Endocrinology of Sexual Function

Add-on effects of a low-dose aripiprazole in resolving hyperprolactinemia induced by risperidone or paliperidone

This study investigated the effects of a low-dose aripiprazole adjunctive treatment for risperidone- or paliperidone-induced hyperprolactinemia in Han Chinese women with schizophrenia. After 4 weeks of risperidone or paliperidone treatment, 60 out of 66 patients improved significantly and experienced hyperprolactinemia. They were randomly assigned to the treatment group (aripiprazole adjunctive treatment) (n=30) or control group (non-adjunctive treatment) (n=30). The dosage of risperidone and paliperidone were maintained; and aripiprazole was maintained at 5mg/day during the 8-week study period. The prolactin levels at the end of the 8th week were significantly lower in the treatment group than in the control group. The estradiol level correlated negatively with serum prolactin level both in the treatment group and the control group at the end of the 8th week and the 4th week respectively. The Positive and Negative Syndrome Scale score improved significantly during the 8-week study period in both groups. The incidence of treatment-emergent adverse event was similar in two groups. Low-dose aripiprazole adjunctive treatment is effective in relieving risperidone- and paliperidone-induced hyperprolactinemia in female schizophrenic patients without increasing adverse event.

Sexuality and androgens in women with cyclical mood changes and pre-menstrual syndrome

OBJECTIVE

To study the relation between androgen levels and sexual interest in women with different kinds of pre-menstrual syndrome (PMS).

DESIGN

Causal comparative study.

SETTING

Swedish university hospital outpatient clinic.

POPULATION

Seventy women with cyclical mood changes.

METHODS

Pre-menstrual syndrome patients were divided into those with and those without preovulatory symptoms. In 37 women, early follicular phase blood samples were analyzed for androstenedione, testosterone, sex hormone-binding globulin (SHBG), progesterone and estradiol, using radioimmunoassay. The participants were divided into subgroups depending on whether the levels of androgens and SHBG were above or below the median. In 33 of them it was possible to compare the cyclicity in sexual parameters between these subgroups.

MAIN OUTCOME MEASURES

Daily ratings of sexual parameters and hormonal analyses.

RESULTS

Plasma testosterone was significantly lower and SHBG significantly higher in women with luteal phase symptoms compared with those with additional follicular phase symptoms. ANOVA showed significant cyclicity for all sexual parameters consistently. For the "sexual feelings" and "pleasant sexual thoughts" parameters, cyclicity was the same whether or not the hormonal levels were "high" or "low."

CONCLUSIONS

The "Pure-PMS" group and the "pre-menstrual-exacerbation" groups differed in their androgen and SHBG levels. Women suffering from PMS with higher neuroticism Eysenck Personality Inventory scores or "low" levels of androgens and SHBG would be more likely to have a decreased sexual interest pre-menstrually than would women with a high level.

The Relationship between Testosterone Deficiency and Men's Health

Testosterone is important in the physiology of various organs and tissues. The serum testosterone concentration gradually declines as one of the processes of aging. Thus, the concept of late-onset hypogonadism has gained increasing attention in the last few years. Reported symptoms of late-onset hypogonadism are easily recognized and include diminished sexual desire and erectile quality, particularly in nocturnal erections, changes in mood with concomitant decreases in intellectual activity and spatial orientation, fatigue, depression and anger, a decrease in lean body mass with associated decreases in muscle volume and strength, a decrease in body hair and skin alterations, and decreased bone mineral density resulting in osteoporosis. Among these various symptoms, sexual dysfunction has been the most common and necessary to treat in the field of urology. It is well known that a low serum testosterone level is associated with erectile dysfunction and hypoactive sexual libido and that testosterone replacement treatment can improve these symptoms in patients with hypogonadism. Recently, in addition to sexual dysfunction, a close relationship between metabolic syndrome, characterized by central obesity, insulin resistance, dyslipidemia, and hypertension, and late-onset hypogonadism has been highlighted by several epidemiologic studies. Several randomized control trials have shown that testosterone replacement treatment significantly decreases insulin resistance in addition to its advantage for obesity. Furthermore, metabolic syndrome is one of the major risk factors for cardiovascular disease, and a low serum testosterone level is closely related to the development of atherosclerosis. Presently, it is speculated that a low serum testosterone level may increase the risk for cardiovascular disease. Thus, testosterone is a key molecule in men's health, especially that of elderly men.

Clinical Chemistry and Other Laboratory Tests on Mouse Plasma or Serum

Besides hematological analyses, many other parameters, including clinical chemistry and endocrinological values, can be determined from mouse blood samples. For most of these tests, plasma or serum samples are used. Data obtained by these investigations provide indications of genotype effects on metabolism and organ functions. Here we describe in detail the considerations that have to be taken into account to get adequate samples for plasma or serum analyses and the recommended sample processing for different investigations. Furthermore, we describe established methods used in the German Mouse Clinic (GMC) to determine clinical chemical parameters; for more in-depth analysis of specific classes of biomarkers, we provide instructions for ELISAs (sandwich and competitive) as well as LC-MS/MS, focusing on markers associated with bone or steroid metabolism in the mouse as working examples. Curr. Protoc. Mouse Biol. 3:69-100 © 2013 by John Wiley & Sons, Inc.

Sexual dysfunction in first-episode schizophrenia patients: results from European First Episode Schizophrenia Trial

Sexual dysfunctions (SDs) occur frequently in schizophrenia patients and have a huge impact on quality of life and compliance. They are often associated with antipsychotic medication. Nicotine consumption, negative or depressive symptoms, and physical illness are also discussed as contributing factors. Data on SD in first-episode schizophrenia patients are scarce.As part of the European First Episode Schizophrenia Trial, first-episode schizophrenia patients were randomly assigned to 5 medication groups. We assessed SD by analyzing selected items from the Udvalg for Kliniske Undersugelser at baseline and at 5 following visits.Differences between antipsychotics were small for all SDs, and fairly little change in the prevalence of SDs was seen over the course of the study. A significantly larger increase of amenorrhea and galactorrhea was seen with amisulpride than with the other medications. In men, higher age, more pronounced Positive and Negative Syndrome Scale general psychopathology symptoms, and higher plasma prolactin levels predicted higher rates of erectile and ejaculatory dysfunctions. Positive and Negative Syndrome Scale negative symptoms and higher age were predictors for decreased libido.In women, higher prolactin plasma levels were identified as a predictor of amenorrhea. Positive and Negative Syndrome Scale negative symptoms predicted decreased libido.All evidence taken together underscores the influence of the disease schizophrenia itself on sexual functioning. In addition, there is a strong correlation between the prolactin-increasing properties of amisulpride and menstrual irregularities.

DOES SILDENAFIL COMBINED WITH TESTOSTERONE GEL IMPROVE ERECTILE DYSFUNCTION IN HYPOGONADAL MEN IN WHOM TESTOSTERONE SUPPLEMENT THERAPY ALONE FAILED?

PURPOSE

We evaluated the efficacy of testosterone gel (T-gel) alone and in combination with sildenafil in hypogonadal patients with erectile dysfunction (ED).

MATERIALS AND METHODS

A total of 49 hypogonadal men (mean age 60.7 years) with ED participated for a mean of 20.2 months. Blood was tested for total and bioavailable testosterone, and prostate specific antigen. Sexual function was assessed using the International Index of Erectile Function questionnaire and a global assessment question (GAQ). Men received 1% 5 gm T-gel for 6 months, and 100 mg sildenafil was added to those with a "no" response to the GAQ after 3 months on testosterone supplement.

RESULTS

A total of 31 patients reported significant improvement in the sexual desire domain (from a mean +/- SD of 4.2 +/- 0.8 to 8.6 +/- 0.4) and erectile function (EF) domain (from 13.6 +/- 1.9 to 27 +/- 0.8) following treatment with testosterone supplement alone. One patient was excluded from study after urinary retention developed and 9 reported irritation at the gel application site. In spite of normalization of total and bioavailable testosterone values, and significant improvement of sexual desire domain scores, the EF of 17 men remained less than 26 or they responded "no" to the GAQ. These men received combined T-gel and sildenafil, after which all graded EF greater than 26 and responded positively to the GAQ.

CONCLUSIONS

Combined treatment with sildenafil and T-gel has a beneficial effect on ED in hypogonadal patients in whom treatment with testosterone supplement alone failed.

Bioavailable Testosterone With Age and Erectile Dysfunction

PURPOSE

Symptoms of partial androgen deficiency of the aging male (PADAM), such as sexual dysfunction and depression, are receiving increased attention. Currently bioavailable testosterone (BT) is considered the most reliable marker for establishing the presence of hypogonadism. We clarified the relationship between BT and other hormones with respect to patient age and PADAM symptoms.

MATERIALS AND METHODS

A total of 130 patients who visited our special clinics for sexual function were included in this study. Endocrinological profiles were evaluated as appropriate, and sexual dysfunction and depression as symptoms of PADAM were assessed by a self-reported questionnaire. The relationship between age and several measures of testosterone, between BT and other hormonal measures, and between BT and PADAM symptoms were analyzed.

RESULTS

Although serum total testosterone did not decrease with age, sex hormone binding globulin increased significantly. BT and free testosterone decreased significantly, and total and free testosterone correlated significantly with BT. The International Index of Erectile Function-5 score for erectile function increased significantly with increases in BT. However, the relationship between the depression score and BT was not significant.

CONCLUSIONS

We consider that BT is a useful marker for diagnosing and treating patients with PADAM because BT correlates significantly with age and International Index of Erectile Function-5 scores. We emphasize that measuring serum testosterone is necessary in aging males.

Visually stimulated erection in castrated men

Sexual interest and activity decrease following castration. We determined by objective criteria the erectile status of 16 men who were sexually active before castration for prostatic cancer. Castration was achieved by orchiectomy or hormonal manipulation. Patients answered a questionnaire regarding the medical status and erectile function before and after castration, and the blood level of testosterone was assessed. During viewing of an erotic videotape penile circumference and erection quality were monitored. Four patients (25%) achieved functional erection. Mean serum free testosterone levels in men who achieved erection were 1.125 +/- 0.362 pg./ml. (standard deviation) and 0.628 +/- 0.098 pg./ml. in those not achieving functional erection (p < 0.001). No statistically significant difference was noted in age, interval since castration, co-morbidity score or method of castration between the men who did and did not achieve erection.

Sexual experience and preference for males or females in the female rat

The influence of sexual experience on preference behavior was investigated in adult female rats. In the first experiment, preference behavior for sexually active males versus estrous females was investigated in female rats who were experienced with mounting behavior. Preference of these mount experienced females was compared to preference of females who were naive in this respect. Mount experience with estrous females induced a female-directed preference in ovariectomized female rats, irrespective of whether the females were treated with OIL or with testosterone-propionate (500 micrograms TP, injected once 48 h prior to testing). Sexually naive, OIL-treated females did not show a preference for males or females, but TP induced a preference for a male. Individual differences in mount frequency were not correlated with preference behavior. In the second experiment, the influence of experience with feminine sexual responses on preference behavior was investigated. OIL-treated and TP-treated females oriented equally toward males and females when they had been given the opportunity to copulate with males prior to the preference tests. The results strongly suggest that prior sexual experience is an important determinant of preference behavior. The female's behavior during sexual interactions was, however, not predictive of later preference.

Androgens, behaviour and nocturnal erection in hypogonadal men: the effects of varying the replacement dose

The behavioural effects of varying the replacement dose of the oral androgen testosterone undecanoate (TU, Restandol) were investigated in eight hypogonadal men. Each man was withdrawn from his previous androgen replacement regimen and after a period of no treatment was administered four doses of TU (40, 80, 120 and 160 mg/d) in four successive one-month treatment periods using a double-blind design. Throughout the study each man recorded his sexual interest, behaviour and mood state using a daily diary form. In addition, four hypogonadal subjects had sleep erections and sleep quality assessed in the laboratory during a state of androgen withdrawal and again after a minimum of 5 months of androgen treatment. A dose response relationship was demonstrated for frequency of sexual thoughts, arousal accompanying sexual thoughts and well-being. Sleep erections improved significantly during testosterone administration. In men, sexual interest and sleep erections are androgen-dependent.

Androgens and personality in normal men and men operated for hypospadias in childhood

Serum levels of LH, FSH, prolactin and androgens were assayed in 33 adult men operated for a penile malformation (hypospadias) in childhood and in 34 matched controls. Two cases of severe hypospadias had signs of hypergonadotrophic hypogonadism. Three moderately severe cases possibly had a central relative androgen receptor insensitivity. Patients had lower levels of 5 alpha-dihydrotestosterone in serum, unrelated to the severity of the hypospadias. The hypospadias patients have previously been shown to be more neurotic and inhibited both socially and sexually than the controls, which might be related to defective androgenic functioning. Relations between androgen levels and psychological variables were studied. Low testosterone levels were related to higher hostility scores in Rorschach. Relations between androgens and other personality characteristics could not be shown.

Changes in erectile responsiveness during androgen replacement therapy

Erections in response to erotic films and fantasies were measured in eight hypogonadal men, with and without androgen replacement, and eight age-matched controls. Erections to films in the hypogonadal men did not differ from those of the controls and were not affected by androgen replacement. Erections to fantasy were significantly smaller and slower to develop in the hypogonadal men and did show significant improvement during androgen replacement. These preliminary results suggest that erections to certain types of stimuli are relatively independent of androgens, whereas the response to fantasy may be androgen dependent. The implications of these findings are discussed.

Hormonal replacement and sexuality in men

Only in the last few years has the scientific study of hormonal replacement therapy for hyposexuality begun in earnest with the advent of appropriately controlled experiment studies. Dose-response relationships can be demonstrated between testosterone (T) and sexual measures, but these have not yet been investigated in detail. Some aspects of sexual function are maintained in the presence of androgen levels well below the normal range, but preliminary evidence suggests that within a normal population high levels of T are correlated with more vigorous responses to visual erotic stimuli. Though T (and to a greater extent free T) declines with aging in parallel with the decline of sexual function, these hormonal changes contribute only to a minor extent to the behavioural change. Some non-aromatizable androgens may be less effective in stimulating sexual behaviour than T, but initial data on effects of dihydrotestosterone suggests that the capacity of an androgen to be aromatized (converted to oestrogen) is not a requirement for its sexual action. While T apparently increases the incidence of all types of male sexual activity, recent data contradict the belief that it directly facilitates the erectile mechanism in men, even though erection frequency is greatly reduced in untreated hypogonadal men. At the present juncture, it appears that the initial action of T may be on libido factors which lead in turn to the stimulation of other aspects of sexuality. Specifically, we propose that androgen acts through stimulating genital sensations and/or other pleasurable awareness of sexual response rather than directly through cognitive processes such as sexual imagery.