, Turner D, Vo D, et al. The Effect of Longer-Acting vs Shorter-Acting Testosterone Therapy on Follicle Stimulating Hormone and Luteinizing Hormone. Sex Med Rev 2021;9:143-148.

Men with Latent Autoimmune Diabetes and Type 2 Diabetes May Have Different Change Patterns in Free Testosterone

Objective

Type 2 diabetic (T2D) male patients with low total testosterone (TT) levels are at an increasing risk of all-cause mortality. However, the levels of TT in male patients with latent autoimmune diabetes in adults (LADA) remain largely unknown. Research Design and Methods. This was a single-center, open, observational study. The inclusion criteria were male patients who were diagnosed with LADA, and sex, body mass index, C-peptide, and glycated hemoglobin (HbA1c) levels matched with those of T2D patients. Islet function/sensitivity and sex hormone concentrations were determined at baseline and 1-year follow-up. The primary endpoint was the changes in androgen levels from baseline to 1-year follow-up in patients with LADA.

Results

Our data showed that TT and Bio-T levels remained unchanged, while FT levels significantly decreased from baseline to 1-year follow-up in patients with T2D. However, TT, Bio-T, and FT concentrations dramatically increased in the LADA group from baseline to 1-year follow-up. Furthermore, a Spearman analysis showed that changes of TT, FT, and Bio-T levels from baseline to endpoint were significantly negatively correlated with Δ homeostasis model assessment-2 IR (ΔHOMA2-IR), respectively.

Conclusions

The FT change patterns in patients with LADA may differ from those in patients with T2D. Our data also indicated the significant negative correlation between insulin sensitivity and changes of TT, FT, and Bio-T levels along with the diabetic duration in patients with T2D and LADA.

The association of decreased testosterone with atherosclerosis and inflammation in male predialysis patients with chronic kidney disease

PURPOSE

To investigate the frequency of hypogonadism and its relationship to inflammation and carotid intima-media thickness (CIMT) in male patients with predialysis chronic kidney disease (CKD).

METHODS

A total of 105 patients with CKD, 55 (52.4%) as stage 3, 33 (31.4%) as stage 4 and 17 (16.2%) as stage 5, were enrolled into the study. Total testosterone (TT) and free testosterone (FT), interleukin 6 (IL-6), C-reactive protein (CRP) levels, and CIMT were measured.

RESULTS

According to TT and FT, hypogonadism was detected in 18 (17.1%) and 22 (20.9%) patients, respectively. There was no difference in terms of TT and FT, CIMT, CRP and IL-6 between the stages of CKD. According to TT, the patients with hypogonadism had significantly higher CRP and high-density lipoprotein cholesterol (HDL-cholesterol) levels (p=0.004 and p=0.005, respectively). There was no significant difference in other parameters. According to FT, the patients with hypogonadism had significantly higher CRP (p=0.017), and TT were negatively correlated with body mass index (BMI), waist circumference (WC), hip circumference, and CRP levels. FT was negatively correlated with age, waist circumference, systolic blood pressure, diastolic blood pressure (DBP) and CRP.

CONCLUSIONS

The frequency of hypogonadism was found around 17-21% among the patients with CKD. Despite similar IL-6 and CIMT levels, CRP was found to be higher in the patients with hypogonadism. We consider that further studies with larger populations are needed to elucidate the entity.

Successful treatment of Post-orgasmic illness syndrome with human chorionic gonadotropin

Post-orgasmic illness syndrome (POIS) is an uncommon condition in which men experience debilitating symptoms following orgasm, including anxiety, weakness, and lassitude. The etiology is unknown, and treatment challenging. We present a 25y man with POIS since puberty. He dreaded ejaculation due to his subsequent symptoms. Multiple prior treatments had failed. Blood tests revealed testosterone (T) deficiency. hCG was prescribed. At 6 weeks T levels normalized with near-complete resolution of symptoms. This successful result argues for hormonal investigation in men with POIS, and a trial of hCG or T therapy if total or free T is low or borderline.