Androgen administration in middle-aged and ageing men: effects of oral testosterone undecanoate on dihydrotestosterone, oestradiol and prostate volume

Testosterone deficiency in men with end stage renal disease and kidney transplantation: a narrative review

Testosterone deficiency is a prevalent condition that frequently affects individuals with end-stage renal disease (ESRD) and those who have undergone renal transplantation. While the etiology of this condition is complex, its implications in this population are far-reaching, impacting various domains such as endocrine profile, sexual and erectile function, bone mineral density (BMD), anemia, and graft survival following renal transplantation. Herein, we review the most recent literature exploring the pathophysiology of testosterone deficiency in ESRD and renal transplant patients, examining its diverse effects on this demographic, and assessing the advantages of testosterone replacement therapy (TRT). Existing evidence suggests that TRT is a safe intervention in ESRD and renal transplant patients, demonstrating improvements across multiple domains. Despite valuable insights from numerous studies, a critical need persists for larger, high-quality prospective studies to comprehensively grasp the nuances of TRT, especially in this vulnerable population. Proactive screening and treatment of testosterone deficiency may prove beneficial, emphasizing the urgency for further research in this area.

An updated systematic review and meta-analysis of the effects of testosterone replacement therapy on erectile function and prostate

Introduction

Testosterone replacement therapy (TRT) is a generally accepted method treating for aging-related late-onset hypogonadism (LOH). However, the efficacy and safety of TRT remain controversial. An updated systematic review and meta-analysis aimed to determine the effectiveness and security of TRT treating for LOH.

Methods

Randomized controlled trials (RCTs) of TRT for LOH were searched in the databases of Pubmed, Embase, Clinicaltrials.gov and Cochrane from 1990 to 2023 and an updated meta-analysis was conducted.

Results

The results of 28 RCTs involving 3461 patients were included and scrutinized in this analysis. Among these, 11 RCTs were of long-term duration (≥12 months), while 18 RCTs were short-term studies (<12 months) comparing TRT with a placebo. TRT modalities comprised injection, oral administration, and transdermal administration. International Index of Erectile Function (IIEF) (Weighted Mean difference (WMD) 3.26; 95%; 95% confidence interval (CI) 1.65-4.88; P<0.0001) was obviously improved in the TRT group. International Prostate Symptom Score (IPSS) (WMD 0.00; 95% CI -0.45-0.45; P=1.0), Prostate Volume (PV) (WMD 0.38; 95% CI -0.64-1.41; P=0.46), Maximum Flow Rate (Qmax) (WMD 1.86; 95% CI -0.98-4.69; P=0.20), Postvoid Residual Urine Volume (PVR) (WMD 3.20; 95% CI -5.87-12.28; P=0.49) and Prostate-Specific Antigen (PSA) (WMD 0.08; 95% CI -0.00-0.17; P=0.06) were not significantly statistical between two groups.

Conclusion

This meta-analysis reveals that TRT could improve the IIEF score of hypogonadal men without detriment to the IPSS score, PV, Qmax, PVR and PSA regardless of the administration method or duration of treatment.The meta-analysis was registered at PROSPERO (CRD42023413434).

Is Testosterone Replacement Therapy in Older Men Effective and Safe?

The number of older adults over 65 years of age is expected to increase to almost 100 million in the US by 2050, more than double the current figure of 46 million. Advanced age is associated with increased frailty among older Americans and often leads to increased disability, hospitalization, institutionalization, and, eventually, mortality. In search of means to improve age-related risks for adverse health outcomes, the question of restoring diminishing sex hormones has gathered much interest and has led to the practice of sex hormone replacement therapies in older men. Recent data suggest that androgen prescription rates in the US for men older than 60 years of age quadrupled from the years 2001 to 2011. While prescription sales of testosterone have increased from $150 million in 2000 to $1.8 billion in 2011, a significant portion of men prescribed testosterone replacement therapy did not meet the laboratory criteria for hypogonadism. While some clinical trials reported an association between testosterone insufficiency in older men and increased risk of death, the exact effects and consequences of testosterone replacement therapy, specifically in older men, remain unclear. This review is aimed at discussing the possible benefits and complications of testosterone replacement therapy in older men over 60 years of age.

Benefits and risks of testosterone therapy in older men

Adult-onset hypogonadism is used to define androgen deficiency and its associated symptoms commonly occurring in middle-aged and elderly men, who are unable to mount an adequate compensatory gonadotropin response but may also have an element of testicular failure. It often occurs in relation with chronic metabolic conditions such as diabetes and the metabolic syndrome. There is a growing demand from elderly men for testosterone therapy. The physician should therefore be well-informed so as the patient can make an informed decision. Indeed, testosterone therapy in older men has been a matter of debate, especially with regard to its impact on cardiovascular events and mortality. Not all studies have reported consistent results regarding its effect on diabetes, obesity and the metabolic syndrome. In contrast, it appears to improve sexual, physical function and bone density and it does not appear to increase the risk of prostate cancer; however, it increases hematocrit and hemoglobin levels. Therefore, testosterone therapy might provide significant beneficial effects in older symptomatic hypogonadal men; treatment should be individualized, and comorbidities addressed. Further research is required into its long-term effects.

Serotonin regulates prostate growth through androgen receptor modulation

Aging and testosterone almost inexorably cause benign prostatic hyperplasia (BPH) in Human males. However, etiology of BPH is largely unknown. Serotonin (5-HT) is produced by neuroendocrine prostatic cells and presents in high concentration in normal prostatic transition zone, but its function in prostate physiology is unknown. Previous evidence demonstrated that neuroendocrine cells and 5-HT are decreased in BPH compared to normal prostate. Here, we show that 5-HT is a strong negative regulator of prostate growth. In vitro, 5-HT inhibits rat prostate branching through down-regulation of androgen receptor (AR). This 5-HT’s inhibitory mechanism is also present in human cells of normal prostate and BPH, namely in cell lines expressing AR when treated with testosterone. In both models, 5-HT’s inhibitory mechanism was replicated by specific agonists of 5-Htr1a and 5-Htr1b. Since peripheral 5-HT production is specifically regulated by tryptophan hydroxylase 1(Tph1), we showed that Tph1 knockout mice present higher prostate mass and up-regulation of AR when compared to wild-type, whereas 5-HT treatment restored the prostate weight and AR levels. As 5-HT is decreased in BPH, we present here evidence that links 5-HT depletion to BPH etiology through modulation of AR. Serotoninergic prostate pathway should be explored as a new therapeutic target for BPH.

Effects of Testosterone on Benign and Malignant Conditions of the Prostate

PURPOSE OF THE REVIEW

This review summarizes the current literature regarding the effects of testosterone therapy (TTh) on common disorders of the prostate.

RECENT FINDINGS

Testosterone therapy has gained credibility over the last several decades as a potentially safe co-treatment modality for men with benign and malignant prostatic conditions. Our understanding of the effects of testosterone on the prostate continues to evolve with ongoing clinical and basic science research. Findings of these studies have reinvigorated the debate over the effects of testosterone on benign and malignant disorders of the prostate, including BPH, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), and prostate cancer.

SUMMARY

Despite the burgeoning body of data claiming the safety and efficacy of TTh in common prostatic conditions (including BPH, CP/CPPS, and prostate cancer), diligent monitoring, appropriate patient selection, and informed consent are critical until more definitive studies are performed.

Adult-onset hypogonadism: evaluation and role of testosterone replacement therapy

Testosterone deficiency (TD) has become a growing concern in the field of men’s sexual health, with an increasing number of men presenting for evaluation of this condition. Given the increasing demand for testosterone replacement therapy (TRT), a panel of experts met in August of 2015 to discuss the treatment of men who present for evaluation in the setting of low or normal gonadotropin levels and the associated signs and symptoms of hypogonadism. This constellation of factors can be associated with elements of both primary and secondary hypogonadism. Because this syndrome commonly occurs in men who are middle-aged and older, it was termed adult-onset hypogonadism (AOH). AOH can be defined by the following elements: low levels of testosterone, associated signs and symptoms of hypogonadism, and low or normal gonadotropin levels. Although there are significant benefits of TRT for patients with AOH, candidates also need to understand the potential risks. Patients undergoing TRT will need to be monitored regularly because there are potential complications that can develop with long-term use. This review is aimed at providing a deeper understanding of AOH, discussing the benefits and risks of TRT, and outlining each modality of TRT in use for AOH.

Adult-Onset Hypogonadism

In August 2015, an expert colloquium commissioned by the Sexual Medicine Society of North America (SMSNA) convened in Washington, DC, to discuss the common clinical scenario of men who present with low testosterone (T) and associated signs and symptoms accompanied by low or normal gonadotropin levels. This syndrome is not classical primary (testicular failure) or secondary (pituitary or hypothalamic failure) hypogonadism because it may have elements of both presentations. The panel designated this syndrome adult-onset hypogonadism (AOH) because it occurs commonly in middle-age and older men. The SMSNA is a not-for-profit society established in 1994 to promote, encourage, and support the highest standards of practice, research, education, and ethics in the study of human sexual function and dysfunction. The panel consisted of 17 experts in men's health, sexual medicine, urology, endocrinology, and methodology. Participants declared potential conflicts of interest and were SMSNA members and nonmembers. The panel deliberated regarding a diagnostic process to document signs and symptoms of AOH, the rationale for T therapy, and a monitoring protocol for T-treated patients. The evaluation and management of hypogonadal syndromes have been addressed in recent publications (ie, the Endocrine Society, the American Urological Association, and the International Society for Sexual Medicine). The primary purpose of this document was to support health care professionals in the development of a deeper understanding of AOH, particularly in how it differs from classical primary and secondary hypogonadism, and to provide a conceptual framework to guide its diagnosis, treatment, and follow-up.

Effects of Testosterone Replacement Therapy on Lower Urinary Tract Symptoms: A Systematic Review and Meta-analysis

CONTEXT

There is a potential risk that testosterone replacement therapy (TRT) may exacerbate lower urinary tract symptoms (LUTS) among aging men with late-onset hypogonadism (LOH) because of testosterone's growth-promoting effects on the prostate.

OBJECTIVE

To compare the change in LUTS severity as assessed using the International Prostate Symptom Score (IPSS) between men receiving TRT versus placebo for the treatment of LOH.

EVIDENCE ACQUISITION

Systematic search of MEDLINE, Embase, ClinicalTrials.gov, and The Cochrane Library for randomized controlled trials of TRT for LOH published between January 1992 and September 2015. Studies were eligible for inclusion if they were a randomized control trial, used TRT, and assessed LUTS outcomes using the IPSS. Estimates were pooled using random effects meta-analysis. Differences by study-level characteristics were estimated using meta-regression.

EVIDENCE SYNTHESIS

Data were extracted from 14 trials involving 2029 participants. The average age was 64.5 yr and the average follow-up was 34.4 mo. Seven studies used topical, five used injectable, and two used oral testosterone. There was no statistically significant difference in pooled changes in IPSS from baseline to follow up in men treated with TRT compared with those receiving placebo (-0.41 points [95% confidence interval: -0.89 to 0.07; I(2)=0%, p=0.28] vs. 0.12 points [95% confidence interval: -0.32 to 0.55; I(2)=0%, p=0.81], between-group difference p>0.05). No between-group differences were noted in subanalyses that controlled for potential confounders such as type of testosterone, change in testosterone, aging male symptom scale, or prostate-specific antigen levels (p>0.05 for all comparisons).

CONCLUSIONS

In this meta-analysis of 14 clinical trials of TRT for LOH, the change in IPSS was similar among men receiving TRT versus placebo, suggesting that TRT treatment does not worsen LUTS among men with LOH.

PATIENT SUMMARY

In this analysis of 14 clinical trials, testosterone replacement therapy did not worsen lower urinary tract symptoms among men being treated for late-onset hypogonadism.

Features of diagnostics and treatment of partial androgen deficiency of aging men

INTRODUCTION

Decreasing of testosterone level is an important part of a male elderly.

MATERIAL AND METHODS

To describe this phenomenon a PubMed and national databases were searched for 17β-dehydrotestosterone, common testosterone, free testosterone, 17β-estradiol, luteinizing hormone, partial androgen deficiency of aging men.

RESULTS

The reduction in intensity of the processes of tissue renewal of the testicles results in a partial androgen deficiency of aging men. A decrease in the levels of total and free testosterone and an increase in the levels of 5α-dihydrotestosterone, 17β-estradiol, sex hormone binding globulin, LH and FSH, along with a decrease in the amplitude of the rhythm of incretion of LH, FSH and total testosterone will testify to a deficiency of testosterone.

CONCLUSIONS

It is very important to make an individualized selection of the dose of testosterone preparation which enters the blood plasma.

Testosterone replacement therapy improves metabolic parameters in hypogonadal men with type 2 diabetes but not in men with coexisting depression: the BLAST study

INTRODUCTION

The association between testosterone deficiency and insulin resistance in men with type 2 diabetes is well established and current endocrine society guidelines recommend the measurement of testosterone levels in all men with type 2 diabetes or erectile dysfunction.

AIM

We report the first double-blind, placebo-controlled study conducted exclusively in a male type 2 diabetes population to assess metabolic changes with long-acting testosterone undecanoate (TU).

METHODS

The type 2 diabetes registers of seven general practices identified 211 patients for a 30-week double-blind, placebo-controlled study of long-acting TU 1,000 mg followed by 52 weeks of open-label use. Because of the established impact of age, obesity, and depression on sexual function, these variables were also assessed for influence on metabolic parameters.

MAIN OUTCOME MEASURE

Changes in glycated hemoglobin (HbA1c) and the level of testosterone at which response are achieved.

RESULTS

Treatment with TU produced a statistically significant reduction in HbA1c at 6 and 18 weeks and after a further 52 weeks of open-label medication most marked in poorly controlled patients with baseline HbA1c greater than 7.5 where the reduction was 0.41% within 6 weeks, and a further 0.46% after 52 weeks of open-label use. There was significant reduction in waist circumference, weight, and body mass index in men without depression, and improvements were related to achieving adequate serum levels of testosterone. There were no significant safety issues.

CONCLUSIONS

Testosterone replacement therapy significantly improved HbA1c, total cholesterol, and waist circumference in men with type 2 diabetes. Improvements were less marked in men with depression at baseline, and therapeutic responses were related to achieving adequate serum testosterone levels. Current advice on 3- to 6-month trials of therapy may be insufficient to achieve maximal response. Patients reported significant improvements in general health.

Significant association between serum dihydrotestosterone level and prostate volume among Taiwanese men aged 40-79 years

INTRODUCTION

We evaluated the association between serum sex hormone levels and prostate volume in Taiwanese men.

METHODS

A cross-sectional study was conducted in 505 men (aged 40-79 years, mean age 58 years). Serum total testosterone (TT), free testosterone (FT), dihydrotestosterone (DHT) and estradiol (E2) levels were measured. Total prostate volume (TPV) and transition zone volume (TZV) were measured by transrectal ultrasonography. Body mass index (BMI), DHT/TT and E2/TT were calculated. Correlations were determined using univariate and multivariate regression analyses.

RESULTS

Apart from DHT, an age-dependent change of sex hormone levels were observed. On univariate analyses, age, BMI, serum DHT level and DHT/TT ratio, as well as serum E2 level and E2/TT ratio, but not serum TT and FT levels showed a significant association with prostate volume. On multivariate analysis, however, only serum DHT level and DHT/TT ratio remained significant. Logistic regression analysis showed that the odds ratios (95% confidence interval) of the second, third, and fourth quartiles of serum DHT levels for benign prostatic hyperplasia (defined as TPV ≥ 20 ml) risk were 2.06 (1.21-3.51), 2.66(1.56-4.53) and 7.15(4.0-12.6), respectively (p < 0.001).

CONCLUSIONS

Higher serum DHT level and DHT/TT ratio were associated with larger prostate volume and higher prevalence of BPH in Taiwanese men.

Late-onset hypogonadism syndrome and lower urinary tract symptoms

Androgen replacement therapy (ART) is a widely accepted form of treatment worldwide for aging men with late-onset hypogonadism (LOH) syndrome. Concurrent with the progressive decline in testosterone from middle age, there is a gradual increase in prostate volume, reflecting the development of benign prostatic hyperplasia (BPH). Prostate growth is dependent on the presence of androgens, and conversely, antiandrogen agents or orchidectomy can decrease prostate volume in patients with BPH. Thus, it is important to investigate whether ART could have any negative effects on prostatic disease or lower urinary tract symptoms (LUTS). Although only limited amounts of information on the correlations between androgen levels in aging men and clinical manifestations of LUTS are available, a few recent studies have suggested that testosterone levels may have some beneficial effects on various urinary functions in men. Androgen receptors are found in the urothelium, urinary bladder, prostate, and urethra, and testosterone could have an impact on the autonomic nervous system, bladder smooth muscle differentiation, nitric oxide synthase, phosphodiesterase-5 and Rho/Rho-kinase activities, and pelvic blood flow. In addition, some previous studies demonstrated that ART had little effect on LUTS or urinary function in aging men with LOH syndrome. Furthermore, some recent randomized controlled trials indicated that short-term ART may be effective in the improvement of LUTS in hypogonadal men with mild BPH. However, only limited information is available regarding the effects of longer-term ART or the safety of ART in men with severe BPH and LUTS, and further studies are required to reach more definitive conclusions.

Androgen replacement therapy contributes to improving lower urinary tract symptoms in patients with hypogonadism and benign prostate hypertrophy: a randomised controlled study

PURPOSE

We performed a randomised controlled study regarding the effects of androgen replacement therapy (ART) on lower urinary tract symptoms (LUTS) in hypogonadal men with benign prostate hypertrophy (BPH).

METHODS

Fifty-two patients with hypogonadism and BPH were randomly assigned to receive testosterone (ART group) as 250 mg of testosterone enanthate every 4 weeks or to the untreated control group. We compared International Prostate Symptom Score (IPSS), uroflowmetry data, post-voiding residual volume (PVR) and systemic muscle volume at baseline and 12 months after treatment.

RESULTS

Forty-six patients (ART group, n=23; control, n=23) were included in the analysis. At the 12-month visit, IPSS showed a significant decrease compared with baseline in the ART group (15.7 +/- 8.7 vs. 12.5 +/- 9.5; p<0.05). No significant changes were observed in the control group. The ART group also showed improvement in maximum flow rate and voided volume (p<0.05), whereas no significant improvements were observed in the controls. PVR showed no significant changes in either group. In addition, the ART group showed significant enhancement of mean muscle volume (p<0.05), whereas no significant changes were seen in the controls.

CONCLUSION

ART improved LUTS in hypogonadal men with mild BPH.

Late-life onset hypogonadism: a review

Increased longevity and population aging will increase the number of men with late-onset hypogonadism, a common condition that is often under diagnosed and under treated. The indication of testosterone replacement therapy (TRT) treatment requires the presence of low testosterone level and symptoms and signs of hypogonadism. Although there is a lack of large-scale, long-term studies assessing the benefits and risks of TRT in men with hypogonadism, reports indicate that TRT may produce a wide range of benefits that include improvement in libido and sexual function, bone density, muscle mass, body composition, mood, erythropoiesis, cognition, quality of life, and cardiovascular disease. Perhaps the most controversial area is the issue of risk, especially the possible stimulation of prostate cancer by testosterone, even though there is no evidence to support this risk. Other possible risks include worsening symptoms of benign prostatic hypertrophy, liver toxicity, hyperviscosity, erythrocytosis, worsening untreated sleep apnea, or severe heart failure. Despite this controversy, testosterone supplementation in the United States has increased substantially in the past several years. The physician should discuss with the patient the potential benefits and risks of TRT. This review discusses the benefits and risks of TRT.

Comparison of oral versus transdermal testosterone supplementation in hypogonadal men

: To compare mean serum total testosterone, bioavailable-testosterone, and dihydrotestosterone levels between transdermal testosterone and oral testosterone undecanoate treatment.

: Multicentre, randomized, cross-over study; 44 men >18 years, testosterone ≤2.5 ng/mL. Two patches (Testopatch

: Mean age 49 years. Mean testosterone before inclusion 1.99 ng/mL. Mean testosterone serum levels over the last 48 h of Testopatch treatment were superior to Pantestone (4.64 vs. 2.58 ng/mL, p<0.001). Testosterone trough levels at the end of each treatment period were significantly higher for Testopatch (3.15 vs. 2.45 ng/mL, p<0.01). Bioavailable-testosterone levels over the first and last 48 h of treatment were significantly greater with Testopatch than with Pantestone (p=0.001 and p<0.01). Dihydrotestosterone levels over the first and last 48 h of treatment (0.71 vs. 1.05 ng/mL and 0.68 vs. 0.89 ng/mL) as well as at trough (0.59 vs. 0.96 ng/mL) were significantly lower with Testopatch than with Pantestone (p<0.001, p<0.05, and p<0.001). SHBG levels decreased by Pantestone but not by Testopatch (p<0.001).

: Testopatch was superior to Pantestone to increase testosterone and bioavailable-testosterone levels in hypogonadal men from the first days and throughout the three weeks of treatment. Pantestone increased dihydrotestosterone to a larger extent and decreased SHBG.

The benefits and risks of testosterone replacement therapy: a review

Increased longevity and population aging will increase the number of men with late onset hypogonadism. It is a common condition, but often underdiagnosed and undertreated. The indication of testosterone-replacement therapy (TRT) treatment requires the presence of low testosterone level, and symptoms and signs of hypogonadism. Although controversy remains regarding indications for testosterone supplementation in aging men due to lack of large-scale, long-term studies assessing the benefits and risks of testosterone-replacement therapy in men, reports indicate that TRT may produce a wide range of benefits for men with hypogonadism that include improvement in libido and sexual function, bone density, muscle mass, body composition, mood, erythropoiesis, cognition, quality of life and cardiovascular disease. Perhaps the most controversial area is the issue of risk, especially possible stimulation of prostate cancer by testosterone, even though no evidence to support this risk exists. Other possible risks include worsening symptoms of benign prostatic hypertrophy, liver toxicity, hyperviscosity, erythrocytosis, worsening untreated sleep apnea or severe heart failure. Despite this controversy, testosterone supplementation in the United States has increased substantially over the past several years. The physician should discuss with the patient the potential benefits and risks of TRT. The purpose of this review is to discuss what is known and not known regarding the benefits and risks of TRT.

Testosterone therapy in hypogonadal men and potential prostate cancer risk: a systematic review

This paper provides a systematic review of the literature about prostate cancer risk associated with testosterone therapy for hypogonadism. A comprehensive search of MEDLINE, EMBASE and other resources was conducted to identify articles that highlight occurrences of prostate cancer in men receiving testosterone therapy for hypogonadism treatment. Articles that met study inclusion criteria were assessed for causality between testosterone treatment and prostate cancer, increased prostate-specific antigen or abnormal digital rectal examination findings. Of 197 articles relating to testosterone therapy, 44 met inclusion criteria: 11 placebo-controlled, randomized studies; 29 non-placebo-controlled studies of men with no prostate cancer history; and 4 studies of hypogonadal men with history of prostate cancer. Of studies that met inclusion criteria, none demonstrated that testosterone therapy for hypogonadism increased prostate cancer risk or increased Gleason grade of cancer detected in treated vs untreated men. Testosterone therapy did not have a consistent effect on prostate-specific antigen levels.

State of the Art Reviews: Male Menopause: Fact or Fiction?

The possible existence of a menopause-like process in aging men has been speculated, given certain age-related hormonal and other biological changes noted to occur. Specifically, a slow decline in serum testosterone levels has been reported to occur with normal male aging. Androgen deficiency, which may result from this process, could have an effect on various systems and physiologic parameters, including bone density, body composition, sexual function, and the cardiovascular system, thus significantly affecting health and quality-of-life issues in older men. There has been an increasing interest in evaluating the possible use of testosterone replacement in preventing some detrimental aspects of aging and age-related hypogonadism, as well as in the investigation of the potential adverse effects of this therapy on different target organs. It is the purpose of this review to summarize currently available information with regard to the changes in testosterone and other hormones in older men, discuss their possible clinical manifestations and relationship with other age-related changes, and provide an updated description of testosterone replacement therapy for older men, including its indications, formulations, and safety considerations.

Testosterone therapy can enhance erectile function response to sildenafil in patients with PADAM: a pilot study

INTRODUCTION

Recent studies suggest a direct relationship between free testosterone and cavernous vasodilatation. Some men with erectile dysfunction (ED) associated with PADAM (partial androgen deficiency in aging men) might possibly benefit from testosterone undecanoate therapy (TRT).

OBJECTIVES

To determine the efficacy of testosterone undecanoate in facilitating the erectile response and patient satisfaction with sildenafil in men 40-70 years old with PADAM symptoms.

DESIGN AND METHODS

Prospective study including 40 patients recruited after a sildenafil therapeutic trial. Total testosterone and sex hormone binding globulin (SHBG) were measured to calculate the free androgen index. Prostate specific antigen (PSA) was measured and repeated 2 months after treatment. A rating score was used for PADAM symptoms, and the 5-point abbreviated version of the International Index of Erectile Function (IIEF-5) to assess erectile function. Men failing to respond to sildenafil were randomized into two groups receiving sildenafil plus continuous TRT (group 1ST), and TRT (group 1T) alone. Men partially responding to sildenafil were randomized into two groups receiving sildenafil plus continuous TRT for 2 months (group 2ST), or sildenafil alone (group 2S). Treatment efficacy was assessed by analysis of between-group differences.

RESULTS

Groups 1T, 2S, and 2ST showed significant improvement in PADAM scores (P<0.05, Wilcoxon matched pairs test). Patients receiving both sildenafil plus continuous TRT (groups 1ST and 2ST) showed significant improvement in IIEF-5 scores (P<0.5, paired t-test). No significant changes in serum levels of PSA were detected (paired t-test).

CONCLUSIONS

We conclude that TRT appears to be beneficial and safe in facilitating the erectile response and patient satisfaction with sildenafil in men with PADAM symptoms. Androgen supplementation should be carried out cautiously with careful monitoring to avoid possible adverse effects.

Risks of testosterone replacement therapy in ageing men

Testosterone has been available to practitioners for several decades. However, testosterone prescriptions have increased in recent years partly because of the introduction of newer delivery systems that are topical and have good bioavailability. In the US alone, approximately 2 million prescriptions for testosterone were written in 2002. This represents a 30% increase from 2001 and a 170% increase from 1999. There has also been a 500% increase in prescription sales in the past 10 years. The rise in prescriptions may be in part due to the increasing recognition of hypogonadism in ageing males or andropause. Treatment relating to hypogonadism has relieved symptoms and improved the quality of life of many individuals. Epidemiological studies point toward an association with increased morbidity and mortality, with low testosterone states in ageing males. For example, there is a higher prevalence of depression, coronary heart disease, osteoporosis, fracture rates, frailty and even dementia with low testosterone states. Recently, there have been some concerns raised regarding the long-term safety of testosterone replacement therapy (TRT) from the Institute of Medicine. Current evidence suggests no causal relationship between prostate cancer and physiological dosing of testosterone, especially with careful selection and monitoring of patients. Cardiovascular risks have, overall, been neutral, although suggestions have been made that there are positive vasodilatory properties with testosterone. Mild eythrocytosis can be a common side effect of TRT, but thromboembolic events have rarely been reported in the literature. This paper addresses the evidence to date regarding the safety aspects of TRT. The medical-legal implications of TRT for men at this point in time is also discussed.

[Testosterone and the prostate]

Testosterone has a distinct role in benign and malignant diseases of the prostate. Therefore, knowledge about the physiological interactions between testosterone and the prostate and the special circumstances under testosterone substitution are of great impact for urologists.PSA value and prostate volume do not show significant changes under testosterone substitution therapy. Even if there are no long-term studies in men under substitution due to decreased testosterone, the therapy seems to be safe under regular control of the prostate with PSA and sonography, and the risk for prostate carcinoma is not increased. In hypogonadal men with high-grade PIN under testosterone substitution, 1 in 20 cases with suspicious rectal examination exhibited a carcinoma; the PSA values did not show a difference between men with or without PIN.Nevertheless, it remains unclear whether men after successful radical prostatectomy should receive testosterone substitution.

Preventing diseases of the prostate in the elderly using hormones and nutriceuticals

The prostate has only one function, namely to secrete fluid containing substances that are needed for reproduction. This requires an extremely high concentration of androgens in the tissues. Benign prostatic hypertrophy (BPH) seems to be related to the long-term exposure of the prostate to the strong androgen 5alpha-dihydrotestosterone (DHT) and, possibly, to estrogens. The relation between prostate cancer and androgens is suggested to be U-shaped, with both extremes of androgen concentrations being associated with increased risk of invasive cancer. In the treatment of patients with BPH, the lipidic liposterolic extracts of Serenoa repens were as effective as the pharmaceutical inhibitors of the 5alpha-reductase enzyme or alpha1-adrenergic blockers in relieving urinary symptoms. In addition to moderately inhibiting the 5alpha-reductase activity, Serenoa seems to exert anti-inflammatory and complementary cellular actions with beneficial effects on the prostate. Unlike the pharmaceutical 5alpha-reductase inhibitors, finasteride and dutasteride, Serenoa does not suppress serum PSA, facilitating the follow-up and the early detection of prostate cancer. We suggest a strategy to prevent prostate cancer that aims at providing men with partial androgen deficiency correct testosterone substitution with a sustained release buccal bio-adhesive tablet. In addition, food supplementation with extracts of Serenoa repens and a combination of the antioxidants selenium, (cis)-lycopene and natural vitamin E, together with fish oil rich in long-chain polyunsaturated essential fatty acids of the omega-3 group seems warranted. Clearly, a holistic approach including careful clinical and biological monitoring of the aging man and his prostate remains mandatory.

Testosterone metabolism, dose-response relationships and receptor polymorphisms: selected pharmacological/toxicological considerations on benefits versus risks of testosterone therapy in men

In this review selected toxicological problems related to testosterone therapy in hypogonadal men are discussed. Applying "classical" pharmacological/toxicological findings (e.g. animal studies on short- and long-term toxicity) to clinical situations is not very helpful. Molecular biological knowledge and especially evaluation of epidemiological studies, as well as intervention studies, on testosterone therapy in hypogonadal men are more useful. Potential risks include overdosage for lifestyle reasons, e.g. excessive muscle building and reduction of visceral obesity, when erythrocytosis occurs concomitantly. Modern galenic formulations of testosterone administration (e.g. transdermal gel, suitable testosterone esters for intramuscular application and newer oral preparations) avoid supraphysiological serum concentrations, therefore significantly reducing the toxicological risk. A hypothetical model of the toxicological risks of testosterone therapy is given that is based on the influence of testosterone metabolism (aromatization vs. reduction) of the respective parameter/target chosen. Finally, the great influence of polymorphisms of the androgen receptor on the assessment of toxicological risk and on the individualization of androgen therapy is shown. Already existing national, continental and international guidelines or recommendations for the testosterone therapy should be harmonized.

Effects of Chronic Administration of Dehydroepiandrosterone on Serum Testosterone Levels and Prostatic Tissue in Rats

PURPOSE

We evaluated the effects of chronic administration of dehydroepiandrosterone (DHEA) on serum total testosterone and DHEA sulfate (DHEAS), prostatic weight and histological features in the rat.

MATERIALS AND METHODS

Wistar rats were divided into 2 groups. The first group of 9 rats received saline solution orally once daily during 5 days of the week for 10 months and the second group of 15 received 5 mg/kg daily DHEA in suspension orally in the same pattern.

RESULTS

At the end of the 10-month study period total testosterone levels were higher in the DHEA group compared with controls (2.0 +/- 0.4 vs 0.8 +/- 0.2 mg/dl, p <0.0001) and DHEAS levels were also greater in the treated group compared with placebo (222.1 +/- 41.5 vs 2.0 +/- 0.3 mg/dl, p <0.0001). Weight of the prostate, testis and body did not differ between the groups (p >0.05). No differences between the 2 groups were noted in regard to the degree of hyperplasia, atrophy, a papillary component or the stromal-to-gland ratio (p >0.05).

CONCLUSIONS

Oral ingestion of DHEA on a chronic basis in the rat increases serum DHEAS and total testosterone without any evident change in prostate weight or histology.

Andropause:

There is increasing evidence that the common condition of hypogonadism in older men when associated with symptoms responds well to testosterone replacement. Over the last few years there has been a marked increase in the awareness and treatment of the andropause [137]. Long-term side effects of testosterone are uncertain with only eight people over 50 years having been studied for 10 years [138]. Testosterone needs to be considered a quality-of-life drug, similar to sildenafil, and at present it should be used only if it produces symptomatic improvement. There is a need for a men's health study to determine the long-term efficacy and safety of testosterone replacement in older persons.