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Ministrini S, Padro T. MicroRNA in cardiometabolic health and disease: The perspectives of sex, gender and personalised medicine. Eur J Clin Invest 2024; 54:e14223. [PMID: 38623918 DOI: 10.1111/eci.14223] [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] [Received: 03/01/2024] [Revised: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Personalized medicine represents a novel and integrative approach that focuses on an individual's genetics and epigenetics, precision medicine, lifestyle and exposures as key players of health status and disease phenotypes. METHODS In this narrative review, we aim to carefully discuss the current knowledge on gender disparities in cardiometabolic diseases, and we consider the sex- specific expression of miRNAs and their role as promising tool in precision medicine. RESULTS Personalised medicine overcomes the restricted care of patient based on a binomial sex approach, by enriching itself with a holistic and dynamic gender integration. Recognized as a major worldwide health emergency, cardiometabolic disorders continue to rise, impacting on health systems and requiring more effective and targeted strategies. Several sex and gender drivers might affect the onset and progression of cardiometabolic disorders in males and females at multiple levels. In this respect, distinct contribution of genetic and epigenetic mechanisms, molecular and physiological pathways, sex hormones, visceral fat and subcutaneous fat and lifestyle lead to differences in disease burden and outcomes in males and females. CONCLUSIONS Sex and gender play a pivotal role in precision medicine because the influence the physiology of each individual and the way they interact with environment from intrauterine life.
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Affiliation(s)
- Stefano Ministrini
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Teresa Padro
- Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain
- Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV) Instituto de Salud Carlos III, Madrid, Spain
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Wang Z, Zhang G, Hu S, Fu M, Zhang P, Zhang K, Hao L, Chen S. Research progress on the protective effect of hormones and hormone drugs in myocardial ischemia-reperfusion injury. Biomed Pharmacother 2024; 176:116764. [PMID: 38805965 DOI: 10.1016/j.biopha.2024.116764] [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] [Received: 02/21/2024] [Revised: 05/05/2024] [Accepted: 05/17/2024] [Indexed: 05/30/2024] Open
Abstract
Ischemic heart disease (IHD) is a condition where the heart muscle does not receive enough blood flow, leading to cardiac dysfunction. Restoring blood flow to the coronary artery is an effective clinical therapy for myocardial ischemia. This strategy helps lower the size of the myocardial infarction and improves the prognosis of patients. Nevertheless, if the disrupted blood flow to the heart muscle is restored within a specific timeframe, it leads to more severe harm to the previously deprived heart tissue. This condition is referred to as myocardial ischemia/reperfusion injury (MIRI). Until now, there is a dearth of efficacious strategies to prevent and manage MIRI. Hormones are specialized substances that are produced directly into the circulation by endocrine organs or tissues in humans and animals, and they have particular effects on the body. Hormonal medications utilize human or animal hormones as their active components, encompassing sex hormones, adrenaline medications, thyroid hormone medications, and others. While several studies have examined the preventive properties of different endocrine hormones, such as estrogen and hormone analogs, on myocardial injury caused by ischemia-reperfusion, there are other hormone analogs whose mechanisms of action remain unexplained and whose safety cannot be assured. The current study is on hormones and hormone medications, elucidating the mechanism of hormone pharmaceuticals and emphasizing the cardioprotective effects of different endocrine hormones. It aims to provide guidance for the therapeutic use of drugs and offer direction for the examination of MIRI in clinical therapy.
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Affiliation(s)
- Zhongyi Wang
- Department of Pharmaceutical Toxicology, School of Pharmacy, China Medical University, Shenyang, 110122, China
| | - Gaojiang Zhang
- Department of Pharmaceutical Toxicology, School of Pharmacy, China Medical University, Shenyang, 110122, China
| | - Shan Hu
- Department of Pharmaceutical Toxicology, School of Pharmacy, China Medical University, Shenyang, 110122, China
| | - Meilin Fu
- Department of Pharmaceutical Toxicology, School of Pharmacy, China Medical University, Shenyang, 110122, China
| | - Pingyuan Zhang
- Department of Pharmaceutical Toxicology, School of Pharmacy, China Medical University, Shenyang, 110122, China
| | - Kuo Zhang
- Department of Pharmaceutical Toxicology, School of Pharmacy, China Medical University, Shenyang, 110122, China
| | - Liying Hao
- Department of Pharmaceutical Toxicology, School of Pharmacy, China Medical University, Shenyang, 110122, China.
| | - Sichong Chen
- Department of Pharmaceutical Toxicology, School of Pharmacy, China Medical University, Shenyang, 110122, China.
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Santi D, Cignarelli A, Baldi M, Sansone A, Spaggiari G, Simoni M, Corona G. The chronic alcohol consumption influences the gonadal axis in men: Results from a meta-analysis. Andrology 2024; 12:768-780. [PMID: 37705506 DOI: 10.1111/andr.13526] [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] [Received: 08/14/2023] [Revised: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Low testosterone concentrations affect 2-13% of adult males, with a direct association between reduction in testosterone (T) concentrations and cardiovascular events. Lifestyle habits have been linked to visceral fat accumulation and endocrine disorders like secondary hypogonadism. Alcohol intake has also been a topic of debate, with studies showing a detrimental effect on sperm production and underlying mechanisms. This meta-analysis aims to comprehensively evaluate the effect of alcohol consumption on T serum concentrations in adult men. METHODS The literature search included only controlled clinical trials comparing men who drink alcohol to men who do not, or who assumed placebo or nonalcoholic beverages. The primary outcome was the comparison of total testosterone serum concentrations between the study and control groups. The publications were examined for publication bias using Egger's test. RESULTS Twenty-one studies were included in the analysis for a total of 30 trials that examined the effects of alcohol consumption on testosterone level in 10,199 subjects. The meta-analysis showed that alcohol consumption overall is related to significant reduction in circulating concentrations of total testosterone (mean difference [MD] = -4.02; 95% CI -6.30, -1.73), free T (MD = -0.17; 95% CI -0.23, -0.12), sex hormone binding globulin (SHBG) (MD = -1.94; 95% CI -3.37, -0.48), an increase in estradiol (E2) (MD = 7.65; 95% CI 1.06, 14.23) and neutral effect on luteinizing hormone (LH) (MD = -0.15; 95% CI -0.36, 0.06), independently by age, body mass index (BMI), E2, and LH serum concentrations and alcohol intake. However, these results are evident only in healthy men exposed to chronic alcohol consumption and not in those with a recognized diagnosis of alcohol use disorder or after acute alcohol intake. CONCLUSION This study suggests how chronic alcohol consumption may inhibit the gonadal axis in healthy men, although the exact pathophysiological mechanisms connecting alcohol exposure and steroidogenesis are still not completely clarified.
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Affiliation(s)
- Daniele Santi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
- Unit of Andrology and Sexual Medicine of the Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Angelo Cignarelli
- Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | - Matteo Baldi
- Unit of Medicine, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, presidio Molinette, Turin, Italy
| | - Andrea Sansone
- Chair of Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giorgia Spaggiari
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
- Unit of Andrology and Sexual Medicine of the Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Manuela Simoni
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
- Unit of Andrology and Sexual Medicine of the Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
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Jaiswal V, Sawhney A, Nebuwa C, Borra V, Deb N, Halder A, Rajak K, Jha M, Wajid Z, Thachil R, Bandyopadhyay D, Mattumpuram J, Lavie CJ. Association between testosterone replacement therapy and cardiovascular outcomes: A meta-analysis of 30 randomized controlled trials. Prog Cardiovasc Dis 2024:S0033-0620(24)00055-0. [PMID: 38589271 DOI: 10.1016/j.pcad.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/01/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The Cardiovascular safety of testosterone replacement therapy (TRT) among men with hypogonadism is not well established to date. Hence, we sought to evaluate the cardiovascular disease (CVD) outcomes among patients receiving testosterone therapy by using all recently published randomized controlled trials. METHODS We performed a systematic literature search on PubMed, EMBASE, and Clinicaltrial.gov for relevant randomized controlled trials (RCTs) from inception until September 30th, 2023. RESULTS A total of 30 randomized trials with 11,502 patients were included in the final analysis. The mean age was ranging from 61.61 to 61.82 years. Pooled analysis of primary and secondary outcomes showed that the incidence of any CVD events (OR, 1.12 (95%CI: 0.77-1.62), P = 0.55), stroke (OR, 1.01 (95%CI: 0.68-1.51), P = 0.94), myocardial infarction (OR, 1.05 (95%CI: 0.76-1.45), P = 0.77), all-cause mortality (OR, 0.94 (95%CI: 0.76-1.17), P = 0.57), and CVD mortality (OR, 0.87 (95%CI: 0.65-1.15), P = 0.31) was comparable between TRT and placebo groups. CONCLUSION Our analysis indicates that for patients with hypogonadism, testosterone replacement therapy does not increase the CVD risk and all-cause mortality.
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Affiliation(s)
- Vikash Jaiswal
- Department of Cardiovascular Research, Larkin Community Hospital, South Miami, FL, USA.
| | - Aanchal Sawhney
- Department of Internal Medicine, Crozer Chester Medical Center, Upland, PA, USA
| | - Chikodili Nebuwa
- Department of Internal Medicine, Nuvance Health, Poughkeepsie, NY, USA
| | - Vamsikalyan Borra
- Department of Internal Medicine, University of Texas Rio Grande Valley, Weslaco, TX, USA
| | - Novonil Deb
- North Bengal Medical College and Hospital, India
| | - Anupam Halder
- Department of Internal Medicine, UPMC, Harrisburg, PA, USA
| | - Kripa Rajak
- Department of Internal Medicine, UPMC, Harrisburg, PA, USA
| | - Mayank Jha
- Department of Medicine, Government Medical College, Surat, India
| | - Zarghoona Wajid
- Department of Internal Medicine, Wayne State University School of Medicine, USA
| | - Rosy Thachil
- Division of Cardiology, Elmhurst Hospital Center, Mount Sinai School of Medicine, New York, USA
| | | | - Jishanth Mattumpuram
- Division of Cardiology, University of Louisville School of Medicine, KY 40202, United States
| | - Carl J Lavie
- Department of Cardiovascular Disease, John Ochsner Heart and Vascular Institute, New Orleans, LA, USA.
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Morgentaler A, Hanafy HM. The testis, eunuchs, and testosterone: a historical review over the ages and around the world. Sex Med Rev 2024; 12:199-209. [PMID: 38146670 DOI: 10.1093/sxmrev/qead051] [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] [Received: 09/26/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 12/27/2023]
Abstract
INTRODUCTION Testosterone therapy for men with testosterone deficiency is widely used, yet remains controversial. The rich and fascinating history of the testicles, including human castration, provides a valuable perspective on this important topic. OBJECTIVES This study reviewed the history of testosterone from antiquity to the modern day. METHODS Primary sources consisted of books and relevant articles, augmented by a MEDLINE search using the key words "testis," "testicles," "castration," "eunuchs," "testosterone," and "testicular function." RESULTS An early scientific observation was that castration reduced sexual development and activity, originating with domestication of animals approximately 10 000 years ago. Human castration appears in ancient Egyptian mythology more than 4000 years ago, in Greek mythology from 8th century BCE, and in the Bible. The history of eunuchs in China spanned 2000 years, beginning with the Hsia dynasty (2205-1766 BCE). The concept that the testicles produced some factor responsible for male sexual development and behavior was thus known throughout the world since the beginning of recorded history. Testosterone was isolated and synthesized in 1935 and was soon available as a treatment. Multiple benefits of testosterone therapy were apparent by 1940. Recent large, controlled testosterone studies have conclusively demonstrated sexual and general health benefits, with a strong safety profile. CONCLUSION Testosterone has been a known substance for <1% of the historical timeline, yet knowledge that the testes were responsible for male sexual development and behavior has been known since the beginning of recorded history. Today, modern evidence has demonstrated the importance of normal levels of testosterone for general health as well as sexual function and desire. Yet, testosterone therapy remains controversial. We believe this historical review provides a helpful perspective on this age-old issue.
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Affiliation(s)
- Abraham Morgentaler
- Division of Urology, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
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Bahat G, Ozkok S. The Current Landscape of Pharmacotherapies for Sarcopenia. Drugs Aging 2024; 41:83-112. [PMID: 38315328 DOI: 10.1007/s40266-023-01093-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2023] [Indexed: 02/07/2024]
Abstract
Sarcopenia is a skeletal muscle disorder characterized by progressive and generalized decline in muscle mass and function. Although it is mostly known as an age-related disorder, it can also occur secondary to systemic diseases such as malignancy or organ failure. It has demonstrated a significant relationship with adverse outcomes, e.g., falls, disabilities, and even mortality. Several breakthroughs have been made to find a pharmaceutical therapy for sarcopenia over the years, and some have come up with promising findings. Yet still no drug has been approved for its treatment. The key factor that makes finding an effective pharmacotherapy so challenging is the general paradigm of standalone/single diseases, traditionally adopted in medicine. Today, it is well known that sarcopenia is a complex disorder caused by multiple factors, e.g., imbalance in protein turnover, satellite cell and mitochondrial dysfunction, hormonal changes, low-grade inflammation, senescence, anorexia of aging, and behavioral factors such as low physical activity. Therefore, pharmaceuticals, either alone or combined, that exhibit multiple actions on these factors simultaneously will likely be the drug of choice to manage sarcopenia. Among various drug options explored throughout the years, testosterone still has the most cumulated evidence regarding its effects on muscle health and its safety. A mas receptor agonist, BIO101, stands out as a recent promising pharmaceutical. In addition to the conventional strategies (i.e., nutritional support and physical exercise), therapeutics with multiple targets of action or combination of multiple therapeutics with different targets/modes of action appear to promise greater benefit for the prevention and treatment of sarcopenia.
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Affiliation(s)
- Gulistan Bahat
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey.
| | - Serdar Ozkok
- Division of Geriatrics, Department of Internal Medicine, Hatay Training and Research Hospital, Hatay, 31040, Turkey
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Sood A, Hosseinpour A, Sood A, Avula S, Durrani J, Bhatia V, Gupta R. Cardiovascular Outcomes of Hypogonadal Men Receiving Testosterone Replacement Therapy: A Meta-analysis of Randomized Controlled Trials. Endocr Pract 2024; 30:2-10. [PMID: 37797887 DOI: 10.1016/j.eprac.2023.09.012] [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] [Received: 08/25/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To investigate the impact of testosterone replacement therapy (TRT) on cardiovascular outcomes in hypogonadal men. METHODS A meta-analysis of 26 randomized controlled trials involving 10 941 participants was conducted. Various clinical outcomes, including all-cause mortality, cardiovascular-related mortality, myocardial infarction, stroke, congestive heart failure, atrial fibrillation, pulmonary embolism, and venous thrombosis, were assessed. RESULTS No statistically significant differences were observed between the TRT group and the control group in terms of these clinical outcomes. Sensitivity analysis and publication bias assessment supported the robustness of the findings. Meta-regression analysis found no significant associations between clinical outcomes and potential covariates, including age, diabetes, hypertension, dyslipidemia, and smoking. DISCUSSION Previous research on TRT and cardiovascular events, with comparisons to studies like the Testosterone Trials and the studies conducted by Vigen et al, Finkle et al, Layton et al, and Wallis et al, is provided. The significance of the systematic review and meta-analysis approach is emphasized, particularly its exclusive focus on hypogonadal patients. CONCLUSION This study offers reassurance that TRT does not increase mortality risk or worsen cardiovascular outcomes in hypogonadal men. However, further research, especially long-term studies involving diverse populations, is essential to strengthen the evidence base and broaden the applicability of these findings.
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Affiliation(s)
- Aayushi Sood
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania.
| | - Alireza Hosseinpour
- Department of Cardiovascular Medicine, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Akshit Sood
- Department of Medicine, Navjivan General and Maternity Hospital, Jalandhar, Punjab, India
| | - Sreekant Avula
- Department of Diabetes, Endocrinology & Metabolism, University of Minnesota, Minneapolis, Minnesota
| | - Jawahar Durrani
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania
| | - Vishal Bhatia
- Division of Endocrinology, Department of Internal Medicine, St Vincent Medical Group, Evansville, Indiana
| | - Rahul Gupta
- Department of Cardiology, Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, Pennsylvania
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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.
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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
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Traish AM. Major cardiovascular disease risk in men with testosterone deficiency (hypogonadism): appraisal of short, medium and long-term testosterone therapy - a narrative review. Sex Med Rev 2023; 11:384-394. [PMID: 37587664 DOI: 10.1093/sxmrev/qead031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/29/2023] [Accepted: 07/04/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Low testosterone (T) levels are associated with obesity, metabolic syndrome, type 2 diabetes mellitus and altered lipid profiles, thus contributing to increased cardiovascular disease risk. Hence T deficiency has a detrimental effect on men's vascular health, quality of life and increased mortality. OBJECTIVES This review aims to present summary of data in the contemporary clinical literature pertaining to the benefits of T therapy in clinical studies with varying durations on vascular health in men with T deficiency. METHODS A Medline search using PubMed and EMBASE was performed using the following key words: "testosterone deficiency," "testosterone therapy," major cardiovascular adverse events", "cardiovascular disease". Relevant studies were extracted, evaluated, and analyzed. We evaluated findings from clinical trials, observational studies and systematic reviews and meta-analyses to develop a comprehensive account of the critical role of T in maintaining vascular health. RESULTS Considerable evidence beginning with studies published in 1940s concomitant with findings from the utmost recent clinical studies suggests a clinical value of T therapy in maintaining vascular health and reducing cardiovascular mortality. The current scientific and clinical evidence demonstrates strong relationship between low circulating T levels and risk of cardiovascular disease and T therapy is deemed safe in men with hypogonadism when given in the physiological range with no apparent harm. CONCLUSION What emerges from the current clinical literature is that, irrespective of the length of study durations, testosterone therapy provides significant health benefits and reduces risk of cardiovascular disease. More important is that data from many observational and registry studies, demonstrated that longer durations of testosterone therapy were associated with greater health benefits and reduced cardiovascular risk. T therapy in men with T deficiency reduces the incidence of major adverse cardiovascular events attributed to improving overall metabolic function.
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Affiliation(s)
- Abdulmaged M Traish
- Department of Biochemistry & Department of Urology, Boston University School of Medicine, Boston, MA 02118, United States
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Green DJ, Chasland LC, Naylor LH, Yeap BB. New Horizons: Testosterone or Exercise for Cardiometabolic Health in Older Men. J Clin Endocrinol Metab 2023; 108:2141-2153. [PMID: 36964918 PMCID: PMC10438896 DOI: 10.1210/clinem/dgad175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/14/2023] [Accepted: 03/22/2023] [Indexed: 03/27/2023]
Abstract
Middle-aged and older men have typically accumulated comorbidities, are increasingly sedentary, and have lower testosterone concentrations (T) compared to younger men. Reduced physical activity (PA) and lower T both are associated with, and may predispose to, metabolically adverse changes in body composition, which contribute to higher risks of cardiometabolic disease. Exercise improves cardiometabolic health, but sustained participation is problematic. By contrast, rates of T prescription have increased, particularly in middle-aged and older men without organic diseases of the hypothalamus, pituitary, or testes, reflecting the unproven concept of a restorative hormone that preserves health. Two recent large randomized trials of T, and meta-analyses of randomized trials, did not show a signal for adverse cardiovascular (CV) events, and T treatment on a background of lifestyle intervention reduced type 2 diabetes by 40% in men at high risk. Men with both higher endogenous T and higher PA levels have lower CV risk, but causality remains unproven. Exercise training interventions improve blood pressure and endothelial function in middle-aged and older men, without comparable benefits or additive effects of T treatment. Therefore, exercise training improves cardiometabolic health in middle-aged and older men when effectively applied as a supervised regimen incorporating aerobic and resistance modalities. Treatment with T may have indirect cardiometabolic benefits, mediated via favorable changes in body composition. Further evaluation of T as a pharmacological intervention to improve cardiometabolic health in aging men could consider longer treatment durations and combination with targeted exercise programs.
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Affiliation(s)
- Daniel J Green
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, WA, 6009, Australia
| | - Lauren C Chasland
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, WA, 6009, Australia
- Allied Health Department, Fiona Stanley Hospital, Perth, WA, 6150, Australia
| | - Louise H Naylor
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, WA, 6009, Australia
- Allied Health Department, Fiona Stanley Hospital, Perth, WA, 6150, Australia
| | - Bu B Yeap
- Medical School, The University of Western Australia, Perth, WA, 6009, Australia
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, WA, 6150, Australia
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Hackett G, Kirby M, Rees RW, Jones TH, Muneer A, Livingston M, Ossei-Gerning N, David J, Foster J, Kalra PA, Ramachandran S. The British Society for Sexual Medicine Guidelines on Male Adult Testosterone Deficiency, with Statements for Practice. World J Mens Health 2023:41.e33. [PMID: 36876744 DOI: 10.5534/wjmh.221027] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/07/2022] [Accepted: 11/23/2022] [Indexed: 03/02/2023] Open
Abstract
Testosterone deficiency (TD) is an increasingly common problem with significant health implications, but its diagnosis and management can be challenging. A multi-disciplinary panel from BSSM reviewed the available literature on TD and provide evidence-based statements for clinical practice. Evidence was derived from Medline, EMBASE and Cochrane searches on hypogonadism, testosterone therapy (T Therapy) and cardiovascular safety from May 2017 to September 2022. This revealed 1,714 articles, including 52 clinical trials and 32 placebo-controlled randomised controlled trials. A total of twenty-five statements are provided, relating to five key areas: screening, diagnosis, initiating T Therapy, benefits and risks of T Therapy, and follow-up. Seven statements are supported by level 1 evidence, eight by level 2, five by level 3, and five by level 4. Recent studies have demonstrated that low levels of testosterone in men are associated with increased risk of incident type 2 diabetes mellitus, worse outcomes in chronic kidney disease and COVID 19 infection with increased all-cause mortality, along with significant quality of life implications. These guidelines should help practitioners to effectively diagnose and manage primary and age-related TD.
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Affiliation(s)
- Geoffrey Hackett
- Department of Urology, Spire Hospital, Little Aston, Birmingham, UK.,Department of Urology, Aston University, Birmingham, UK.
| | - Michael Kirby
- Trends in Urology and Men's Health, Letchworth, UK.,Faculty of Health & Human Sciences, University of Hertfordshire & The Prostate Centre, London, UK
| | - Rowland W Rees
- Department of Urology, University Hospital Southampton and UCLH, London, UK
| | - T Hugh Jones
- Department of Endocrinology, Barnsley Hospital, Barnsley, UK.,Department of Biochemistry, Royal Hallamshire Hospital, University of Sheffield Medical School, Sheffield, UK
| | - Asif Muneer
- Division of Surgery and Interventional Science, NIHR Biomedical Research Centre UCLH, London, UK
| | - Mark Livingston
- Department of Biochemistry, Black Country Pathology Services, Walsall Manor Hospital, Walsall, UK
| | - Nick Ossei-Gerning
- Cardiff and Vale NHS Trust, Cardiff, UK.,University of South Wales TDS, Bridgend, UK.,Department of Cardiology, University of Cape Coast, Cape Coast, Ghana
| | | | | | - Philip A Kalra
- Department of Nephrology, NCA, Salford Royal Hospital, Salford, UK
| | - Sudarshan Ramachandran
- Department of Clinical Biochemistry, University Hospitals Birmingham NHS Foundation Trust, Sutton Coldfield, West Midlands, UK
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12
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Butler EN, Zhou CK, Curry M, McMenamin Ú, Cardwell C, Bradley MC, Graubard BI, Cook MB. Testosterone therapy and cancer risks among men in the SEER-Medicare linked database. Br J Cancer 2023; 128:48-56. [PMID: 36307648 PMCID: PMC9814238 DOI: 10.1038/s41416-022-02019-7] [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] [Received: 02/04/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND We examined associations between two forms of testosterone therapy (TT) and risks of seven cancers among men. METHODS SEER-Medicare combines cancer registry data from the Surveillance, Epidemiology, and End Results programme with Medicare claims. Our population-based case-control study included incident cancer cases diagnosed between 1992-2015: prostate (n = 130,713), lung (n = 105,466), colorectal (n = 56,433), bladder (n = 38,873), non-Hodgkin lymphoma (n = 17,854), melanoma (n = 14,241), and oesophageal (n = 9116). We selected 100,000 controls from a 5% random sample of Medicare beneficiaries and used logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS TT was associated with lower risk of distant-stage prostate cancer (injection/implantation OR = 0.72, 95% CI: 0.60-0.86; topical OR = 0.50, 95% CI: 0.24-1.03). We also observed inverse associations for distant-stage colorectal cancer (injection/implantation OR = 0.75, 95% CI: 0.62-0.90; topical OR = 0.11, 95% CI: 0.05-0.24). Risks of distant-stage colorectal and prostate cancers decreased with time after initiating TT by injection/implantation. By contrast, TT was positively associated with distant-stage melanoma (injection/implantation OR = 1.70, 95% CI: 1.37-2.11). TT was not associated with bladder cancer, oesophageal cancer, lung cancer or non-Hodgkin lymphoma. CONCLUSION TT was inversely associated with distant-stage prostate and colorectal cancers but was positively associated with distant-stage melanoma. These observations may suggest an aetiologic role for TT or the presence of residual confounding.
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Affiliation(s)
- Eboneé N Butler
- Integrative Tumor Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA.
- University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA.
| | - Cindy Ke Zhou
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Michael Curry
- Information Management Services, Inc, Calverton, MD, USA
| | - Úna McMenamin
- Cancer Epidemiology Research Group, Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Christopher Cardwell
- Cancer Epidemiology Research Group, Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Marie C Bradley
- Integrative Tumor Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Barry I Graubard
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Michael B Cook
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
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13
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Joung KI, Hwang JE, Oh IS, Cho SI, Shin JY. Association between ranitidine use with potential NDMA impurities and risk of cancer in Korea. Sci Rep 2022; 12:22396. [PMID: 36575247 PMCID: PMC9794704 DOI: 10.1038/s41598-022-26691-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 12/19/2022] [Indexed: 12/28/2022] Open
Abstract
N-Nitrosodimethylamine (NDMA) detected above the acceptable level in ranitidine products has been a great global concern. To examine the risk of cancer among people treated with ranitidine, we conducted a cohort study using the National Health Insurance Service-National Sample Cohort data (2002-2015) of South Korea. Patients were aged 40 or above as of January 2004 and began receiving ranitidine or other histamine-2 receptor antagonist (H2RA), active comparator, without a history of H2RAs prescription during the prior 2-years. The lag time was designated up to 6 years. The outcomes were an overall incident cancer risk and the risk of major single cancers during the follow-up. The association between ranitidine use and cancer risk was examined by Cox regression model. After exclusion and propensity score matching, 25,360 patients were available for analysis. The use of ranitidine was not associated with the overall cancer risk and major individual cancers [overall cancer: incidence rate per 1000 person-years, 2.9 vs 3.0 among the ranitidine users and other H2RAs users, respectively; adjusted hazard ratio (HR) and 95% confidence interval (95% CI) for all cancers, 0.98 (0.81-1.20)]. The higher cumulative exposure to ranitidine did not increase the cancer risk. Given the insufficient follow-up period, these findings should be interpreted carefully.
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Affiliation(s)
- Kyung-In Joung
- grid.410886.30000 0004 0647 3511School of AI Healthcare, College of Integrated Health Sciences, Cha University, Pocheon, Republic of Korea ,grid.264381.a0000 0001 2181 989XSchool of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-Do Republic of Korea ,grid.264381.a0000 0001 2181 989XDepartment of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, Gyeonggi-Do Republic of Korea
| | - Jung Eun Hwang
- grid.264381.a0000 0001 2181 989XSchool of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-Do Republic of Korea
| | - In-Sun Oh
- grid.264381.a0000 0001 2181 989XSchool of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-Do Republic of Korea ,grid.14709.3b0000 0004 1936 8649Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC Canada ,grid.414980.00000 0000 9401 2774Centre for Clinical Epidemiology, Lady Davis Research Institute - Jewish General Hospital, 3755 Cote Ste-Catherine, H-410.1, Montreal, QC Canada
| | - Sung-il Cho
- grid.31501.360000 0004 0470 5905Department of Public Health Science, Graduate School of Public Health and Institute of Health and Environment, Seoul National University, Seoul, Republic of Korea
| | - Ju-Young Shin
- grid.264381.a0000 0001 2181 989X(16419) Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea
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14
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Trivedi B, Desai R, Mishra K, Hechanova LA, Abolbashari M. Role of Sex in Atherosclerosis: Does Sex Matter? Curr Cardiol Rep 2022; 24:1791-1798. [PMID: 36269533 DOI: 10.1007/s11886-022-01800-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Atherosclerosis is the largest cause of death in the western world with the role of sex yet to be determined. The purpose of this review is to investigate the role sex may play in the development of atherosclerosis. RECENT FINDINGS Differences in plaque burden play a role in atherosclerotic outcome. Men have a higher prevalence of plaque burden, while women have less plaque rupture, necrotic core, and calcium. Differences in hormones, vascular anatomy, and overall lifestyle all play a role. Estrogen's cardioprotective effect is well known, but there is a lack of consensus on testosterone's role. There are varying rates of atherosclerosis between the sexes. Studies have also shown varying differences in the progression of plaque and the type of plaques between sexes. Further investigations need to be done to solidify the role sex may play as a variable in the development of atherosclerosis and how that may impact future treatment goals.
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Affiliation(s)
- Bhavi Trivedi
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, 145 W Castellano Dr., Apt #2, El Paso, TX, 79912, USA.
| | - Rohan Desai
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, 145 W Castellano Dr., Apt #2, El Paso, TX, 79912, USA
| | - Kunal Mishra
- Department of Cardiovascular Medicine, University of Virginia, Charlottesville, VA, USA
| | - Lisa Aimee Hechanova
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, 145 W Castellano Dr., Apt #2, El Paso, TX, 79912, USA
| | - Mehran Abolbashari
- Department of Cardiovascular Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
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15
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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: 28] [Impact Index Per Article: 14.0] [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.
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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
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16
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Comeau KD, Shokoples BG, Schiffrin EL. Sex Differences in the Immune System in Relation to Hypertension and Vascular Disease. Can J Cardiol 2022; 38:1828-1843. [PMID: 35597532 DOI: 10.1016/j.cjca.2022.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/08/2022] [Accepted: 05/12/2022] [Indexed: 12/14/2022] Open
Abstract
Hypertension is the leading risk factor for cardiovascular disease and mortality worldwide. Despite intensive research into the mechanisms underlying the development of hypertension, it remains difficult to control blood pressure in a large proportion of patients. Young men have a higher prevalence of hypertension compared with age-matched women, and this holds true until approximately the fifth decade of life. Following the onset of menopause, the incidence of hypertension among women begins to surpass that of men. The immune system has been demonstrated to play a role in the pathophysiology of hypertension, and biological sex and sex hormones can affect the function of innate and adaptive immune cell populations. Recent studies in male and female animal models of hypertension have begun to unravel the relationship among sex, immunity, and hypertension. Hypertensive male animals show a bias toward proinflammatory T-cell subsets, including interleukin (IL) 17-producing TH17 cells, and increased renal infiltration of T cells and inflammatory macrophages. Conversely, premenopausal female animals are largely protected from hypertension, and have a predilection for anti-inflammatory T regulatory cells and production of anti-inflammatory cytokines, such as IL-10. Menopause abrogates female protection from hypertension, which may be due to changes among anti-inflammatory T regulatory cell populations. Since development of novel treatments for hypertension has plateaued, determining the role of sex in the pathophysiology of hypertension may open new therapeutic avenues for both men and women.
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Affiliation(s)
- Kevin D Comeau
- Hypertension and Vascular Research Unit, Lady Davis Institute for Medical Research, McGill University, Montréal, Québec, Canada
| | - Brandon G Shokoples
- Hypertension and Vascular Research Unit, Lady Davis Institute for Medical Research, McGill University, Montréal, Québec, Canada
| | - Ernesto L Schiffrin
- Hypertension and Vascular Research Unit, Lady Davis Institute for Medical Research, McGill University, Montréal, Québec, Canada; Department of Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montréal, Québec, Canada.
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17
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Thirumalai A, Anawalt BD. Relationships between endogenous and exogenous testosterone and cardiovascular disease in men. Rev Endocr Metab Disord 2022; 23:1305-1322. [PMID: 36219323 DOI: 10.1007/s11154-022-09752-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2022] [Indexed: 01/11/2023]
Abstract
In this narrative review, we discuss the evidence about the controversy about the cardiovascular effects of endogenous and exogenous testosterone in men. Prospective cohort studies with follow-up of ~5-15 years generally indicate no association or a possible inverse relationship between serum endogenous testosterone concentrations and composite major cardiovascular events, cardiovascular deaths and overall mortality. Pharmacoepidemiological studies of large databases generally show no association between testosterone therapy and incident major cardiovascular events, and some pharmacoepidemiological studies demonstrate an association with decreased overall mortality. Randomized, placebo-controlled trials indicate that there is no increased incidence of overall major cardiovascular events with 1-3 years of testosterone therapy. These placebo-controlled trials have major limitations including small numbers of participants, short duration of testosterone therapy and follow-up, and lack of systematic adjudication of cardiovascular events. Overall, the evidence indicates that endogenous testosterone concentrations and testosterone therapy at physiological dosages confer no or minimal effects on the incidence of cardiovascular outcomes. There is insufficient evidence to make conclusions about testosterone therapy for patients at high risk of cardiovascular events (e.g., men with recent myocardial infarctions or stroke and men with recurrent idiopathic deep venous thromboses). In general, clinicians should avoid prescribing supraphysiological testosterone therapy to hypogonadal men or men with slightly low to low-normal serum testosterone concentrations and no identified disorder of the hypothalamus-pituitary-testicular axis because of the uncertain cardiovascular risks and the lack of proven health benefits. For most men with bona fide hypogonadism, benefits of testosterone therapy exceed the potential risk of adverse cardiovascular effects.
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Affiliation(s)
- Arthi Thirumalai
- Department of Medicine, University of Washington School of Medicine, Box 356420 Department of Medicine, 1959 NE Pacific Avenue, Seattle, WA, 98195, USA
| | - Bradley D Anawalt
- Department of Medicine, University of Washington School of Medicine, Box 356420 Department of Medicine, 1959 NE Pacific Avenue, Seattle, WA, 98195, USA.
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18
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Testosterone replacement therapy and cardiovascular disease. Int J Impot Res 2022; 34:685-690. [PMID: 34999717 DOI: 10.1038/s41443-021-00516-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 01/23/2023]
Abstract
The use of testosterone therapy has a complex history of apprehension and questions regarding its safety. Despite an eventual consensus that testosterone therapy was safe and effective, several studies relating to cardiovascular risks emerged in the last decade, rekindling skepticism regarding the safety of testosterone therapy. Given the utility of testosterone therapy in treating the symptoms of hypogonadism, it remains crucial to closely examine the safety of testosterone therapy. The present article synthesizes the current evidence regarding cardiovascular risks that may be associated with testosterone therapy, the potential mechanisms regarding testosterone's efficacy, and future directions in evaluating the safety of its use.
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19
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Fallara G, Pozzi E, Corsini C, Belladelli F, Boeri L, Capogrosso P, Montorsi F, Salonia A. Morbidity and mortality in men: Role of androgens. Best Pract Res Clin Endocrinol Metab 2022; 36:101662. [PMID: 35484028 DOI: 10.1016/j.beem.2022.101662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In this narrative review we provide an overview of the current literature on male hypogonadism and related comorbidities, also depicting the role of testosterone therapy (TTh) in the various settings. Male hypogonadism has been associated with major comorbidities such as type 2 diabetes mellitus, obesity and cardiovascular diseases, promoting a vicious cycle that may lead to further hypogonadism. The biological underpinnings of this association are currently under investigations, but clearly emerges the relevance of the hypothalamic-pituitary-gonadal axis. Hypogonadism has also been associated with increased risk of mortality. As such, TTh has the potential to oppose these patterns and improve cardiovascular and metabolic health in hypogonadal men. Clinical and observational data suggest that in males with hypogonadism, TTh, together with lifestyle changes and diabetes medications, may improve glycemia, reduce risk of progression to diabetes and provides positive effects on cardiovascular risk. Conversely, available data does not fully support any increased risk of prostate cancer in men under TTh. Of clinical relevance, a possible harmful role of hypogonadal status in men with COVID-19 eventually emerged.
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Affiliation(s)
- Giuseppe Fallara
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy.
| | - Edoardo Pozzi
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy.
| | - Christian Corsini
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy.
| | - Federico Belladelli
- 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.
| | - Francesco Montorsi
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy.
| | - Andrea Salonia
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy.
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20
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Di Lodovico E, Facondo P, Delbarba A, Pezzaioli LC, Maffezzoni F, Cappelli C, Ferlin A. Testosterone, Hypogonadism, and Heart Failure. Circ Heart Fail 2022; 15:e008755. [PMID: 35392658 DOI: 10.1161/circheartfailure.121.008755] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Male hypogonadism is defined as low circulating testosterone level associated with signs and symptoms of testosterone deficiency. Although the bidirectional link between hypogonadism and cardiovascular disease has been clarified, the association between testosterone and chronic heart failure (HF) is more controversial. Herein, we critically review published studies relating to testosterone, hypogonadism, and HF and provide practical clinical information on proper diagnosis and treatment of male hypogonadism in patients with HF. In general, published studies are extremely heterogeneous, frequently have not adhered to hypogonadism guidelines, and suffer from many intrinsic methodological inaccuracies; therefore, data provide only low-quality evidence. Nevertheless, by selecting the few methodologically robust studies, we show the prevalence of testosterone deficiency (30%-50%) and symptomatic hypogonadism (15%) in men with HF is significant. Low testosterone correlates with HF severity, New York Heart Association class, exercise functional capacity, and a worse clinical prognosis and mortality. Interventional studies on testosterone treatment in men with HF are inconclusive but do suggest beneficial effects on exercise capacity, New York Heart Association class, metabolic health, and cardiac prognosis. We suggest that clinicians should measure testosterone levels in men with HF who have symptoms of a testosterone deficiency and conditions that predispose to hypogonadism, such as obesity and diabetes. These patients-if diagnosed as hypogonadal-may benefit from the short- and long-term effects of testosterone replacement therapy, which include improvements in both cardiac prognosis and systemic outcomes. Further collaborative studies involving both cardiologists and endocrinologists are warranted.
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Affiliation(s)
- Elena Di Lodovico
- Department of Clinical and Experimental Sciences, University of Brescia, Italy (E.D.L., P.F., L.C.P., C.C., A.F.)
| | - Paolo Facondo
- Department of Clinical and Experimental Sciences, University of Brescia, Italy (E.D.L., P.F., L.C.P., C.C., A.F.)
| | - Andrea Delbarba
- Unit of Endocrinology and Metabolism, ASST Spedali Civili, Brescia, Italy (A.D., F.M., C.C., A.F.)
| | - Letizia Chiara Pezzaioli
- Department of Clinical and Experimental Sciences, University of Brescia, Italy (E.D.L., P.F., L.C.P., C.C., A.F.)
| | - Filippo Maffezzoni
- Unit of Endocrinology and Metabolism, ASST Spedali Civili, Brescia, Italy (A.D., F.M., C.C., A.F.)
| | - Carlo Cappelli
- Department of Clinical and Experimental Sciences, University of Brescia, Italy (E.D.L., P.F., L.C.P., C.C., A.F.).,Unit of Endocrinology and Metabolism, ASST Spedali Civili, Brescia, Italy (A.D., F.M., C.C., A.F.)
| | - Alberto Ferlin
- Department of Clinical and Experimental Sciences, University of Brescia, Italy (E.D.L., P.F., L.C.P., C.C., A.F.).,Unit of Endocrinology and Metabolism, ASST Spedali Civili, Brescia, Italy (A.D., F.M., C.C., A.F.).,Now with Department of Medicine, Unit of Andrology and Reproductive Medicine, University of Padova, Italy (A.F.)
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21
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Falqueto H, dos Santos MR, Manfredi LH. Anabolic-Androgenic Steroids and Exercise Training: Breaking the Myths and Dealing With Better Outcome in Sarcopenia. Front Physiol 2022; 13:838526. [PMID: 35370776 PMCID: PMC8969048 DOI: 10.3389/fphys.2022.838526] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/21/2022] [Indexed: 11/13/2022] Open
Abstract
Sarcopenia is an emerging clinical condition determined by the reduction in physical function and muscle mass, being a health concern since it impairs quality of life and survival. Exercise training is a well-known approach to improve physical capacities and body composition, hence managing sarcopenia progression and worsening. However, it may be an ineffective treatment for many elderly with exercise-intolerant conditions. Thus, the use of anabolic-androgenic steroids (AAS) may be a plausible strategy, since these drugs can increase physical function and muscle mass. The decision to initiate AAS treatment should be guided by an evidence-based patient-centric perspective, once the balance between risks and benefits may change depending on the clinical condition coexisting with sarcopenia. This mini-review points out a critical appraisal of evidence and limitation of exercise training and AAS to treat sarcopenia.
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Affiliation(s)
- Hugo Falqueto
- Medical School, Federal University of Fronteira Sul, Chapecó, Brazil
- Graduate Program in Biomedical Sciences, UFFS, Chapecó, Brazil
| | | | - Leandro H. Manfredi
- Medical School, Federal University of Fronteira Sul, Chapecó, Brazil
- Graduate Program in Biomedical Sciences, UFFS, Chapecó, Brazil
- *Correspondence: Leandro H. Manfredi,
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22
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Zornitzki T, Tshori S, Shefer G, Mingelgrin S, Levy C, Knobler H. Seasonal Variation of Testosterone Levels in a Large Cohort of Men. Int J Endocrinol 2022; 2022:6093092. [PMID: 35782408 PMCID: PMC9242810 DOI: 10.1155/2022/6093092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/02/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The aim of the study was to evaluate in a large cohort of males with a wide range of age, metabolic status, and coexistent morbidities whether month of blood test performance was associated with total and bioavailable testosterone levels independent of age, body mass index (BMI), existing cardiovascular disease (CVD), and CVD risk factors. METHODS Cross-sectional study includes data from computerized medical records of 27,328 men aged 20-70, treated by the largest healthcare organization in Israel, who had undergone testosterone measurement. In 7,940 subjects with available sex-hormone-binding globulin levels, bioavailable testosterone was calculated. RESULTS Total and bioavailable testosterone levels gradually decreased with age and BMI (P < 0.001) and were significantly lower in men with diabetes, hypertension, hyperlipidemia, and known CVD, but were higher in current smokers compared with nonsmokers (P < 0.001). Hormone levels were highest in August-October declined after and lowest in March. Overall, both total and bioavailable testosterone levels were significantly lower in March compared to August-October (P < 0.001). In a linear regression analysis, age, BMI, current smoking, and month of testing were independently associated with total (P < 0.001) and bioavailable testosterone levels (P=0.002), and diabetes was associated with total testosterone (P < 0.001). CONCLUSION In a large cohort of men with a wide range of age, BMI, and comorbidities, month of testing was independently associated with total and bioavailable testosterone levels. These data provide strong evidence that seasonal variation has to be considered in clinical practice.
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Affiliation(s)
- Taiba Zornitzki
- Diabetes, Endocrinology and Metabolic Disease Institute, Kaplan Medical Center, Rehovot, Israel
- Hebrew University, The Faculty of Medicine, Jerusalem, Israel
| | - Sagi Tshori
- Hebrew University, The Faculty of Medicine, Jerusalem, Israel
- Research Authority, Kaplan Medical Center, Rehovot, Israel
| | - Galit Shefer
- Hebrew University, The Faculty of Medicine, Jerusalem, Israel
- Research Authority, Kaplan Medical Center, Rehovot, Israel
| | - Shira Mingelgrin
- Hebrew University, The Faculty of Medicine, Jerusalem, Israel
- Research Authority, Kaplan Medical Center, Rehovot, Israel
| | - Carmit Levy
- Department of Human Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hilla Knobler
- Diabetes, Endocrinology and Metabolic Disease Institute, Kaplan Medical Center, Rehovot, Israel
- Hebrew University, The Faculty of Medicine, Jerusalem, Israel
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23
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Zeng B, Qiu S, Xiong X, Su X, Zhang Z, Wei Q, Yang L. The effect of different administrations of testosterone therapy on adverse prostate events: A Bayesian network meta-analysis. Front Endocrinol (Lausanne) 2022; 13:1009900. [PMID: 36419763 PMCID: PMC9678341 DOI: 10.3389/fendo.2022.1009900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Hypogonadism has become a major cause endangering men's health and quality of life all over the world. Testosterone Therapy (TT) is a widely accepted treatment for relieving hypogonadal symptoms. However, the effect of different administrations of TT on prostate safety is still unclear. METHODS We did a thorough search of PubMed, Embase and Cochrane Library to identify eligible studies up to January 2022. Randomized controlled trials (RCTs) and Cohort studies evaluating the impacts of using different formulations of TT on prostate parameters were included. Changes of prostate-specific antigen (PSA) level and prostate cancer (Pca) cases were used as the primary outcomes. Quality of individual studies was estimated by RoB2 (Cochrane tool for assessing the risk of bias in randomized trials) and the Newcastle-Ottawa scale (Tool for assessing non-RCTs). Certainty of evidence for each study was evaluated according to the evidence assessment criteria of the Oxford Evidence-based Medicine Center. Random-effect network meta-analysis(NMA)was performed based on the Bayesian model. RESULTS Thirty-five studies (30 RCTs and 5 Cohort studies) with 7,740 participants were included. TT administration led to fewer Pca patients (RR=0.62, 95%CI [0.39,0.99], I2=0%), while little decreasing in PSA level (MD=-0.05, 95%CI [-0.08, -0.02], I2=0%). The NMA revealed that compared with other formulations, the intramuscular injection was the most likely to rank first in decreasing Pca cases. The TT also resulted in more biopsy cases (RR=2.38, 95%CI [1.01,5.60], I2=0%). As for NMA, intramuscular injection also performed relatively better in fewer prostate biopsy cases compared with transdermal group. CONCLUSION TT does not lead to abnormal PSA changes and increased risk of Pca in patients with hypogonadism or low testosterone level. Compared with other preparations of TT, intramuscular injection proved better in minimizing Pca cases and was more likely to result in fewer prostate biopsy cases.
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Affiliation(s)
- Bin Zeng
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Shi Qiu
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
- Center of Biomedical Big Data, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xingyu Xiong
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Xingyang Su
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Zilong Zhang
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Qiang Wei
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Qiang Wei, ; Lu Yang,
| | - Lu Yang
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Qiang Wei, ; Lu Yang,
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24
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The Effect of Testosterone on Cardiovascular Disease and Cardiovascular Risk Factors in Men: A Review of Clinical and Preclinical Data. CJC Open 2021; 3:1238-1248. [PMID: 34888506 PMCID: PMC8636244 DOI: 10.1016/j.cjco.2021.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/09/2021] [Indexed: 11/20/2022] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of death worldwide. The effects of testosterone, the primary male sex hormone, on cardiovascular risk have been of special interest due to the increased risk of CVD in men. Although it is well established that testosterone levels decline and cardiovascular mortality increases with age, the association between testosterone and CVD remains unclear. Observational and randomized studies on the effects of endogenous and exogenous testosterone have produced conflicting data, and meta-analyses have been inconclusive, suggesting significant study heterogeneity. Despite a lack of adequately powered randomized controlled trials, large observational studies in the early 2010s led to advisories on the use of testosterone replacement therapy. Similar advisories have been mandated for certain types of androgen deprivation therapy. Additional research suggests that testosterone shortens the heart-rate-corrected QT interval, improves glycemic control, induces vasodilation, is prothrombotic, and has anti-obesity effects, whereas associations with atherosclerosis and inflammation are less clear. Despite inconclusive evidence on cardiovascular risk and inconsistencies among clinical practice guidelines, millions of men continue to use testosterone replacement and androgen deprivation therapy. In addition to summarizing clinical and preclinical data, this review provides insight on potential mechanisms of action of testosterone on CVD, applications of this knowledge to clinical settings, and avenues for future research.
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25
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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.
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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
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26
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Al-Qudimat A, Al-Zoubi RM, Yassin AA, Alwani M, Aboumarzouk OM, AlRumaihi K, Talib R, Al Ansari A. Testosterone treatment improves liver function and reduces cardiovascular risk: A long-term prospective study. Arab J Urol 2021; 19:376-386. [PMID: 34552789 PMCID: PMC8451678 DOI: 10.1080/2090598x.2021.1959261] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objectives: To report the association between testosterone treatment in hypogonadal men with hepatic steatosis, non-alcoholic fatty liver disease and cardiovascular disease (CVD). Methods: A prospective study was conducted to assess the physiological and functional performance of the long-term effects of testosterone undecanoate treatment on hepatic steatosis in 496 hypogonadal men. Two groups were studied, the treatment group (T-group) of 312 patients treated with TU 1000 mg every 12 weeks and followed for 8 years, and an untreated control group (C-group) of 184 patients. We evaluated liver functions and Fatty Liver Index (FLI) according to Mayo Clinic parameters and guidelines. Results: The T-group showed a decrease in the FLI (from a mean [SD] of 83.70 [12.15] to 67.12 [19.21]), bilirubin (from a mean [SD] of 1.69 [4.21] to 1.31 [1.91] mg/dL), triglycerides (from a mean [SD] of 254.87 [92.99] to 213.37 [66.91] mg/dL), and gamma-glutamyl-transferase (from a mean [SD] of 39.45 [11.51] to 29.11 [7.68] U/L) over the duration of the study. Other parameters were also reduced in the T-group such as body mass index (from a mean [SD] of 31.59 [4.51] to 29.50 [3.84] kg/m2) and waist circumference (from a mean [SD] of 107.51 [9.95] to 101.86 [9.28] cm). A total of 25 deaths (7.8%) were recorded in the T-group, among them, 11 (44%) were related to CVD. While in the C-group 28 deaths (15.2%) were recorded and all the reported deaths (100%) were related to CVD. Conclusions: The findings suggest that long-term testosterone therapy in hypogonadal men improves liver function. While, the physiological and functional improvements in the liver may be associated with a decrease in CVD-related mortality. Abbreviations ALT: alanine transaminase; AR: androgen receptor; AST: aspartate transaminase; BMI: body mass index; CVD: cardiovascular disease; FLI: Fatty Liver Index; γ-GT: gamma-glutamyl-transferase; MetS: metabolic syndrome; LDL: low-density lipoprotein; NAFLD: non-alcoholic fatty liver disease; RCT: randomised controlled trial; T2DM: type II diabetes mellitus; TT: total testosterone; TTh: testosterone therapy; TU: testosterone undecanoate; WC: waist circumference
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Affiliation(s)
- Ahmad Al-Qudimat
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Raed M Al-Zoubi
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha, Qatar.,Department of Chemistry, Jordan University of Science and Technology, Irbid, Jordan
| | - Aksam A Yassin
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha, Qatar.,Department of Surgery, Division of Urology/Andrology, Hamad Medical Corporation, Doha, Qatar.,Center of Medicine and Health Sciences, Dresden International University, Dresden, Germany
| | - Mustafa Alwani
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha, Qatar.,School of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Omar M Aboumarzouk
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Khaled AlRumaihi
- Department of Surgery, Division of Urology/Andrology, Hamad Medical Corporation, Doha, Qatar
| | - Raidh Talib
- Department of Surgery, Division of Urology/Andrology, Hamad Medical Corporation, Doha, Qatar
| | - Abdulla Al Ansari
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha, Qatar
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27
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Shores MM, Walsh TJ, Korpak A, Krakauer C, Forsberg CW, Fox AE, Moore KP, Heckbert SR, Thompson ML, Smith NL, Matsumoto AM. Association Between Testosterone Treatment and Risk of Incident Cardiovascular Events Among US Male Veterans With Low Testosterone Levels and Multiple Medical Comorbidities. J Am Heart Assoc 2021; 10:e020562. [PMID: 34423650 PMCID: PMC8649267 DOI: 10.1161/jaha.120.020562] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background Testosterone treatment is common in men, although risks for major cardiovascular events are unclear. Methods and Results A study was conducted in US male veterans, aged ≥40 years, with low serum testosterone and multiple medical comorbidities and without history of myocardial infarction, stroke, venous thromboembolism, prostate cancer, or testosterone treatment in the prior year. For the primary outcome, we examined if testosterone treatment was associated with a composite cardiovascular outcome (incident myocardial infarction, ischemic stroke, or venous thromboembolism). Testosterone use was modeled as intramuscular or transdermal and as current use, former use, and no use. Current testosterone users were compared with former users to reduce confounding by indication. The cohort consisted of 204 857 men with a mean (SD) age of 60.9 (9.9) years and 4.7 (3.5) chronic medical conditions. During follow‐up of 4.3 (2.8) years, 12 645 composite cardiovascular events occurred. In adjusted Cox regression analyses, current use of transdermal testosterone was not associated with risk for the composite cardiovascular outcome (hazard ratio [HR], 0.89; 95% CI, 0.76–1.05) in those without prevalent cardiovascular disease, and in those with prevalent cardiovascular disease was associated with lower risk (HR, 0.80; 95% CI, 0.70–0.91). In similar analyses, current use of intramuscular testosterone was not associated with risk for the composite cardiovascular outcome in men without or with prevalent cardiovascular disease (HR, 0.91; 95% CI, 0.80–1.04; HR, 0.98; 95% CI, 0.89–1.09, respectively). Conclusions In a large cohort of men without a history of myocardial infarction, stroke, or venous thromboembolism, testosterone treatment was not associated with increased risk for incident composite cardiovascular events.
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Affiliation(s)
- Molly M Shores
- Department of Psychiatry and Behavioral Sciences University of Washington Seattle WA.,VA Puget Sound Health Care System (VAPSHCS) Seattle WA
| | - Thomas J Walsh
- Department of Urology University of Washington Seattle WA
| | - Anna Korpak
- VA Puget Sound Health Care System (VAPSHCS) Seattle WA.,Seattle Epidemiologic Research and Information Center (ERIC) VAPSHCS Seattle WA
| | - Chloe Krakauer
- Kaiser Permanente Washington Health Research Institute Seattle WA
| | - Christopher W Forsberg
- VA Puget Sound Health Care System (VAPSHCS) Seattle WA.,Seattle Epidemiologic Research and Information Center (ERIC) VAPSHCS Seattle WA
| | - Alexandra E Fox
- VA Puget Sound Health Care System (VAPSHCS) Seattle WA.,Seattle Epidemiologic Research and Information Center (ERIC) VAPSHCS Seattle WA
| | - Kathryn P Moore
- VA Puget Sound Health Care System (VAPSHCS) Seattle WA.,Seattle Epidemiologic Research and Information Center (ERIC) VAPSHCS Seattle WA
| | - Susan R Heckbert
- Kaiser Permanente Washington Health Research Institute Seattle WA.,Department of Epidemiology University of Washington Seattle WA
| | - Mary Lou Thompson
- Seattle Epidemiologic Research and Information Center (ERIC) VAPSHCS Seattle WA.,Kaiser Permanente Washington Health Research Institute Seattle WA.,Department of Biostatistics University of Washington Seattle WA
| | - Nicholas L Smith
- VA Puget Sound Health Care System (VAPSHCS) Seattle WA.,Seattle Epidemiologic Research and Information Center (ERIC) VAPSHCS Seattle WA.,Kaiser Permanente Washington Health Research Institute Seattle WA.,Department of Epidemiology University of Washington Seattle WA
| | - Alvin M Matsumoto
- VA Puget Sound Health Care System (VAPSHCS) Seattle WA.,Department of Medicine University of Washington School of Medicine Seattle WA.,Geriatric Research Education and Clinical Center (GRECC) VAPSHCS Seattle WA
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28
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Lee JH, Shah PH, Uma D, Salvi DJ, Rabbani R, Hamid P. Testosterone Replacement Therapy in Hypogonadal Men and Myocardial Infarction Risk: Systematic Review & Meta-Analysis. Cureus 2021; 13:e17475. [PMID: 34513525 PMCID: PMC8405174 DOI: 10.7759/cureus.17475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/26/2021] [Indexed: 01/23/2023] Open
Abstract
Testosterone replacement therapy (TRT) has become increasingly popular over the years and there has been an increasing debate on whether testosterone replacement should be offered to older men due to its association with cardiovascular events. In this study, we evaluated the risk of myocardial infarction (MI) associated with TRT in hypogonadal men through a meta-analysis. We carried out the analysis by following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines and conducted a literature search utilizing the following databases: Google Scholar, PubMed, Science Direct, Cochrane Library trials, and ClinicalTrials.gov. The search strategy resulted in a total of 782 articles, after applying our inclusion and exclusion criteria. Six observational studies and two randomized controlled trials (RCTs) were included for the analysis. A total of 55,806 hypogonadal men with baseline testosterone levels <300ng/mL were included in the analysis. The intervention group received testosterone in various routes including transdermal patches, gels, mouth patches, testosterone injections, and deposits. The incidence of MI was taken to be the primary measure outcomes. The pooled data from eight studies showed MI incidence in 249 out of 11,720 (2.1%) in the TRT group and 1420 out of 33,086 (4.3%) in the control group. The pooled OD showed no statistically significant association of TRT and MI compared to the control group (OR = 0.76, 95% CI 0.36-1.31; p=0.48). The model revealed high heterogeneity with I2 =79%. With sensitivity analysis and, excluding two studies out of the eight, the pooled data was able to achieve low heterogeneity with I2 = 0%. The newly pooled data from six studies showed MI incidence in 226 out of 10,137 (2.2%) in the TRT group and 969 out of 36,304 (2.7%) in the control group. The pooled OD shows no statistical significance in the association between TRT treatment and MI compared to the control group. (OR =0.87, 95% CI 0.75-1.01; P =0.08). It appears that TRT does not increase the risk of MI as compared to the non-intervention group. Further RCTs with greater population size are needed that could produce more solid results, allowing more definitive conclusions to be made on this topic.
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Affiliation(s)
- Jun Hee Lee
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Prutha H Shah
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Davuluri Uma
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Dhairya J Salvi
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Rizwan Rabbani
- Nephrology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Pousette Hamid
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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29
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Cittadini A, Isidori AM, Salzano A. Testosterone therapy and cardiovascular diseases. Cardiovasc Res 2021; 118:2039-2057. [PMID: 34293112 DOI: 10.1093/cvr/cvab241] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/16/2021] [Indexed: 11/14/2022] Open
Abstract
Since it was first synthesised in 1935, testosterone (T) has been viewed as the mythical Fountain of Youth, promising rejuvenation, restoring sexual appetites, growing stronger muscles, and quicker thinking. T is endowed with direct effects on myocardial and vascular structure and function, as well as on risk factors for cardiovascular (CV) disease. Indeed, low serum T levels are a risk factor for diabetes, metabolic syndrome, inflammation, and dyslipidaemia. Moreover, many studies have shown that T deficiency per se is an independent risk factor of CV and all-cause mortality. On this background and due to direct-to-patient marketing by drug companies, we have witnessed to the widespread use of T replacement therapy (TT) without clear indications particularly in late-life onset hypogonadism. The current review will dwell upon current evidence and controversies surrounding the role of T in the pathophysiology of CV diseases, the link between circulating T levels and CV risk, and the use of replacing T as a possible adjuvant treatment in specific CV disorders. Specifically, recent findings suggest that heart failure and type 2 diabetes mellitus represent two potential targets of T therapy once that a state of hypogonadism is diagnosed. However, only if ongoing studies solve the CV safety issue the T orchid may eventually 'bloom'.
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Affiliation(s)
- Antonio Cittadini
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Interdisciplinary Research Centre on Biomaterials (CRIB), Federico II University, Naples, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea Salzano
- IRCCS SDN, Diagnostic and Nuclear Research Institute, Naples, Italy
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30
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Abstract
Androgens are potent drugs requiring prescription for valid medical indications but are misused for invalid, unproven, or off-label reasons as well as being abused without prescription for illicit nonmedical application for performance or image enhancement. Following discovery and first clinical application of testosterone in the 1930s, commercialization of testosterone and synthetic androgens proliferated in the decades after World War II. It remains among the oldest marketed drugs in therapeutic use, yet after 8 decades of clinical use, the sole unequivocal indication for testosterone remains in replacement therapy for pathological hypogonadism, organic disorders of the male reproductive system. Nevertheless, wider claims assert unproven, unsafe, or implausible benefits for testosterone, mostly representing wishful thinking about rejuvenation. Over recent decades, this created an epidemic of testosterone misuse involving prescription as a revitalizing tonic for anti-aging, sexual dysfunction and/or obesity, where efficacy and safety remains unproven and doubtful. Androgen abuse originated during the Cold War as an epidemic of androgen doping among elite athletes for performance enhancement before the 1980s when it crossed over into the general community to become an endemic variant of drug abuse in sufficiently affluent communities that support an illicit drug industry geared to bodybuilding and aiming to create a hypermasculine body physique and image. This review focuses on the misuse of testosterone, defined as prescribing without valid clinical indications, and abuse of testosterone or synthetic androgens (androgen abuse), defined as the illicit use of androgens without prescription or valid indications, typically by athletes, bodybuilders and others for image-oriented, cosmetic, or occupational reasons.
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Affiliation(s)
- David J Handelsman
- ANZAC Research Institute, University of Sydney, Sydney, Australia.,Andrology Department, Concord Hospital, Sydney, Australia
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31
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Burte C, Lejeune H, Faix A, Desvaux P, Almont T, Cuzin B, Huyghe E. [Practical recommendations for the management of testosterone deficiency]. Prog Urol 2021; 31:458-476. [PMID: 34034926 DOI: 10.1016/j.purol.2020.09.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/16/2020] [Accepted: 09/20/2020] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- C Burte
- Cabinet de médecine sexuelle, 4, rue des États-Unis, Cannes, France
| | - H Lejeune
- Service de médecine de la reproduction, hôpital Femme-Mère-Enfant, HCL, Bron, France
| | - A Faix
- Cabinet d'urologie, 265, avenue des États-du-Languedoc, Montpellier, France
| | - P Desvaux
- Cabinet de médecine sexuelle, 11, rue Magellan, 75008 Paris, France
| | - T Almont
- Service d'oncologie, CHU de Martinique, Fort-de-France, Martinique
| | - B Cuzin
- Service d'urologie, chirurgie de la transplantation, hôpital Édouard-Herriot, CHU de Lyon, France
| | - E Huyghe
- Médecine de la reproduction, CHU de Toulouse, site de Paule-de-Viguier, Toulouse, France; Département d'urologie, transplantation rénale et andrologie, hôpital Rangueil, CHU de Toulouse, France.
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32
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Abstract
: Sexual health is an integral part of overall health, and an active and healthy sexual life is an essential aspect of a good life quality. Cardiovascular disease and sexual health share common risk factors (arterial hypertension, diabetes mellitus, dyslipidemia, obesity, and smoking) and common mediating mechanisms (endothelial dysfunction, subclinical inflammation, and atherosclerosis). This generated a shift of thinking about the pathophysiology and subsequently the management of sexual dysfunction. The introduction of phosphodiesterase type 5 inhibitors revolutionized the management of sexual dysfunction in men. This article will focus on erectile dysfunction and its association with arterial hypertension. This update of the position paper was created by the Working Group on Sexual Dysfunction and Arterial Hypertension of the European Society of Hypertension. This working group has been very active during the last years in promoting the familiarization of hypertension specialists and related physicians with erectile dysfunction, through numerous lectures in national and international meetings, a position paper, newsletters, guidelines, and a book specifically addressing erectile dysfunction in hypertensive patients. It was noted that erectile dysfunction precedes the development of coronary artery disease. The artery size hypothesis has been proposed as a potential explanation for this observation. This hypothesis seeks to explain the differing manifestation of the same vascular condition, based on the size of the vessels. Clinical presentations of the atherosclerotic and/or endothelium disease in the penile arteries might precede the corresponding manifestations from larger arteries. Treated hypertensive patients are more likely to have sexual dysfunction compared with untreated ones, suggesting a detrimental role of antihypertensive treatment on erectile function. The occurrence of erectile dysfunction seems to be related to undesirable effects of antihypertensive drugs on the penile tissue. Available information points toward divergent effects of antihypertensive drugs on erectile function, with diuretics and beta-blockers possessing the worst profile and angiotensin receptor blockers and nebivolol the best profile.
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Perioperative Transgender Hormone Management: Avoiding Venous Thromboembolism and Other Complications. Plast Reconstr Surg 2021; 147:1008-1017. [DOI: 10.1097/prs.0000000000007786] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Yeap BB, Dwivedi G. Androgens and Heart Failure: New Observations Illuminating an Aging Conundrum. J Clin Endocrinol Metab 2021; 106:e1476-e1478. [PMID: 32960971 DOI: 10.1210/clinem/dgaa676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/18/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Bu B Yeap
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Girish Dwivedi
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
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Testosterone stimulates cholesterol clearance from human macrophages by activating LXRα. Life Sci 2021; 269:119040. [PMID: 33453241 DOI: 10.1016/j.lfs.2021.119040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/05/2021] [Accepted: 01/05/2021] [Indexed: 01/04/2023]
Abstract
AIMS Low testosterone in men is associated with increased cardiovascular events and mortality. Testosterone has beneficial effects on several cardiovascular risk factors including cholesterol, endothelial dysfunction and inflammation as key mediators of atherosclerosis. Although evidence suggests testosterone is anti-atherogenic, its mechanism of action is unknown. The present study investigates whether testosterone exerts anti-atherogenic effects by stimulating cholesterol clearance from macrophages via activation of liver X receptor (LXRα), a nuclear master regulator of cellular cholesterol homeostasis, lipid regulation, and inflammation. MAIN METHODS Using human monocyte THP-1 cells differentiated into macrophages, the effect of testosterone (1-10 nM) treatment (24-72 h) on the expression of LXRα and LXR- targets apolipoprotein E (APOE), ATP-binding cassette transporter A1 (ABCA1), sterol regulatory element-binding transcription factor 1 (SREBF1) and fatty acid synthase (FAS), was investigated via qPCR and western blotting, with or without androgen receptor blockade with flutamide or LXR antagonism with CPPSS-50. Cholesterol clearance was measured by monitoring fluorescent dehydroergosterol (DHE) cellular clearance and ABCA1 cellular translocation was observed via immunocytochemistry in testosterone treated macrophages. KEY FINDINGS Testosterone increased mRNA and protein expression of LXRα, APOE, ABCA1, SREBF1 and FAS. These effects were blocked by flutamide and independently by LXR antagonism with CPPSS-50. Furthermore testosterone stimulated cholesterol clearance from the macrophages and promoted the translocation of ABCA1 toward the cell membrane. SIGNIFICANCE Testosterone acts via androgen receptor-dependent pathways to stimulate LXRα and downstream targets to induce cholesterol clearance in human macrophages. This may, in part, explain the anti-atherogenic effects of testosterone frequently seen clinically.
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Khera M, Miner M, Jaffe J, Pastuszak AW. Testosterone Therapy and Cardiovascular Risk: A Critical Analysis of Studies Reporting Increased Risk. J Sex Med 2020; 18:83-98. [PMID: 33317996 DOI: 10.1016/j.jsxm.2020.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 10/05/2020] [Accepted: 10/26/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Treatment of "adult-onset hypogonadism" (AOH) with exogenous testosterone therapy (TTh) to raise serum testosterone (T) levels may influence cardiovascular (CV) risk factors in patients with AOH, whereas low endogenous T levels are associated with an increased CV risk and mortality. AIM To critically evaluate studies reporting increased CV risk associated with TTh and to provide an overview of the risks and benefits of restoring T levels through exogenous TTh. METHODS A review of publications focusing on the association between TTh and increased CV risk was conducted, and the study methodologies and conclusions of each were critically evaluated. Further, recent clinical and epidemiological studies associating AOH or TTh with a change in CV risk, and pertinent hematologic and vascular effects noted in animal studies and in vitro, as well as in clinical practice were also reviewed. OUTCOMES A review of the literature shows that untreated testosterone deficiency and/or low T is associated with an increase in CV risk and adverse outcomes, with numerous studies and meta-analyses to support a positive association between exogenous TTh and an improvement in CV risk factors in men with AOH. RESULTS Numerous studies in the literature demonstrate the positive benefits of using TTh; however, since 2013, some publications have suggested a link to increased CV risk associated with TTh. A number of these studies retrospectively analyzed insurance claims databases using diagnosis codes, procedures codes, and prescription information. Many reviews published since have pointed out the methodological flaws and debatable conclusions of these studies. CLINICAL IMPLICATIONS A careful assessment of the patient's current health status and CV risk factors should be weighed against the benefits and possible risks resulting from TTh, and consideration should be given to deferring treatment pending resolution or stabilization of CV disease or risk factors. STRENGTHS & LIMITATIONS In this review, we provide an in-depth analysis of studies reporting increased CV risk with TTh. Many of the studies were not well-designed, randomized, double-blind, prospective clinical trials but rather post hoc analyses of cohort data. These studies may reflect bias in how treatment and nontreatment decisions are made or reflect conclusions based on widely cited methodological flaws. CONCLUSION Appropriate patient selection supported by low pre-treatment T levels and monitoring T levels during treatment with the goal of achieving and maintaining physiologic levels all contribute to the safe and effective use of TTh in men with AOH. Khera M, Miner M, Jaffe J, et al. Testosterone Therapy and Cardiovascular Risk: A Critical Analysis of Studies Reporting Increased Risk. J Sex med 2021;18:83-98.
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Affiliation(s)
- Mohit Khera
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.
| | - Martin Miner
- Clinical Professor of Family Medicine and Urology, Brown University, Providence, RI, USA
| | | | - Alexander W Pastuszak
- Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
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Yassin AA, Alwani M, Talib R, Almehmadi Y, Nettleship JE, Alrumaihi K, Albaba B, Kelly DM, Saad F. Long-term testosterone therapy improves liver parameters and steatosis in hypogonadal men: a prospective controlled registry study. Aging Male 2020; 23:1553-1563. [PMID: 33439074 DOI: 10.1080/13685538.2020.1867094] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is associated with cardiovascular disease (CVD) and both are prevalent in men with testosterone deficiency. Long-term effects of testosterone therapy (TTh) on NAFLD are not well studied. This observational, prospective, cumulative registry study assesses long-term effects of testosterone undecanoate (TU) on hepatic physiology and function in 505 hypogonadal men (T levels ≤350 ng/dL). Three hundred and twenty one men received TU 1000 mg/12 weeks for up to 12 years following an initial 6-week interval (T-group), while 184 who opted against TTh served as controls (C-group). T-group patients exhibited decreased fatty liver index (FLI, calculated according to Mayo Clinic guidelines) (83.6 ± 12.08 to 66.91 ± 19.38), γ-GT (39.31 ± 11.62 to 28.95 ± 7.57 U/L), bilirubin (1.64 ± 4.13 to 1.21 ± 1.89 mg/dL) and triglycerides (252.35 ± 90.99 to 213 ± 65.91 mg/dL) over 12 years. Waist circumference and body mass index were also reduced in the T-group (107.17 ± 9.64 to 100.34 ± 9.03 cm and 31.51 ± 4.32 to 29.03 ± 3.77 kg/m2). There were 25 deaths (7.8%) in the T-group of which 11 (44%) were cardiovascular related. In contrast, 28 patients (15.2%) died in C-group, and all deaths (100%) were attributed to CVD. These data suggest that long-term TTh improves hepatic steatosis and liver function in hypogonadal men. Improvements in liver function may have contributed to reduced CVD-related mortality.
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Affiliation(s)
- Aksam A Yassin
- Department of Surgery, Division of Urology/Andrology & Men's Health, Hamad Medical Corporation, Doha, Qatar
- Weill Cornell Medical School (WCM-Q), Doha, Qatar
- Center of Medicine and Health Sciences, Dresden International University, Dresden, Germany
- Institute of Urology & Andrology, Andrology Program, Norderstedt, Germany
| | - Mustafa Alwani
- School of Medicine, University of Science and Technology Jordan, Irbid, Jordan
| | - Riadh Talib
- Department of Surgery, Division of Urology/Andrology & Men's Health, Hamad Medical Corporation, Doha, Qatar
- Weill Cornell Medical School (WCM-Q), Doha, Qatar
| | - Yousef Almehmadi
- Institute of Urology & Andrology, Andrology Program, Norderstedt, Germany
- Rabigh Medical College, King Abdulaziz University, Rabigh, Saudi Arabia
| | - Joanne E Nettleship
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, UK
| | - Khalid Alrumaihi
- Department of Surgery, Division of Urology/Andrology & Men's Health, Hamad Medical Corporation, Doha, Qatar
- Weill Cornell Medical School (WCM-Q), Doha, Qatar
- Center of Medicine and Health Sciences, Dresden International University, Dresden, Germany
| | - Bassam Albaba
- Center of Medicine and Health Sciences, Dresden International University, Dresden, Germany
| | - Daniel M Kelly
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, UK
- Biomolecular Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Farid Saad
- Center of Medicine and Health Sciences, Dresden International University, Dresden, Germany
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Kharaba ZJ, Buabeid MA, Ibrahim NA, Jirjees FJ, Obaidi HJA, Kaddaha A, Khajehkarimoddini L, Alfoteih Y. Testosterone therapy in hypogonadal patients and the associated risks of cardiovascular events. Biomed Pharmacother 2020; 129:110423. [PMID: 32570122 DOI: 10.1016/j.biopha.2020.110423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/06/2020] [Accepted: 06/13/2020] [Indexed: 10/24/2022] Open
Abstract
Since the male secondary sex characters, libido and fertility are attributed to their major androgen hormone testosterone, the sub-optimum levels of testosterone in young adults may cause infertility and irregularities in their sexual behaviour. Such deficiency is often secondary to maladies involving testes, pituitary or hypothalamus that could be treated with an administration of exogenous testosterone. In the last few decades, the number of testosterone prescriptions has markedly increased to treat sub-optimal serum levels even though its administration in such conditions is not yet approved. On account of its associated cardiovascular hazards, the food and drug authority in the United States has issued safety alerts on testosterone replacement therapy (TRT). Owing to a great degree of conflict among their findings, the published clinical trials seem struggling in presenting a decisive opinion on the matter. Hence, the clinicians remain uncertain about the possible cardiovascular adversities while prescribing TRT in hypogonadal men. The uncertainty escalates even further while prescribing such therapy in older men with a previous history of cardiovascular ailments. In the current review, we analysed the pre-clinical and clinical studies to evaluate the physiological impact of testosterone on cardiovascular and related parameters. We have enlisted studies on the association of cardiovascular health and endogenous testosterone levels with a comprehensive analysis of epidemiological studies, clinical trials, and meta-analyses on the cardiovascular risk of TRT. The review is aimed to assist clinicians in making smart decisions regarding TRT in their patients.
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Affiliation(s)
- Zelal Jaber Kharaba
- Department of Clinical Sciences, College of Pharmacy, Al-Ain University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Manal Ali Buabeid
- Department of Clinical Sciences, Ajman University, Ajman, 346, United Arab Emirates
| | - Nihal A Ibrahim
- Department of Clinical Sciences, Ajman University, Ajman, 346, United Arab Emirates
| | | | | | | | | | - Yassen Alfoteih
- City University College of Ajman, Ajman, 18484, United Arab Emirates.
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Abstract
In the early days of its use, testosterone therapy faced skepticism regarding its safety and efficacy. After a converging consensus that testosterone therapy was safe and effective for the treatment of hypogonadism, several recent studies showed adverse cardiovascular outcomes associated with testosterone treatment, ultimately resulting in a mandated FDA label warning about the unknown safety of testosterone therapy. Given the clear efficacy of testosterone therapy in the treatment of hypogonadism, establishing the safety of this therapeutic tool is essential. This article summarizes the current evidence regarding the cardiovascular safety of testosterone therapy for the management of hypogonadism, as well as the proposed mechanisms that may explain testosterone's underlying effects.
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Affiliation(s)
- Jeremy M Auerbach
- Department of Urology, Baylor College of Medicine , Houston, TX, USA
| | - Mohit Khera
- Department of Urology, Baylor College of Medicine , Houston, TX, USA
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Sesti F, Pofi R, Minnetti M, Tenuta M, Gianfrilli D, Isidori AM. Late-onset hypogonadism: Reductio ad absurdum of the cardiovascular risk-benefit of testosterone replacement therapy. Andrology 2020; 8:1614-1627. [PMID: 32737921 DOI: 10.1111/andr.12876] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Low testosterone (T) level is considered a marker of poor cardiovascular health. Ten years ago, the Testosterone in Older Men with Mobility Limitations (TOM) trial was discontinued due to a higher number of adverse events in men receiving T compared with placebo. Since then, several studies have investigated the risks of T replacement therapy (TRT) in late-onset hypogonadism (LOH). OBJECTIVE To review the mechanism by which TRT could damage the cardiovascular system. MATERIALS AND METHODS Comprehensive literature search of recent clinical and experimental studies. RESULTS The mechanisms of T-mediated coronary vasodilation were reviewed with emphasis on calcium-activated and ATP-sensitive potassium ion channels. We showed how T regulates endothelial nitric oxide synthase (eNOS) and phosphoinositide 3-kinase/protein kinase B/eNOS signaling pathways in vessel walls and its direct effects on cardiomyocytes via β1-adrenergic and ryanodine receptors and provided data on myocardial infarction and heart failure. Vascular smooth muscle senescence could be explained by the modulation of growth factors, matrix metalloproteinase-2, and angiotensin II by T. Furthermore, leukocyte trafficking, facilitated by changes in TNF-α, could explain some of the effects of T on atheromatous plaques. Conflicting data on prothrombotic risk linked to platelet aggregation inhibition via NO-triggered arachidonate synthesis or increased aggregability due to enhanced thromboxane A in human platelets provide evidence regarding the hypotheses on plaque maturation and rupture risk. The effects of T on cardiac electrophysiology and oxygen delivery were also reviewed. DISCUSSION The effects of TRT on the cardiovascular system are complex. Although molecular studies suggest a potential benefit, several clinical observations reveal neutral or occasionally detrimental effects, mostly due to confounding factors. CONCLUSIONS Attempts to demonstrate that TRT damages the cardiovascular system via systematic analysis of the putative mechanisms led to the contradiction of the initial hypothesis. Current evidence indicates that TRT is safe once other comorbidities are addressed.
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Affiliation(s)
- Franz Sesti
- Department of Experimental Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Riccardo Pofi
- Department of Experimental Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Marta Tenuta
- Department of Experimental Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, "Sapienza" University of Rome, Rome, Italy
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Kharaba ZJ, Buabeid MA, Alfoteih YA. Effectiveness of testosterone therapy in hypogonadal patients and its controversial adverse impact on the cardiovascular system. Crit Rev Toxicol 2020; 50:491-512. [PMID: 32689855 DOI: 10.1080/10408444.2020.1789944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Testosterone is the major male hormone produced by testicles which are directly associated with man's appearance and secondary sexual developments. Androgen deficiency starts when the male hormonal level falls from its normal range though, in youngsters, the deficiency occurs due to disruption of the normal functioning of pituitary, hypothalamus glands, and testes. Thus, testosterone replacement therapy was already known for the treatment of androgen deficiency with lesser risks of producing cardiovascular problems. Since from previous years, the treatment threshold in the form of testosterone replacement therapy has effectively increased to that extent that it was prescribed for those conditions which it was considered as inappropriate. However, there are some research studies and clinical trials available that proposed the higher risk of inducing cardiovascular disease with the use of testosterone replacement therapy. Thus under the light of these results, the FDA has published the report of the increased risk of cardiovascular disease with the increased use of testosterone replacement therapy. Nevertheless, there is not a single trial available or designed that could evaluate the risk of cardiovascular events with the use of testosterone replacement therapy. As a result, the use of testosterone still questioned the cardiovascular safety of this replacement therapy. Thus, this literature outlines the distribution pattern of disease by investigating the data and link between serum testosterone level and the cardiovascular disease, also the prescription data of testosterone replacement therapy patients and their tendency of inducing cardiovascular disease, meta-analysis and the trials regarding testosterone replacement therapy and its connection with the risks of causing cardiovascular disease and lastly, the possible effects of testosterone replacement therapy on the cardiovascular system. This study aims to evaluate the available evidence regarding the use of testosterone replacement therapy when choosing it as a treatment plan for their patients.
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Affiliation(s)
- Zelal Jaber Kharaba
- Department of Clinical Sciences, College of Pharmacy, Al-Ain University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Manal Ali Buabeid
- Department of Clinical Sciences, Ajman University, Ajman, United Arab Emirates
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Kirlangic OF, Yilmaz-Oral D, Kaya-Sezginer E, Toktanis G, Tezgelen AS, Sen E, Khanam A, Oztekin CV, Gur S. The Effects of Androgens on Cardiometabolic Syndrome: Current Therapeutic Concepts. Sex Med 2020; 8:132-155. [PMID: 32201216 PMCID: PMC7261691 DOI: 10.1016/j.esxm.2020.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 01/31/2020] [Accepted: 02/11/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Cardiometabolic syndrome (CMS), as a bunch of metabolic disorders mainly characterized by type 2 diabetes mellitus (T2DM), hypertension, atherosclerosis, central adiposity, and abdominal obesity triggering androgen deficiency, is one of the most critical threats to men. Although many significant preclinical and clinical findings explain CMS, new approaches toward common pathophysiological mechanisms and reasonable therapeutic targets are lacking. AIM To gain a further understanding of the role of androgen levels in various facets of CMS such as the constellation of cardiometabolic risk factors including central adiposity, dyslipidemia, insulin resistance, diabetes, and arterial hypertension and to define future directions for development of effective therapeutic modalities. METHODS Clinical and experimental data were searched through scientific literature databases (PubMed) from 2009 to October 2019. MAIN OUTCOME MEASURE Evidence from basic and clinical research was gathered with regard to the causal impact and therapeutic roles of androgens on CMS. RESULTS There are important mechanisms implicated in androgen levels and the risk of CMS. Low testosterone levels have many signs and symptoms on cardiometabolic and glycometabolic risks as well as abdominal obesity in men. CLINICAL IMPLICATIONS The implications of the findings can shed light on future improvements in androgen levels and add potentially predictive risk for CMS, as well as T2DM, abdominal obesity to guide clinical management in the early stage. STRENGTHS & LIMITATIONS This comprehensive review refers to the association between androgens and cardiovascular health. A limitation of this study is the lack of large, prospective population-based studies that analyze the effects of testosterone treatment on CMS or mortality. CONCLUSION Low testosterone levels have several common features with metabolic syndrome. Thus, testosterone may have preventive role in the progress of metabolic syndrome and subsequent T2DM, abdominal obesity, and cardiovascular disease and likely affect aging men's health mainly through endocrine and vascular mechanisms. Further studies are necessary to evaluate the therapeutic interventions directed at preventing CMS in men. Kirlangic OF, Yilmaz-Oral D, Kaya-Sezginer E, et al. The Effects of Androgens on Cardiometabolic Syndrome: Current Therapeutic Concepts. Sex Med 2020;8:132-155.
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Affiliation(s)
- Omer Faruk Kirlangic
- University of Health Sciences, Gulhane Faculty of Medicine, Department of Medical Biochemistry, Ankara, Turkey
| | - Didem Yilmaz-Oral
- Cukurova University, Faculty of Pharmacy, Department of Pharmacology, Adana, Turkey
| | - Ecem Kaya-Sezginer
- Ankara University, Faculty of Pharmacy, Department of Biochemistry, Ankara, Turkey
| | - Gamze Toktanis
- Ankara University, Faculty of Pharmacy, Department of Pharmacology, Ankara, Turkey
| | | | - Ekrem Sen
- Ankara University, Faculty of Pharmacy, Department of Pharmacology, Ankara, Turkey
| | - Armagan Khanam
- Ankara University, Faculty of Pharmacy, Department of Pharmacology, Ankara, Turkey
| | - Cetin Volkan Oztekin
- Department of Urology, Faculty of Medicine, University of Kyrenia, Girne, Turkish Republic of North Cyprus, Mersin 10, Turkey
| | - Serap Gur
- Ankara University, Faculty of Pharmacy, Department of Pharmacology, Ankara, Turkey.
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Collet TH, Ewing SK, Ensrud KE, Laughlin GA, Hoffman AR, Varosy PD, Stefanick ML, Stone KL, Orwoll E, Bauer DC. Endogenous Testosterone Levels and the Risk of Incident Cardiovascular Events in Elderly Men: The MrOS Prospective Study. J Endocr Soc 2020; 4:bvaa038. [PMID: 32337470 PMCID: PMC7173399 DOI: 10.1210/jendso/bvaa038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/22/2020] [Indexed: 12/11/2022] Open
Abstract
Context Observational studies show discordant links between endogenous testosterone levels and cardiovascular diseases (CVD). Objective We assessed whether sex hormones and sex hormone–binding globulin (SHBG) are associated with CVD in community-dwelling elderly men. Design, Setting and Participants Prospective study of incident CVD among 552 men ≥ 65 years in the MrOS Sleep Study without prevalent CVD and no testosterone therapy at baseline. Outcomes Fasting serum levels of total testosterone and estradiol were measured using liquid chromatography-mass spectrometry, and SHBG by chemiluminescent substrate. The association of sex hormones and SHBG with incident coronary heart disease (CHD), cerebrovascular (stroke and transient ischemic attack) and peripheral arterial disease (PAD) events were assessed by quartile and per SD increase in proportional hazards models. Results After 7.4 years, 137 men (24.8%) had at least 1 CVD event: 90 CHD, 45 cerebrovascular and 26 PAD. The risk of incident CVD events was not associated with quartiles of baseline sex hormones or SHBG (all P ≥ 0.16). For +1 SD in total testosterone, the multivariate-adjusted hazard ratio was 1.04 (95% CI, 0.80-1.34) for CHD, 0.86 (0.60-1.25) for cerebrovascular, and 0.81 (0.52-1.26) for PAD events. When analyzed as continuous variables or comparing highest to low quartile, levels of bioavailable testosterone, total estradiol, testosterone/estradiol ratio and SHBG were not associated with CVD events. Conclusions In community-dwelling elderly men, endogenous levels of testosterone, estradiol, and SHBG were not associated with increased risk of CHD, cerebrovascular, or PAD events. These results are limited by the small number of events and should be explored in future studies.
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Affiliation(s)
- Tinh-Hai Collet
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital and the University of Lausanne, Lausanne, Switzerland
| | - Susan K Ewing
- Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, California
| | - Kristine E Ensrud
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Gail A Laughlin
- Family Medicine and Public Health, University of California at San Diego, La Jolla, California
| | - Andrew R Hoffman
- Stanford University Prevention Research Center, Stanford, California
| | - Paul D Varosy
- Veterans Administration Eastern Colorado Health Care System and the University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Katie L Stone
- Research Institute, California Pacific Medical Center, San Francisco, California
| | - Eric Orwoll
- Bone and Mineral Unit, Oregon Health & Science University, Portland, Oregon
| | - Douglas C Bauer
- Division of General Internal Medicine, University of California at San Francisco, San Francisco, California
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Chiang JM, Kaysen GA, Segal M, Chertow GM, Delgado C, Johansen KL. Low testosterone is associated with frailty, muscle wasting and physical dysfunction among men receiving hemodialysis: a longitudinal analysis. Nephrol Dial Transplant 2020; 34:802-810. [PMID: 30085235 DOI: 10.1093/ndt/gfy252] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Despite the high prevalence of frailty among patients receiving hemodialysis, few preventable or treatable contributing causes have been identified. Hypogonadism is also common in this population and low serum testosterone concentrations share several clinical phenotypes with frailty. We hypothesized that low serum testosterone concentrations would be associated with frailty and several of its individual components. METHODS We used data from 440 men from A Cohort Study To Investigate the Value of Exercise in ESRD/Analysis Designed to Investigate the Paradox of Obesity and Survival in ESRD, a longitudinal study that recruited participants from 14 dialysis centers in Atlanta, GA and the San Francisco, CA Bay Area from 2009 to 2011. We assessed frailty using the Fried Frailty Phenotype. We examined the association between free testosterone (as a continuous and dichotomous variable) and frailty, individual frailty components, sarcopenia, lower extremity function and muscle mass estimation by creatinine and body impedance spectroscopy over 12 months using generalized estimating equations. RESULTS The mean age was 56.1 ± 14.2 years and 27% were white. A 50% lower concentration of free testosterone was associated with 1.40-fold higher odds of being frail [95% confidence interval (CI) 1.05-1.53] and 1.40-fold higher odds of becoming frail over 12 months (95% CI 1.07-1.73). This association was mainly due to an association with two components of frailty: grip strength and gait speed. In addition, 50% lower free testosterone concentration was associated with a 1.55-fold higher odds of having sarcopenia (95% CI 1.09-2.02) and 1.72-fold higher odds for developing sarcopenia (95% CI 1.13-2.33) as well as with lower muscle mass and a decrease in muscle mass over 12 months as estimated by serum creatinine and by bioelectrical impedance spectroscopy. CONCLUSION Serum free testosterone concentration was associated with frailty, physical function, sarcopenia and muscle mass as well as with changes in these outcomes over 12 months. Testosterone replacement may be a feasible therapeutic target toward prevention of frailty, although clinical trials are needed to test this possibility.
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Affiliation(s)
- Janet M Chiang
- Department of Medicine, Division of Endocrinology, University of California, San Francisco, San Francisco, CA, USA
| | - George A Kaysen
- Department of Medicine, Division of Nephrology, University of California, Davis, Davis, CA, USA
| | - Mark Segal
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Glenn M Chertow
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, CA, USA
| | - Cynthia Delgado
- Department of Medicine, Division of Nephrology, University of California, San Francisco, San Francisco, CA, USA.,San Francisco VA Medical Center, Department of Medicine, Division of Nephrology, San Francisco, CA, USA
| | - Kirsten L Johansen
- Department of Medicine, Division of Nephrology, University of California, San Francisco, San Francisco, CA, USA.,San Francisco VA Medical Center, Department of Medicine, Division of Nephrology, San Francisco, CA, USA
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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.
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Affiliation(s)
- Eduardo P Miranda
- Division of Urology, Universidade Federal do Ceara, Fortaleza, Brazil
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Abstract
This article contains a systematic review of the main developments that have occurred in the area of male hypogonadism between the publication of the Endocrine Society Guidelines of 2010 and 2018 and after 2018.
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Affiliation(s)
- Marco Marcelli
- Department of Medicine, Division of Endocrinology, Baylor College of Medicine, Houson, Texas, USA .,Section of Endocrinology, Michael E DeBakey VA Medical Center, Houston, Texas, USA
| | - Sanjay Navin Mediwala
- Department of Medicine, Division of Endocrinology, Baylor College of Medicine, Houson, Texas, USA.,Section of Endocrinology, Michael E DeBakey VA Medical Center, Houston, Texas, USA
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Diem SJ, Greer NL, MacDonald R, McKenzie LG, Dahm P, Ercan-Fang N, Estrada A, Hemmy LS, Rosebush CE, Fink HA, Wilt TJ. Efficacy and Safety of Testosterone Treatment in Men: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Ann Intern Med 2020; 172:105-118. [PMID: 31905375 DOI: 10.7326/m19-0830] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Testosterone treatment rates in adult men have increased in the United States over the past 2 decades. PURPOSE To assess the benefits and harms of testosterone treatment for men without underlying organic causes of hypogonadism. DATA SOURCES English-language searches of multiple electronic databases (January 1980 to May 2019) and reference lists from systematic reviews. STUDY SELECTION 38 randomized controlled trials (RCTs) of at least 6 months' duration that evaluated transdermal or intramuscular testosterone therapies versus placebo or no treatment and reported prespecified patient-centered outcomes, as well as 20 long-term observational studies, U.S. Food and Drug Administration review data, and product labels that reported harms information. DATA EXTRACTION Data extraction by a single investigator was confirmed by a second, 2 investigators assessed risk of bias, and evidence certainty was determined by consensus. DATA SYNTHESIS Studies enrolled mostly older men who varied in age, symptoms, and testosterone eligibility criteria. Testosterone therapy improved sexual functioning and quality of life in men with low testosterone levels, although effect sizes were small (low- to moderate-certainty evidence). Testosterone therapy had little to no effect on physical functioning, depressive symptoms, energy and vitality, or cognition. Harms evidence reported in trials was judged to be insufficient or of low certainty for most harm outcomes. No trials were powered to assess cardiovascular events or prostate cancer, and trials often excluded men at increased risk for these conditions. Observational studies were limited by confounding by indication and contraindication. LIMITATION Few trials exceeded a 1-year duration, minimum important outcome differences were often not established or reported, RCTs were not powered to assess important harms, few data were available in men aged 18 to 50 years, definitions of low testosterone varied, and study entry criteria varied. CONCLUSION In older men with low testosterone levels without well-established medical conditions known to cause hypogonadism, testosterone therapy may provide small improvements in sexual functioning and quality of life but little to no benefit for other common symptoms of aging. Long-term efficacy and safety are unknown. PRIMARY FUNDING SOURCE American College of Physicians. (PROSPERO: CRD42018096585).
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Affiliation(s)
- Susan J Diem
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Nancy L Greer
- Minneapolis VA Health Care System, Minneapolis, Minnesota (N.L.G., R.M., L.G.M.)
| | - Roderick MacDonald
- Minneapolis VA Health Care System, Minneapolis, Minnesota (N.L.G., R.M., L.G.M.)
| | - Lauren G McKenzie
- Minneapolis VA Health Care System, Minneapolis, Minnesota (N.L.G., R.M., L.G.M.)
| | - Philipp Dahm
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Nacide Ercan-Fang
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Allison Estrada
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Laura S Hemmy
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Christina E Rosebush
- Minneapolis VA Health Care System and University of Minnesota School of Public Health, Minneapolis, Minnesota (C.E.R.)
| | - Howard A Fink
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Timothy J Wilt
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
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Abstract
Testosterone is the main male sex hormone and is essential for the maintenance of male secondary sexual characteristics and fertility. Androgen deficiency in young men owing to organic disease of the hypothalamus, pituitary gland or testes has been treated with testosterone replacement for decades without reports of increased cardiovascular events. In the past decade, the number of testosterone prescriptions issued for middle-aged or older men with either age-related or obesity-related decline in serum testosterone levels has increased exponentially even though these conditions are not approved indications for testosterone therapy. Some retrospective studies and randomized trials have suggested that testosterone replacement therapy increases the risk of cardiovascular disease, which has led the FDA to release a warning statement about the potential cardiovascular risks of testosterone replacement therapy. However, no trials of testosterone replacement therapy published to date were designed or adequately powered to assess cardiovascular events; therefore, the cardiovascular safety of this therapy remains unclear. In this Review, we provide an overview of epidemiological data on the association between serum levels of endogenous testosterone and cardiovascular disease, prescription database studies on the risk of cardiovascular disease in men receiving testosterone therapy, randomized trials and meta-analyses evaluating testosterone replacement therapy and its association with cardiovascular events and mechanistic studies on the effects of testosterone on the cardiovascular system. Our aim is to help clinicians to make informed decisions when considering testosterone replacement therapy in their patients.
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USE OF TESTOSTERONE REPLACEMENT THERAPY AFTER RADICAL PROSTATECTOMY MIGHT KILL TWO BIRDS WITH ONE STONE FROM THE PERSPECTIVE OF MEN’S HEALTH AND DISEASE CONTROL. JOURNAL OF MEN'S HEALTH 2020. [DOI: 10.15586/jomh.v16isp1.271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Li SY, Zhao YL, Yang YF, Wang X, Nie M, Wu XY, Mao JF. Metabolic Effects of Testosterone Replacement Therapy in Patients with Type 2 Diabetes Mellitus or Metabolic Syndrome: A Meta-Analysis. Int J Endocrinol 2020; 2020:4732021. [PMID: 33061966 PMCID: PMC7545471 DOI: 10.1155/2020/4732021] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/29/2020] [Accepted: 09/17/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Testosterone replacement therapy (TRT) is commonly used for the treatment of hypogonadism in men, which is often associated with type 2 diabetes mellitus (T2DM) and metabolic syndrome (Mets). Recent compiling evidence shows that TRT has beneficial metabolic effects on these patients. OBJECTIVE A meta-analysis has been conducted to evaluate the effects of TRT on cardiovascular metabolic factors. METHODS We conducted a systemic search on PubMed, Embase, Cochrane Library, Wanfang, and CNKI and selected randomized controlled trials (RCTs) to include. The efficacy of TRT on glycemia, insulin sensitivity, lipid profile, and body weight was meta-analyzed by Review Manager. RESULTS A total of 18 RCTs, containing 1415 patients (767 in TRT and 648 in control), were enrolled for the meta-analysis. The results showed that TRT could reduce HbA1c (MD = -0.67, 95% CI -1.35, -0.19, and P=0.006) and improve HOMA-IR (homeostatic model assessment of insulin resistance) (SMD = -1.94, 95% CI -2.65, -1.23, and P < 0.0001). TRT could also decrease low-density lipoprotein (SMD = -0.50, 95% CI -0.82, -0.90, and P=0.002) and triglycerides (MD = -0.64, 95% CI -0.91, -0.36, and P < 0.0001). In addition, TRT could reduce body weight by 3.91 kg (MD = -3.91, 95% CI -4.14, -3.69, and P < 0.00001) and waist circumference by 2.8 cm (MD -2.80, 95% CI -4.38, -1.21 and P=0.0005). Erectile dysfunction (measured by IIEF-5) did not improve, while aging-related symptoms (measured by AMS scores) significantly improved. CONCLUSIONS TRT improves glycemic control, insulin sensitivity, and lipid parameters in hypogonadism patients with T2DM and MetS, partially through reducing central obesity.
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Affiliation(s)
- Shu-ying Li
- Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Division of Endocrinology, Beijing 100730, China
| | - Ya-ling Zhao
- Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Division of Endocrinology, Beijing 100730, China
| | - Yu-fan Yang
- Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Division of Endocrinology, Beijing 100730, China
| | - Xi Wang
- Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Division of Endocrinology, Beijing 100730, China
| | - Min Nie
- Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Division of Endocrinology, Beijing 100730, China
| | - Xue-yan Wu
- Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Division of Endocrinology, Beijing 100730, China
| | - Jiang-feng Mao
- Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Division of Endocrinology, Beijing 100730, China
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