1
|
Kanakis GA, Pofi R, Goulis DG, Isidori AM, Armeni E, Erel CT, Fistonić I, Hillard T, Hirschberg AL, Meczekalski B, Mendoza N, Mueck AO, Simoncini T, Stute P, van Dijken D, Rees M, Lambrinoudaki I. EMAS position statement: Testosterone replacement therapy in older men. Maturitas 2023; 178:107854. [PMID: 37845136 DOI: 10.1016/j.maturitas.2023.107854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Late-onset hypogonadism is the clinical entity characterised by low testosterone concentrations associated with clinical symptoms in the absence of organic disease in ageing men. It has been associated with metabolic syndrome, reduced bone mineral density, and increased cardiovascular morbidity and mortality risk. Although testosterone replacement therapy (TRT) reverses most of these conditions in young hypogonadal men, the risk/benefit ratio of TRT in older men is debatable. AIM To update the 2015 EMAS statement on TRT in older men with new research on late-onset hypogonadism and TRT. MATERIALS AND METHODS Literature review and consensus of expert opinion. SUMMARY RECOMMENDATIONS TRT should be offered only to symptomatic older men with confirmed low testosterone concentrations after explaining the uncertainties regarding the long-term safety of this treatment. TRT may be offered to men with severe hypogonadism and erectile dysfunction to improve sexual desire, erectile, and orgasmic function. It should also be considered in hypogonadal men with severe insulin resistance or pre-diabetes mellitus. TRT may also be considered, in combination with proven treatment strategies, for osteoporosis, or for selected patients with persistent mild depressive symptoms and/or low self-perceived quality of life, combined with standard medical care for each condition. TRT is contraindicated in hypogonadal men actively seeking fertility treatment. Due to a lack of data, TRT should not be routinely used in older men to improve exercise capacity/physical function, improve cognitive function, or prevent cognitive decline. TRT must be avoided in older, frail men with known breast cancer or untreated prostate cancer and all men who have had myocardial infarction or stroke within the last four months, and those with severe or decompensated heart failure. The quality of evidence regarding patients with previous prostate cancer or cardiovascular disease is too low to draw definitive conclusions. Any limits on duration of use are arbitrary, and treatment should continue for as long as the man feels the benefits outweigh the risks for him, and decisions must be made on an individual basis. Withdrawal should be considered when hypogonadism is reversed after the resolution of underlying disorder. Short-acting transdermal preparations should be preferred for TRT initiation in older men, but injectable forms may be considered subsequently. Older men on TRT should be monitored at 3, 6, and 12 months after initiation and at least yearly thereafter, or earlier and more frequently if indicated. Evaluation should include assessment of the clinical response, and measurement of total testosterone, haematocrit, and prostate-specific antigen (PSA) concentrations. Bone density and/or quality should also be assessed. Obese and overweight patients should be encouraged to undergo lifestyle modifications, including exercise and weight loss, to increase endogenous testosterone.
Collapse
Affiliation(s)
- George A Kanakis
- Department of Endocrinology & IVF Unit, Athens Naval and Veteran Affairs Hospital, Athens, Greece.
| | - Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Greece
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Eleni Armeni
- Second Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Greece; Royal Free Hospital, London, UK
| | - C Tamer Erel
- İstanbul-Cerrahpaşa University, Cerrahpaşa School of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
| | - Ivan Fistonić
- Faculty for Health Studies, University of Rijeka, Rijeka, Croatia
| | - Timothy Hillard
- Department of Obstetrics & Gynaecology, University Hospitals Dorset, Poole, UK
| | - Angelica-Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Blazej Meczekalski
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, Poznan, Poland
| | - Nicolás Mendoza
- Department of Obstetrics and Gynecology, University of Granada, Spain
| | - Alfred O Mueck
- Department of Women's Health, University Hospital Tuebingen, Germany; Beijing OB/GYN Hospital, Capital Medical University, China
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56100 Pisa, Italy
| | - Petra Stute
- Department of Obstetrics and Gynecology, University Clinic Inselspital, Bern, Switzerland
| | - Dorenda van Dijken
- Department of Obstetrics and Gynecology, OLVG Hospital, Amsterdam, the Netherlands
| | - Margaret Rees
- Women's Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Irene Lambrinoudaki
- Second Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Greece
| |
Collapse
|
2
|
Isidori AM, Aversa A, Calogero A, Ferlin A, Francavilla S, Lanfranco F, Pivonello R, Rochira V, Corona G, Maggi M. Adult- and late-onset male hypogonadism: the clinical practice guidelines of the Italian Society of Andrology and Sexual Medicine (SIAMS) and the Italian Society of Endocrinology (SIE). J Endocrinol Invest 2022; 45:2385-2403. [PMID: 36018454 PMCID: PMC9415259 DOI: 10.1007/s40618-022-01859-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/29/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE To provide the evidence-based recommendations on the role of testosterone (T) on age-related symptoms and signs remains. METHODS The Italian Society of Andrology and Sexual Medicine (SIAMS) and the and the Italian Society of Endocrinology (SIE) commissioned an expert task force to provide an updated guideline on adult-onset male hypogonadism. Derived recommendations were based on Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. RESULTS Clinical diagnosis of adult-onset hypogonadism should be based on a combination of clinical and biochemical parameters. Testosterone replacement therapy (TRT) should be offered to all symptomatic subjects with hypogonadism after the exclusion of possible contraindications. T gels and the long-acting injectable T are currently available preparations showing the best efficacy/safety profile. TRT can improve all aspects of sexual function, although its effect is limited in more complicated patients. Body composition (reducing fat mass and increasing lean mass) is improved after TRT, either in subjects with or without metabolic syndrome or type 2 diabetes. Conversely, the role of TRT in improving glycometabolic control is more conflicting. TRT can result in increasing bone mineral density, particularly at lumbar site, but no information on fracture risk is available. Limited data support the use of TRT for improving other outcomes, including mood frailty and mobility. CONCLUSIONS TRT can improve sexual function and body composition particularly in less complicated adult and in aging subjects with hypogonadism. When hypogonadism is adequately diagnosed, T appropriately prescribed and subjects correctly followed up, no short-term increased risk of adverse events is observed. Longer and larger studies are advisable to better clarify TRT long-term efficacy/safety profile.
Collapse
Affiliation(s)
- A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome - Policlinico Umberto I Hospital, Rome, Italy
| | - A Aversa
- Department of Experimental and Clinical Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - A Calogero
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - A Ferlin
- Unit of Andrology and Reproductive Medicine, Department of Medicine, University of Padova, Padua, Italy
| | - S Francavilla
- Andrology Unit, Department of Clinical Medicine, Public Health, Life and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - F Lanfranco
- Division of Endocrinology, Andrology and Metabolism, Humanitas Gradenigo, Department of Medical Sciences, University of Turin, Turin, Italy
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e della Sessualità Maschile e Femminile, Università Federico II di Napoli, Naples, Italy
- Staff of UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - V Rochira
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - G Corona
- Endocrinology Unit, Medical Department, Azienda Usl Bologna Maggiore-Bellaria Hospital, Largo Nigrisoli, 2, 40133, Bologna, Italy.
| | - M Maggi
- Endocrinology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| |
Collapse
|
3
|
Rosellen J, Diemer T, Hauptmann A, Wagenlehner F. [Testosterone treatment]. UROLOGIE (HEIDELBERG, GERMANY) 2022; 61:1260-1275. [PMID: 36279006 DOI: 10.1007/s00120-022-01957-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 06/16/2023]
Abstract
Male hypogonadism is a congenital or acquired disorder that exerts a negative influence on various organ functions and can massively impair the quality of life through the relative or absolute deficiency of testosterone. A variety of preparations are available for substitution treatment, which differ in administration form and intake interval. For the execution of testosterone treatment various guidelines exist with clear and practical instructions on the indications, contraindications, treatment procedure and monitoring. Of particular importance are cardiovascular aspects and diseases of the prostate gland, which underlines the central position of the urologist in the treatment.
Collapse
Affiliation(s)
- Jens Rosellen
- Klinik für Urologie, Kinderurologie und Andrologie, Justus-Liebig-Universität Gießen, Rudolf-Buchheim-Straße 8, 35392, Gießen, Deutschland.
| | - Thorsten Diemer
- Klinik für Urologie, Kinderurologie und Andrologie, Justus-Liebig-Universität Gießen, Rudolf-Buchheim-Straße 8, 35392, Gießen, Deutschland
| | - Arne Hauptmann
- Klinik für Urologie, Kinderurologie und Andrologie, Justus-Liebig-Universität Gießen, Rudolf-Buchheim-Straße 8, 35392, Gießen, Deutschland
| | - Florian Wagenlehner
- Klinik für Urologie, Kinderurologie und Andrologie, Justus-Liebig-Universität Gießen, Rudolf-Buchheim-Straße 8, 35392, Gießen, Deutschland
| |
Collapse
|
4
|
Rajan P, Tharakan T, Chen R. Safety of androgen therapy in men with prostate cancer. Best Pract Res Clin Endocrinol Metab 2022; 36:101628. [PMID: 35248487 DOI: 10.1016/j.beem.2022.101628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Prostate cancer is one of the most frequently diagnosed malignancies in men worldwide and the life expectancy for men with prostate cancer is improving due to advancements in diagnostics and treatment. Male hypogonadism is associated with obesity, diabetes, and other comorbidities and also has been linked with increasing age; the primary therapy modality for this condition is testosterone replacement therapy (TRT). There are concerns that testosterone therapy may cause prostate cancer disease progression. However, contemporary evidence suggests that testosterone replacement therapy may be safe in specific groups of patients with prostate cancer. This chapter will summarise the contemporary literature regarding TRT use in hypogonadal men with prostate cancer, including limitations and future research goals.
Collapse
Affiliation(s)
- Prabhakar Rajan
- Centre for Cancer Cell and Molecular Biology, Barts Cancer Institute, Queen Mary University of London, London EC1M 6BQ, UK.
| | - Tharu Tharakan
- Urology Department, Charing Cross Hospital, Fulham Palace Rd, London W6 8RF, UK.
| | - Runzhi Chen
- Sir Alexander Fleming Building, Imperial College Rd, London SW7 2AZ, UK.
| |
Collapse
|
5
|
Wu FCW. Ageing male (part 2): Management of functional hypogonadism in older men, a patient-centric holistic approach. Best Pract Res Clin Endocrinol Metab 2022; 36:101626. [PMID: 35461757 DOI: 10.1016/j.beem.2022.101626] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The diagnosis of functional hypogonadism should prompt a thorough assessment and optimization of general health, including lifestyle changes, weight reduction, care of comorbidities and cessation of offending medications, some of which can lead to meaningful gains in endogenous testosterone (T) concentrations. Having excluded or addressed reversible causes and contra-indications, patients with functional hypogonadism can be offered a trial of testosterone replacement therapy (TRT) after full discussion on the anticipated benefits and potential risks. T treatment improves libido but may be less effective for erectile dysfunction (ED). T treatment can also have modest positive effects on insulin resistance, bone strength, some measures of physical strength, and mild depressive symptoms but the clinical significance of these relatively short-term improvements remain uncertain in terms of longer-term patient-important outcomes. Initiation of TRT is a joint decision between patient and clinician since longer-term benefits and risks have not been adequately defined.
Collapse
Affiliation(s)
- Frederick C W Wu
- Division of Endocrinology, Diabetes & Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9WL, UK.
| |
Collapse
|
6
|
Hayes FJ. Monitoring of Testosterone Replacement Therapy to Optimize the Benefit-to-Risk Ratio. Endocrinol Metab Clin North Am 2022; 51:99-108. [PMID: 35216723 DOI: 10.1016/j.ecl.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
For hypogonadal men treated with testosterone, the goal is to ensure that benefits are optimized, risks are minimized, and any adverse effects are identified early and managed appropriately. This can best be achieved by careful patient selection, excluding men with contraindications and addressing any modifiable risk factors in those at increased risk. A standardized plan should be used for monitoring that includes evaluation of symptoms, side effects, adherence, and measurement of testosterone and hematocrit. Shared decision making should be used to determine whether to screen for prostate cancer and informed by age, baseline cancer risk, and patient preference.
Collapse
Affiliation(s)
- Frances J Hayes
- Reproductive Endocrine Unit, BHX5, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| |
Collapse
|
7
|
Exploring the Role of Testosterone Replacement Therapy in Benign Prostatic Hyperplasia and Prostate Cancer: A Review of Safety. URO 2022. [DOI: 10.3390/uro2010005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Increased risk of prostate diseases triggered by testosterone replacement therapy (TRT) remains a worldwide concern. That said, we reviewed the safety of TRT in the spheres of benign prostatic hyperplasia (BPH) and prostate cancer (PCa), exploring clinical findings in this regard. Compelling evidence based on meta-analyses of randomized and observational studies indicates safety for TRT in patients suffering from prostate disorders such as BPH and PCa, at the same time improving lower tract urinary symptoms. Thus, the harmful relationship geared toward androgens and BPH seems to be overestimated as TRT has sufficient safety and, if properly prescribed, may counteract several metabolic problems. Even after PCa treatment, the benefits of TRT could outweigh the risk of recurrence, but further long-term randomized clinical trials are needed to elucidate unresolved questions.
Collapse
|
8
|
Lunenfeld B, Mskhalaya G, Zitzmann M, Corona G, Arver S, Kalinchenko S, Tishova Y, Morgentaler A. Recommendations on the diagnosis, treatment and monitoring of testosterone deficiency in men. Aging Male 2021; 24:119-138. [PMID: 34396893 DOI: 10.1080/13685538.2021.1962840] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
The relative proportional increase of the elderly population within many countries will become one of the most significant social transformations of the twenty-first century and, for the first time in history, persons aged 65 or above outnumbered children under five years of age globally. One in four persons living in Europe and Northern America will be aged 65 or over. One of the goals of ISSAM is to raise awareness of the special health needs of older men. Since a significant number of aging men will eventually become testosterone deficient, the Hypogonadism panel of ISSAM updates its guidelines.
Collapse
Affiliation(s)
- Bruno Lunenfeld
- Faculty of Life Sciences, Bar-Ilan University, Ramat Gan, Israel
| | | | - Michael Zitzmann
- Center for Reproductive Medicine and Andrology/Clinical and Surgical Andrology, University Hospital of Münster, Münster, Germany
| | - Giovanni Corona
- Medical Department, Endocrinology Unit, Maggiore Bellaria Hospital, Bologna, Italy
| | - Stefan Arver
- Department of Medicine/Huddinge Karolinska Institutet and ANOVA, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Kalinchenko
- Department of Endocrinology, People's Friendship University of Russia, Moscow, Russia
| | | | | |
Collapse
|
9
|
Salonia A, Bettocchi C, Boeri L, Capogrosso P, Carvalho J, Cilesiz NC, Cocci A, Corona G, Dimitropoulos K, Gül M, Hatzichristodoulou G, Jones TH, Kadioglu A, Martínez Salamanca JI, Milenkovic U, Modgil V, Russo GI, Serefoglu EC, Tharakan T, Verze P, Minhas S. European Association of Urology Guidelines on Sexual and Reproductive Health-2021 Update: Male Sexual Dysfunction. Eur Urol 2021; 80:333-357. [PMID: 34183196 DOI: 10.1016/j.eururo.2021.06.007] [Citation(s) in RCA: 326] [Impact Index Per Article: 108.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/09/2021] [Indexed: 02/07/2023]
Abstract
CONTEXT The present summary of the European Association of Urology (EAU) guidelines is based on the latest guidelines on male sexual health published in March 2021, with a last comprehensive update in January 2021. OBJECTIVE To present a summary of the 2021 version of the EAU guidelines on sexual and reproductive health. EVIDENCE ACQUISITION A literature review was performed up to January 2021. The guidelines were updated, and a strength rating for each recommendation was included based on either a systematic review of the evidence or a consensus opinion from the expert panel. EVIDENCE SYNTHESIS Late-onset hypogonadism is a clinical condition in the ageing male combining low levels of circulating testosterone and specific symptoms associated with impaired hormone production and/or action. A comprehensive diagnostic and therapeutic work-up, along with screening recommendations and contraindications, is provided. Erectile dysfunction (ED) is the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance. Along with a detailed basic and advanced diagnostic approach, a novel decision-making algorithm for treating ED in order to better tailor therapy to individual patients is provided. The EAU guidelines have adopted the definition of premature ejaculation (PE), which has been developed by the International Society for Sexual Medicine. After the subtype of PE has been defined, patient's expectations should be discussed thoroughly and pharmacotherapy must be considered as the first-line treatment for patients with lifelong PE, whereas treating the underlying cause must be the initial goal for patients with acquired PE. Haemospermia is defined as the appearance of blood in the ejaculate. Several reasons of haemospermia have been acknowledged; the primary goal over the management work-up is to exclude malignant conditions and treat any other underlying cause. CONCLUSIONS The 2021 guidelines on sexual and reproductive health summarise the most recent findings, and advise in terms of diagnosis and treatment of male hypogonadism and sexual dysfunction for their use in clinical practice. These guidelines reflect the multidisciplinary nature of their management. PATIENT SUMMARY Updated European Association of Urology guidelines on sexual and reproductive health are presented, addressing the diagnosis and treatment of the most prevalent conditions in men. Patients must be fully informed of all relevant diagnostic and therapeutic options and, together with their treating physicians, decide on optimal personalised management strategies.
Collapse
Affiliation(s)
- Andrea Salonia
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy.
| | | | - Luca Boeri
- Department of Urology, Foundation IRCCS Ca' Granda - Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Paolo Capogrosso
- Department of Urology and Andrology, Ospedale di Circolo and Macchi Foundation, Varese, Italy
| | - Joana Carvalho
- CPUP: Center for Psychology of Porto University, Faculty of Psychology and Educational Sciences, Porto University, Porto, Portugal
| | - Nusret Can Cilesiz
- Department of Urology, Taksim Training & Research Hospital, Istanbul, Turkey
| | - Andrea Cocci
- Department of Minimally Invasive and Robotic Urologic Surgery and Kidney Transplantation, University of Florence, Florence, Italy
| | - Giovanni Corona
- Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Kostantinos Dimitropoulos
- Academic Urology Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK; Department of Urology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Murat Gül
- School of Medicine, Department of Urology, Selcuk University, Konya, Turkey
| | | | - T Hugh Jones
- Centre for Diabetes and Endocrinology, Barnsley Hospital NHS Trust, Barnsley, UK
| | - Ates Kadioglu
- Department of Urology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Juan Ignatio Martínez Salamanca
- Department of Urology, Hospital Universitario Puerta de Hierro-Majadahonda, Lyx Institute of Urology, Universidad Francisco de Vitoria, Madrid, Spain
| | - Uros Milenkovic
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Vaibhav Modgil
- Manchester Andrology Centre, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Giorgio Ivan Russo
- Urology Section, Department of Surgery, University of Catania, Catania, Italy
| | - Ege Can Serefoglu
- Department of Urology, Biruni University School of Medicine, Istanbul, Turkey
| | - Tharu Tharakan
- Department of Urology, Imperial Healthcare NHS Trust, Charing Cross Hospital, London, UK; Section of Investigative Medicine, Department of Medicine, Imperial College London, London, UK
| | - Paolo Verze
- Department of Medicine and Surgery "Scuola Medica Salernitana", University of Salerno, Fisciano, Campania, Italy
| | - Suks Minhas
- Department of Urology, Imperial Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | | |
Collapse
|
10
|
Natale C, Carlos C, Hong J, Khera M, Baum N, Raheem OA. Testosterone Therapy After Prostate Cancer Treatment: A Review of Literature. Sex Med Rev 2021; 9:393-405. [PMID: 33516741 DOI: 10.1016/j.sxmr.2020.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/07/2020] [Accepted: 12/13/2020] [Indexed: 02/01/2023]
Abstract
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.
Collapse
Affiliation(s)
- Caleb Natale
- Department of Urology, Tulane University, New Orleans, LA, USA
| | - Carmen Carlos
- Department of Urology, Tulane University, New Orleans, LA, USA
| | - Jennifer Hong
- Department of Urology, Tulane University, New Orleans, LA, USA
| | - Mohit Khera
- Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Neil Baum
- Department of Urology, Tulane University, New Orleans, LA, USA
| | - Omer A Raheem
- Department of Urology, Tulane University, New Orleans, LA, USA.
| |
Collapse
|
11
|
Abstract
PURPOSE OF REVIEW We aim to conduct a systematic review of the literature, document all reported cases of breast cancer development in cis men and female-to-male (FtM) transgender men undergoing testosterone replacement therapy (TRT), and determine if testosterone poses a substantial risk of breast cancer development and recurrence. RECENT FINDINGS A systematic search through December 2019 was performed. Out of 1890, 15 studies were eligible for inclusion in the final analyses. In total, 22 patients have developed breast cancer while on testosterone treatment. Four cases were cis men, whereas 18 cases were FtM. Age ranged from 18 to 61 years. Testosterone treatment duration ranged from 5 weeks up to 25 years. SUMMARY There is a relatively higher incidence of BCa in FtM on CSH therapy compared with cis men on TRT. Because of the small sample size of reported cases, we cannot delineate the exact relationship between testosterone therapy and BCa development. Additionally, we have limited data to suggest that TRT should or should not be contraindicated in cis men and FtM with a prior history of breast cancer.
Collapse
|
12
|
Corona G, Goulis DG, Huhtaniemi I, Zitzmann M, Toppari J, Forti G, Vanderschueren D, Wu FC. European Academy of Andrology (EAA) guidelines on investigation, treatment and monitoring of functional hypogonadism in males: Endorsing organization: European Society of Endocrinology. Andrology 2020; 8:970-987. [PMID: 32026626 DOI: 10.1111/andr.12770] [Citation(s) in RCA: 179] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Evidence regarding functional hypogonadism, previously referred to as 'late-onset' hypogonadism, has increased substantially during the last 10 year. OBJECTIVE To update the European Academy of Andrology (EAA) guidelines on functional hypogonadism. METHODS Expert group of academicians appointed by the EAA generated a series of consensus recommendations according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system. RESULTS The diagnosis of functional hypogonadism should be based on both the presence of clinical symptoms supported by repeatedly low morning fasting serum total testosterone (T) measured with a well-validated assay, after exclusion of organic causes of hypogonadism. Lifestyle changes and weight reduction should be the first approach in all overweight and obese men. Whenever possible, withdrawal/modification of drugs potentially interfering with T production should be advised. Testosterone replacement therapy (TRT) is contraindicated in men with untreated prostate or breast cancer, as well as severe heart failure. Severe low urinary tract symptoms and haematocrit >48%-50% represent relative contraindications for TRT. Prostate-specific antigen and digital rectal examination of the prostate should be undertaken in men >40 years of age before initiating TRT to exclude occult prostate cancer. Transdermal T should be preferred for initiation of TRT, whereas gonadotrophin therapy is only recommended when fertility is desired in men with secondary hypogonadism. TRT is able to improve sexual function in hypogonadal men. Other potential positive outcomes of TRT remain uncertain and controversial. CONCLUSION TRT can reliably improve global sexual function in men with hypogonadism in the short term. Long-term clinical benefits, and safety of TRT in functional hypogonadism, remain to be fully documented. Clinicians should therefore explicitly discuss the uncertainties and benefits of TRT and engage them in shared management decision-making.
Collapse
Affiliation(s)
- Giovanni Corona
- Endocrinology Unit, Medical Department, Azienda USL, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ilpo Huhtaniemi
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, London, UK.,Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Turku, Finland
| | - Michael Zitzmann
- Institute of Reproductive Medicine, University Clinic Muenster, Muenster, Germany
| | - Jorma Toppari
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Turku, Finland.,Department of Pediatrics, Turku University Hospital, Turku, Finland
| | - Gianni Forti
- Endocrinology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | | | - Frederick C Wu
- Division of Endocrinology, Diabetes and Gastroenterology, School of Medical Sciences, University of Manchester, Manchester, UK
| |
Collapse
|
13
|
Testosterone Therapy: What We Have Learned From Trials. J Sex Med 2020; 17:447-460. [DOI: 10.1016/j.jsxm.2019.11.270] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 11/20/2019] [Accepted: 11/24/2019] [Indexed: 01/17/2023]
|
14
|
Miranda EP, Torres LO. Late-onset hypogonadism: Prostate safety. Andrology 2020; 8:1606-1613. [PMID: 32056383 DOI: 10.1111/andr.12772] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/27/2020] [Accepted: 02/11/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND There have always been concerns regarding testosterone replacement therapy and prostate safety because of the central role of testosterone in prostate tissue. Even though there is a body of evidence supporting that the benefits of testosterone replacement therapy outbalance the risks of prostate disease, this matter is still debatable and represents a common concern among testosterone prescribers. OBJECTIVES The aim of this article was to review the influence of testosterone on prostate pathophysiology and discuss the potential impact of testosterone replacement therapy on the most common prostate pathologies, including benign prostatic hyperplasia and prostate cancer. MATERIALS AND METHODS We have performed an extensive PubMed review of the literature examining the effects of testosterone replacement therapy on the prostate and its most common affections, especially in terms of safety. RESULTS Testosterone replacement therapy has been shown to improve components of metabolic syndrome and decrease prostate inflammation, which is related to the worsening of lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia. Studies evaluating the link between testosterone replacement therapy and benign prostatic hyperplasia/LUTS have mostly demonstrated no change in symptom scores and even some benefits. There are a significant number of studies demonstrating the safety of testosterone replacement therapy in individuals with late-onset hypogonadism and a history of prostate cancer. The most recently published guidelines have already acknowledged this fact and do not recommend against T treatment in this population, particularly in non-high-risk disease. CONCLUSION Testosterone replacement therapy could be considered for most men with late-onset hypogonadism regardless of their history of prostate disease. However, a discussion about the risks and benefits of testosterone replacement therapy is always advised, especially in men with prostate cancer. Appropriate monitoring is mandatory.
Collapse
Affiliation(s)
- Eduardo P Miranda
- Division of Urology, Universidade Federal do Ceara, Fortaleza, Brazil
| | | |
Collapse
|