Androgens in men--uses and abuses

Association of salivary testosterone levels during the post-awakening period with age and symptoms suggestive of late-onset hypogonadism in men

BACKGROUND

The lack of association between serum testosterone levels and symptoms suggestive of hypogonadism is a significant barrier in the determination of late-onset hypogonadism (LOH) in men. This study explored whether testosterone levels increase after morning awakening, likewise the cortisol awakening response (CAR) in the hypothalamic-pituitary-adrenal (HPA) axis, and whether testosterone levels during the post-awakening period are associated with age and symptoms suggestive of late-onset hypogonadism (LOH) in men.

METHODS

Testosterone and cortisol levels were determined in saliva samples collected immediately upon awakening and 30 and 60 min after awakening, and scores of the Aging Males' Symptoms (AMS) questionnaire were obtained from 225 healthy adult men.

RESULTS

A typical CAR (an increase in cortisol level ≥ 2.5 nmol/L above individual baseline) was observed in 155 participants (the subgroup exhibiting typical CAR). In the subgroup exhibiting CAR, testosterone levels sharply increased during the post-awakening period, showing a significant negative correlation with age, total AMS score, and the scores of 11 items on the somatic, psychological, and sexual AMS subscales. Of these items, three sexual items (AMS items #15-17) were correlated with age. Meanwhile, there was no notable increase in testosterone levels and no significant correlation of testosterone levels with age and AMS score in the subgroup exhibiting no typical CAR (n = 70).

CONCLUSIONS

The results indicate that the hypothalamus-pituitary-gonad (HPG) axis responds to morning awakening, and determining testosterone levels during the post-awakening period in men with typical CAR may be useful for assessing HPG axis function and LOH.

Ethosomes as a carrier for transdermal drug delivery system: methodology and recent developments

Transdermal drug delivery systems (TDDS) have received significant attention in recent years. TDDS are flexible systems that transport active components to the skin for either localized or systemic delivery of drugs through the skin. Among the three main layers of skin, the outermost layer, called the stratum corneum (SC), prevents the entry of water-loving bacteria and drugs with a high molecular weight. The challenge lies in successfully delivering drugs through the skin, which crosses the stratum corneum. The popularity of lipid-based vesicular delivery systems has increased in recent years due to their ability to deliver both hydrophilic and hydrophobic drugs. Ethosomes are specialized vesicles made of phospholipids that can store large amounts of ethanol. Ethosome structure and substance promote skin permeability and bioavailability. This article covers ethosome compositions, types, medication delivery techniques, stability, and safety. In addition to this, an in-depth analysis of the employment of ethosomes in drug delivery applications for a wide range of diseases has also been discussed. This review article highlights different aspects of ethosomes, such as their synthesis, characterization, marketed formulation, recent advancements in TDDS, and applications.

Testosterone replacement therapy: clinical considerations

INTRODUCTION

As an increasingly popular therapeutic option, testosterone replacement therapy (TRT) has gained significant notoriety for its health benefits in indicated populations, such as those suffering from hypogonadism.

AREAS COVERED

Benefits such as improved libido, muscle mass, cognition, and quality of life have led to widened public interest in testosterone as a health supplement. No therapy exists without side effects; testosterone replacement therapy has been associated with side effects such as an increased risk of polycythemia, benign prostate hypertrophy (BPH), prostate cancer, gynecomastia, testicular atrophy, and infertility. Testosterone replacement therapy is often accompanied by several prophylactic co-therapies aimed at reducing the prevalence of these side effects. Literature searches for sections on the clinical benefits and risks associated with TRT were performed to include clinical trials, meta-analyses, and systematic reviews from the last 10 years.

EXPERT OPINION

Data from clinical studies over the last decade suggest that the benefits of this therapy outweigh the risks and result in overall increased quality of life and remission of symptoms related to hypogonadism. With this in mind, the authors of this review suggest that carefully designed clinical trials are warranted for the investigation of TRT in symptomatic age-related hypogonadism.

The Influence of Sex Hormones in Liver Function and Disease

The liver performs a multitude of bodily functions, whilst retaining the ability to regenerate damaged tissue. In this review, we discuss sex steroid biology, regulation of mammalian liver physiology and the development of new model systems to improve our understanding of liver biology in health and disease. A major risk factor for the development of liver disease is hepatic fibrosis. Key drivers of this process are metabolic dysfunction and pathologic activation of the immune system. Although non-alcoholic fatty liver disease (NAFLD) is largely regarded as benign, it does progress to non-alcoholic steatohepatitis in a subset of patients, increasing their risk of developing cirrhosis and hepatocellular carcinoma. NAFLD susceptibility varies across the population, with obesity and insulin resistance playing a strong role in the disease development. Additionally, sex and age have been identified as important risk factors. In addition to the regulation of liver biochemistry, sex hormones also regulate the immune system, with sexual dimorphism described for both innate and adaptive immune responses. Therefore, sex differences in liver metabolism, immunity and their interplay are important factors to consider when designing, studying and developing therapeutic strategies to treat human liver disease. The purpose of this review is to provide the reader with a general overview of sex steroid biology and their regulation of mammalian liver physiology.

Gaps in the management of diabetes in Asia: A need for improved awareness and strategies in men's sexual health

Sexual dysfunction, which is defined as 'difficulty during any stage of the sexual encounter that prevents or impairs the individual or couple from enjoying sexual activity', is globally prevalent in males with prediabetes and diabetes. It is an early harbinger of cardiovascular diseases and has a profound impact on one's physical, mental, and social health. Among patients with either prediabetes or diabetes, the most common male sexual dysfunctions are hypogonadism, erectile dysfunction, and premature ejaculation. In Asia, although sexual health is an important factor of men's health, it is rarely discussed freely in real-life practice. Addressing sexual health in Asian males has always been challenging with multiple barriers at the levels of patients and health care providers. Therefore, the assessment and management of sexual dysfunction in routine clinical practice should involve a holistic approach with effective patient-provider communication. In this review, we discuss the epidemiology, pathophysiology, and the management of hypogonadism, erectile dysfunction, and premature ejaculation among males with either prediabetes or diabetes (type 1 and type 2), as well as the evidence gaps across Asia.

The Safety of Human Chorionic Gonadotropin Monotherapy Among Men With Previous Exogenous Testosterone Use

Background and objective

Human chorionic gonadotropin (hCG) is homologous to luteinizing hormone (LH) and stimulates endogenous testosterone (T) production. Current American Urological Association (AUA) guidelines recommend hCG for T-deficient men who wish to preserve their fertility. However, there is no data available regarding the long-term efficacy and safety of hCG monotherapy in men with a history of exogenous T use. We hypothesized that transitioning to hCG would be a safe and effective option in this population.

Methodology

We performed a retrospective analysis involving 28 men with previous exogenous T use who were switched to hCG monotherapy and underwent follow-up lab work at least one month later. We evaluated changes in hormones [T, LH, follicle-stimulating hormone (FSH), and estradiol], hematocrit (HCT), glycated hemoglobin (HbA1c), and prostate-specific antigen (PSA).

Results

Among the entire cohort, we found no significant change in mean hormone levels (including T), HbA1c, or PSA. There was a significant (p<0.05) decrease in HCT (45.27 ±4.06 to 44.16 ±3.48%, n=15). No thromboembolic events were reported. Additionally, among men who had their baseline labs completed outside their previous T therapy therapeutic time window prior to starting hCG monotherapy, there was a statistically significant increase in mean T levels (307.36 ±148.74 to 422.11 ±268.15 ng/dL, n=30 and 31, pre- and post-hCG, respectively) and a statistically significant decrease in mean PSA levels (0.91 ±0.35 to 0.69 ±0.23 ng/mL, n=5).

Conclusions

These results suggest that hCG is a safe and effective alternative to traditional T therapy for men with a history of exogenous T use and may lead to an advantageous decrease in HCT. hCG may serve as an alternative form of T therapy with a lower risk for secondary erythrocytosis, and further research is warranted to gain deeper insights into the topic.

Characterizing skeletal muscle dysfunction in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine condition affecting women. It has traditionally been viewed as a primarily reproductive disorder; however, it is increasingly recognized as a lifelong metabolic disease. Women with PCOS are at increased risk of insulin resistance (IR), type 2 diabetes mellitus, non-alcoholic fatty liver disease and cardiovascular disease. Although not currently a diagnostic criterion, IR is a cardinal pathophysiological feature and highly prevalent in women with PCOS. Androgens play a bidirectional role in the pathogenesis of IR, and there is a complex interplay between IR and androgen excess in women with PCOS. Skeletal muscle has a key role in maintaining metabolic homeostasis and is also a metabolic target organ of androgen action. Skeletal muscle is the organ responsible for the majority of insulin-mediated glucose disposal. There is growing interest in the relationship between skeletal muscle, androgen excess and mitochondrial dysfunction in the pathogenesis of metabolic disease in PCOS. Molecular mechanisms underpinning defects in skeletal muscle dysfunction in PCOS remain to be elucidated, but may represent promising targets for future therapeutic intervention. In this review, we aim to explore the role of skeletal muscle in metabolism, focusing particularly on perturbations in skeletal muscle specific to PCOS as observed in recent molecular and in vivo human studies. We review the possible role of androgens in the pathophysiology of skeletal muscle abnormalities in PCOS, and identify knowledge gaps, areas for future research and potential therapeutic implications. Despite increasing interest in the area of skeletal muscle dysfunction in women with PCOS, significant challenges and unanswered questions remain, and going forward, novel innovative approaches will be required to dissect the underlying mechanisms.

Testosterone Deficiency Promotes Hypercholesteremia and Attenuates Cholesterol Liver Uptake via AR/PCSK9/LDLR Pathways

BACKGROUND

Testosterone deficiency is reportedly correlated with an elevation of cholesterol in plasma, but the mechanism remains unclear. Our objective was to investigate the effects of testosterone deficiency on cholesterol metabolism and the corresponding molecular changes in vivo and in vitro.

METHODS

SD rats were randomized into three groups: sham-operated (SHAM), subtotal orchiectomized (SO), and orchiectomized (ORX) and fed for 8 weeks. HepG2 cells were cultured with medium containing testosterone with the final concentrations of 0, 10, 30, and 300 nM. Method of isotope tracing and fluorescence labelling was adopted to investigate cholesterol metabolism. Several key molecules of cholesterol metabolism were also analyzed.

RESULTS

SO and ORX rats displayed dysfunctional liver uptake of cholesterol. HepG2 cells incubated with testosterone of lower and excessive level exhibited reduced capacity of cholesterol uptake. Further investigation revealed that lack of testosterone induced increased proprotein convertase subtilisin/kexin type 9 (PCSK9) and decreased low-density lipoprotein receptor (LDLR) both in vivo and in vitro. Moreover, the androgen receptor (AR) antagonist flutamide mimicked the effects of testosterone deficiency on PCSK9 and LDLR indicating the role of AR as a mediator in triggering attenuating liver cholesterol uptake in which testosterone instead of dihydrotestosterone (DHT) is the major functional form of androgen.

CONCLUSION

Testosterone deficiency attenuated cholesterol liver uptake mediated by the PCSK9-LDLR pathway, in which AR and testosterone without transforming to DHT play important roles.

Anabolic Androgenic Steroids in Orthopaedic Surgery: Current Concepts and Clinical Applications

Despite the well-documented effects of testosterone and its synthetic derivatives—collectively termed anabolic androgenic steroids (AASs)—on the musculoskeletal system, the therapeutic use of these agents has received limited investigation within the field of orthopaedic surgery. In the last 2 decades, preclinical and clinical research has started to identify promising applications of the short-term use of AASs in the perioperative period. There is evidence to suggest that AASs may improve postoperative recovery after anterior cruciate ligament reconstruction and total joint arthroplasty. In addition, AASs may augment the biological healing environment in specific clinical scenarios including muscle injury, fracture repair, and rotator cuff repair. Current literature fails to present strong evidence for or against the use of AASs in orthopaedics, but there is continuous research on this topic. The purpose of this study was to provide a comprehensive overview of the current status of AAS applications in orthopaedic surgery, with an emphasis on preclinical data, clinical studies, and future directions.

Clinical efficiency of combination therapy using testosterone replacement therapy, phosphodiesterase 5 inhibitors and Kampo herbal medicine for eugonadal patients with late-onset hypogonadism syndrome

In the present study, the initial treatment efficiency of combination therapy using testosterone replacement therapy (TRT), herbal medicine and phosphodiesterase 5 inhibitors (PDE5i) in male patients with late-onset hypogonadism (LOH) were assessed. A total of 21 patients were enrolled and after 12 weeks, the clinical efficacy was evaluated based on improvement of LOH symptoms via laboratory parameters and several questionnaires, including the Ageing Males' Symptoms (AMS) scale. The overall AMS scores, as well as the psychological, physical and sexual AMS factors prior to and after treatment in the TRT, testosterone enanthate (T enanthate) monotherapy and T enanthate + PDE5i treatment groups were significantly improved. In the herbal medicine group, only the AMS physiological factors were significantly improved after treatment compared with the baseline. The improvement of the overall AMS scores, as well as the physiological and sexual AMS factors, were significantly negatively correlated with the free testosterone (FT) value prior to treatment. In conclusion, treatment with combination therapy using TRT, herbal medicine and PDE5i improved AMS scores in patients with LOH syndrome. Particularly in patients with LOH syndrome and low FT, the symptoms were significantly improved following combination therapy.

Structure-property and structure-activity relationships of phenylferrocene derivatives as androgen receptor antagonists

Ferrocene is a representative organometallic compound having a sandwich structure with high stability and hydrophobicity. In this study, we determined the physicochemical properties of a series of nitro- and cyanophenylferrocenes, and evaluated their biological activity as androgen receptor (AR) antagonists. Ferrocene derivatives exhibited hydrophobicity parameter π values in the range between 2.54 and 3.23, depending on the substituents, indicating that the hydrophobicity of ferrocene is suitable for its application as a hydrophobic core structure of nuclear receptor ligands. The synthesized ferrocene derivatives showed AR-antagonistic activity, and among them, 3-nitrophenylferrocene 14 exhibited the most potent activity with an IC₅₀ value of 0.28 μM. The developed compounds may be candidates for further structural development as AR antagonists. These findings also support the utility of organometallic species as structural options for drug discovery.

Age-Related Changes in the Testicular Morphophysiology of the Cane Rat (Thryonomys swinderianus)

This study evaluated age-related changes in the testicular morphophysiology of the cane rat (Thryonomys swinderianus) using histological, histochemical, and sex hormonal profile approaches. Twenty (20) pathogen-free male cane rats were used for the investigation. Cane rats were divided into four groups: prepubertal (≤4 months), pubertal (>4 ≤12 months), adult (>12 ≤30 months), and aged (>30 months) of 5 rats each. Blood was collected from the different cane rat groups and processed for sex serum hormonal levels. Testes were also excised and processed routinely for variations in histology, histochemistry (using Masson's trichrome [MT] and Periodic acid-Schiff [PAS]), and histomorphometric evaluations using GIMP2 software. Testosterone concentrations were significantly elevated (P < 0.05) in the prepubertal to adult, while there were no significant differences (P > 0.05) in this hormone between adult and aged. The concentrations of follicle-stimulating hormone (FSH) decreased significantly (P < 0.05) for prepubertal, pubertal, and adult, respectively. There were no significant differences (P > 0.05) between adult and aged for FSH and luteinizing hormone. Histologically, there were scanty interstitial cells, lack of patent lumen, and incomplete spermatogenetic cell series in prepubertal compared to other age groups. Testicular capsular (MT and PAS) staining intensity increased with age advancement, while in the parenchyma, remarkably high intensity was displayed by the pubertal compared to others. Seminiferous tubular and luminal diameters (LD) significantly (P < 0.05) increased with advancing age whereas epithelial height (EH) was markedly increased in pubertal relative to other groups. In conclusion, these sets of data have shown that reproductive activity is directly related to age and is at maximum in adult cane rat.

Anabolic androgenic steroid-induced hypogonadism, a reversible condition in male individuals? A systematic review

The anabolic-androgenic steroids (AAS) are clinically used as an androgen replacement, in hypogonadism treatment, to induce puberty, and also in the treatment of chronic degenerative diseases. The AAS use out of clinical context is becoming massively, being used merely for aesthetic reasons. AAS abuse may cause severe disarrangement on the HPG axis and generate a significant decrease in testosterone synthesis and secretion by the testes. This review aims to evaluate whether the hypogonadism induced by AAS abuse is reversible and under what circumstances the reversibility is possible. For this, PRISMA guidelines and several databases are used between July and September 2020. Altogether, this systematic review identified and analysed 179 cases of AAS users. Of these, 168 cases had the hypogonadism clearly diagnosed and proven to be linked exclusively to AAS abuse. However, between these 168 cases, only 38 cases presented fully known outcomes and among these, merely in 4, the hypogonadism was completely reversible (2 based on drug therapy) with HPG axis recovery. In conclusion, this review presents evidences that AAS-induced hypogonadism is a seriously underestimated problem, and in the majority of cases, full recovery is very difficult to succeed.

Physical and Psychological Effects of Gender-Affirming Hormonal Treatment Using Intramuscular Testosterone Enanthate in Japanese Transgender Men

INTRODUCTION

The evidence on gender-affirming hormonal treatment (HT) for transgender persons is still insufficient.

AIM

To characterize the physical and psychological effects of HT using testosterone enanthate in transgender men, and to validate the safety of this treatment.

METHODS

A total of 85 Japanese transgender men who were followed up for at least 1 year at our gender clinic from 2004 to 2017 were included in this study. All self-reported effects that they recognized and regularly acquired laboratory data were investigated after initiation of HT.

MAIN OUTCOME MEASURE

HT mainly using testosterone enanthate 250 mg every 2 weeks caused the most desired physical effects to appear promptly and effectively, whereas small but not negligible numbers of undesired physical and psychological effects were also confirmed.

RESULTS

The initial dose of testosterone enanthate was 250 mg for 72 (84.7%) subjects, and the injection interval was maintained every 2 weeks for 70 (82.3%). Most physical effects appeared within 6 months. A deepened voice (87.1%), cessation of menses (78.8%), acne (69.4%), and facial (52.9%)/body (37.6%) hair growth occurred within 3 months. Although recognition of psychological effects was rare, emotional instability (9.4%) and increased libido (7.1%) appeared in the relatively early phase after beginning HT. The mean values for red blood cells, hemoglobin, uric acid, and alkaline phosphatase were significantly increased for 2 year. During the observation period, there were no life-threatening adverse effects in any subjects.

CONCLUSION

The present HT strategy is effective and safe for Japanese transgender men. The information from self-reported effects and objective data from blood tests can help both physicians and transgender men to understand testosterone HT. Kirisawa T, Ichihara K, Sakai Y, et al. Physical and Psychological Effects of Gender-Affirming Hormonal Treatment Using Intramuscular Testosterone Enanthate in Japanese Transgender Men. Sex Med 2021;9:100306.

Development of Androgen-Antagonistic Coumarinamides with a Unique Aromatic Folded Pharmacophore

First-generation nonsteroidal androgen receptor (AR) antagonists, such as flutamide (2a) and bicalutamide (3), are effective for most prostate cancer patients, but resistance often appears after several years due to the mutation of AR. Second-generation AR antagonists are effective against some of these castration-resistant prostate cancers, but their structural variety is still limited. In this study, we designed and synthesized 4-methyl-7-(N-alkyl-arylcarboxamido)coumarins as AR antagonist candidates and evaluated their growth-inhibitory activity toward androgen-dependent SC-3 cells. Coumarinamides with a secondary amide bond did not show inhibitory activity, but their N-methylated derivatives exhibited AR-antagonistic activity. Especially, 19b and 31b were more potent than the lead compound 7b, which was comparable to hydroxyflutamide (2b). Conformational analysis showed that the inactive coumarinamides with a secondary amide bond have an extended structure with a trans-amide bond, while the active N-methylated coumarinamides have a folded structure with a cis-amide bond, in which the two aromatic rings are placed face-to-face. Docking study suggested that this folded structure is important for binding to AR. Selected coumarinamide derivatives showed AR-antagonistic activity toward LNCaP cells with T877A AR, and they had weak progesterone receptor (PR)-antagonistic activity. The folded coumarinamide structure appears to be a unique pharmacophore, different from those of conventional AR antagonists.

Human efflux transport of testosterone, epitestosterone and other androgen glucuronides

Several drug-metabolizing enzymes are known to control androgen homeostasis in humans. UDP-glucuronosyltransferases convert androgens to glucuronide conjugates in the liver and intestine, which enables subsequent elimination of these conjugated androgens via urine. The most important androgen is testosterone, while others are the testosterone metabolites androsterone and etiocholanolone, and the testosterone precursor dehydroepiandrosterone. Epitestosterone is another endogenous androgen, which is included as a crucial marker in urine doping tests. Since glucuronide conjugates are hydrophilic, efflux transporters mediate their excretion from tissues. In this study, we employed the membrane vesicle assay to identify the efflux transporters for glucuronides of androsterone, dehydroepiandrosterone, epitestosterone, etiocholanolone and testosterone. The human hepatic and intestinal transporters MRP2 (ABCC2), MRP3 (ABCC3), MRP4 (ABCC4), BCRP (ABCG2) and MDR1 (ABCB1) were studied in vitro. Of these transporters, only MRP2 and MRP3 transported the androgen glucuronides investigated. In kinetic analyses, MRP3 transported glucuronides of androsterone, epitestosterone and etiocholanolone at low K_m values, between 0.4 and 4 μM, while the K_m values for glucuronides of testosterone and dehydroepiandrosterone were 14 and 51 μM, respectively. MRP2 transported the glucuronides at lower affinity, as indicated by K_m values over 100 μM. Interestingly, the MRP2-mediated transport of androsterone and epitestosterone glucuronides was best described by sigmoidal kinetics. The inability of BCRP to transport any of the androgen glucuronides investigated is drastically different from its highly active transport of several estrogen conjugates. Our results explain the transporter-mediated disposition of androgen glucuronides in humans, and shed light on differences between the human efflux transporters MRP2, MRP3, MRP4, BCRP and MDR1.

Effect of Androgens on Anemia and Malnutrition in Renal Failure: Implications for Patients on Peritoneal Dialysis

Objective

To analyze the implications of the potential use of androgens in peritoneal dialysis patients, focusing on their effects on hematologic and nutritional parameters. This manuscript reviews the different compounds for clinical use, dosage schedules, adverse effects, and how therapy with androgens might be used to treat anemia and malnutrition in these dialysis patients.

Data Sources

Studies in the literature dealing with the effects of androgens on hematologic and nutritional parameters, and their role in uremic anemia and malnutrition.

Study Selection

Studies in which uremic patients received androgens as therapy for anemia or malnutrition.

Data Extraction

Data were abstracted from all of these studies.

Results

This review shows that androgens are anabolic substances that also have significant actions on erythropoiesis. A number of clinical studies in uremic patients have found that these compounds have beneficial effects on hematologic parameters and nutritional status, similarly to other therapies, such as recombinant human erythropoietin and recombinant human growth hormone, respectively.

Conclusions

Androgens have been shown to have a beneficial effect on anemia due to renal disease and on nutritional status in uremic patients. Further studies need to be done with larger groups of patients. Objectives for additional research are suggested.

Is There Room for SERMs or SARMs as Alternative Therapies for Adult Male Hypogonadism?

Hypogonadotropic hypogonadism (HH) can be sustained by organic or functional alterations of the hypothalamic-pituitary-testicular axis. Functional HH is related to systemic alterations, such as obesity or chronic inflammatory diseases, but could contribute to a negative course of the illness. For such situation, according to results obtained in infertile women, the administration of selective estrogen receptor modulators (SERMs) has been proposed in males too, with positive results on both metabolic and sexual function. This class of medications increases gonadotropin levels via antagonism to the estrogenic receptor; similar biological effects are also exerted by aromatase inhibitors (AIs), despite different mechanism of action. After a brief review of trials regarding SERMs and AIs use in male HH, we describe the structure and function of the androgen receptor (AR) as a basis for clinical research about compounds able to bind to AR, in order to obtain specific effects (SARMs). The tissue selectivity and different metabolic fate in comparison to testosterone can potentiate anabolic versus androgenic effects; therefore, they might be a valid alternative to testosterone replacement therapy avoiding the negative effects of testosterone (i.e., on prostate, liver, and hematopoiesis). Trials are still at an early phase of investigation and, at the moment, the application seems to be more useful for chronic disease with catabolic status while the validation as replacement for hypogonadism requires further studies.

Drug-induced endocrine blood pressure elevation

Patients with uncontrolled hypertension are at risk for cardiovascular complications. The majority of them suffers from unidentified forms of hypertension and a fraction has so-called secondary hypertension with an identifiable cause. The patient's medications, its use of certain herbal supplements and over-the-counter agents represent potential causal factors for secondary hypertension that are often overlooked. The current review focuses on drugs that are likely to elevate blood pressure by affecting the human endocrine system at the level of steroid synthesis or metabolism, mineralocorticoid receptor activity, or by affecting the catecholaminergic system. Drugs with known adverse effects but where benefits outweigh their risks, drug candidates and market withdrawals are reviewed. Finally, potential therapeutic strategies are discussed.

Androgen receptor modulators: a review of recent patents and reports (2012-2018)

INTRODUCTION

Androgen receptor (AR) is one of the most promising targets of drug discovery because of its importance in male reproductive systems and homeostasis of bone and muscle. Various AR-modulating agents have been developed and used clinically to treat androgen-dependent disorders, including prostate cancer, and some new-generation antiandrogens have recently been approved. Intensive studies are underway to develop various AR-modulating compounds, including conventional antagonists, tissue-specific AR modulators (SARMs), degraders, and nonconventional AR-modulating compounds that target sites other than the ligand-binding domain (LBD), such as the N-terminal domain (NTD) or the DNA-binding domain (DBD).

AREAS COVERED

The authors provide an overview of AR-modulating agents from 2012 to 2018.

EXPERT OPINION

The LBD has been the primary target for AR modulation, and important AR-modulating agents, including SARMs and recently approved antiandrogens such as enzalutamide and apalutamide, have been developed as conventional LBD antagonists. Development of LBD-targeting antiandrogens to treat prostate cancer is a kind of cat-and-mouse game between clinical agents and AR mutations, and therefore next-generation antiandrogens are still required. Development of nonconventional AR-modulating agents targeting NTD and DBD, is likely to be a promising approach to develop multiple and synergistic strategies able to overcome any kind of androgen-dependent condition.

Severe and protracted cholestasis in 44 young men taking bodybuilding supplements: assessment of genetic, clinical and chemical risk factors

BACKGROUND

Bodybuilding supplements can cause a profound cholestatic syndrome.

AIM

To describe the drug-Induced liver injury network's experience with liver injury due to bodybuilding supplements.

METHODS

Liver injury pattern, severity and outcomes, potential genetic associations, and exposure to anabolic steroids by product analysis were analysed in prospectively enrolled subjects with bodybuilding supplement-induced liver injury with causality scores of probable or higher.

RESULTS

Forty-four males (mean age 33 years) developed liver injury with a median latency of 73 days. Forty-one per cent presented with hepatocellular pattern of liver injury as defined by the R > 5 ([Fold elevation of ALT] ÷ [Fold elevation of Alk Phos] (mean, range = 6.4, 0.5-31.4, n = 42) despite all presenting with clinical features of cholestatic liver injury (100% with jaundice and 84% with pruritus). Liver biopsy (59% of subjects) demonstrated a mild hepatitis and profound cholestasis in most without bile duct injury, loss or fibrosis. Seventy-one per cent were hospitalised, and none died or required liver transplantation. In some, chemical analysis revealed anabolic steroid controlled substances not listed on the label. No enrichment of genetic variants associated with cholestatic syndromes was found, although mutations in ABCB11 (present in up to 20%) were significantly different than in ethnically matched controls.

CONCLUSIONS

Patients with bodybuilding supplements liver injury uniformly presented with cholestatic injury, which slowly resolved. The ingested products often contained anabolic steroids not identified on the label, and no enrichment in genetic variants was found, indicating a need for additional studies.

Evaluation of the effectiveness and safety of a daily dose of 5 mg of tadalafil, over an 8-week period, for improving quality of life among Korean men with andropause symptoms, including erectile dysfunction: A pilot study

BACKGROUND

The primary aim of this study was to evaluate the effects of a once-a-day 5 mg dose of tadalafil, prescribed for 8 weeks, on the quality of life (QoL) of South Korean men with andropause symptoms, including erectile dysfunction (ED), using a single group, open-labeled, before-and-after preliminary trial. The secondary objective was to evaluate the effectiveness and safety of tadalafil for ED.

METHODS

Forty South Korean men (>35 years of age) with andropause symptoms including ED were enrolled into our trial. Andropause syndrome was defined using the androgen deficiency in aging males (ADAM) questionnaire and other screening tests, including testosterone levels. The following outcome measures were obtained at baseline and at 4 and 8 weeks of tadalafil treatment: physical examination, adverse effects, Short Form 12 Health Survey (SF-12) score, International Index of Erectile Function (IIEF-5) score, bioelectrical impedance analysis (BIA), and free radical testing.

RESULTS

Treatment increased the SF-12 Mental component score, used as a proxy measure of quality of life, from baseline to at 4 and 8 weeks (P < .05). In addition, the mean IIEF-5 score, which assesses sexual function, increased from baseline at 4 and 8 weeks (P < .05), with this increase being significant at both time points. No adverse effects were noted.

CONCLUSION

Tadalafil (5 mg dose, once daily) is a safe and effective treatment to improve ED, and overall QoL, among Korean men with andropause symptoms, including ED.

Transdermal applications of ethosomes - a detailed review

Skin, the largest organ of the body serves as a potential route of drug delivery for local and systemic effects. However, the outermost layer of skin, the stratum corneum (SC) acts as a tough barrier that prevents penetration of hydrophilic and high molecular weight drugs. Ethosomes are a novel phospholipid vesicular carrier containing high ethanol concentrations and offer improved skin permeability and efficient bioavailability due to their structure and composition. This article gives a review of ethosomes including their compositions, types, mechanism of drug delivery, stability, and safety behaviour. This article also provides a detailed overview of drug delivery applications of ethosomes in various diseases.

Functional and structural changes in internal pudendal arteries underlie erectile dysfunction induced by androgen deprivation

Androgen deficiency is strongly associated with erectile dysfunction (ED). Inadequate penile arterial blood flow is one of the major causes of ED. The blood flow to the corpus cavernosum is mainly derived from the internal pudendal arteries (IPAs); however, no study has evaluated the effects of androgen deprivation on IPA's function. We hypothesized that castration impairs IPAs reactivity and structure, contributing to ED. In our study, Wistar male rats, 8-week-old, were castrated and studied 30 days after orchiectomy. Functional and structural properties of rat IPAs were determined using wire and pressure myograph systems, respectively. Protein expression was determined by Western blot and immunohistochemistry. Plasma testosterone levels were determined using the IMMULITE 1000 Immunoassay System. Castrated rats exhibited impaired erectile function, represented by decreased intracavernosal pressure/mean arterial pressure ratio. IPAs from castrated rats exhibited decreased phenylephrine- and electrical field stimulation (EFS)-induced contraction and decreased acetylcholine- and EFS-induced vasodilatation. IPAs from castrated rats exhibited decreased internal diameter, external diameter, thickness of the arterial wall, and cross-sectional area. Castration decreased nNOS and α-actin expression and increased collagen expression, p38 (Thr180/Tyr182) phosphorylation, as well as caspase 3 cleavage. In conclusion, androgen deficiency is associated with impairment of IPA reactivity and structure and increased apoptosis signaling markers. Our findings suggest that androgen deficiency-induced vascular dysfunction is an event involving hypotrophic vascular remodeling of IPAs.

Side effects of anabolic steroids used by athletes at Unaizah Gyms, Saudi Arabia: a pilot study

BACKGROUND

A large number of Saudi athletes are recently shown to use androgenic anabolic steroid (AAS) products to achieve rapid muscle growth without realizing the serious health risks of these drugs. Aim of this study was to elucidate the side effects encountered with prolonged use of AAS products by Saudi athletes.

METHODS

A cross-sectional study was conducted, in which 16 regular gym members, 12 of them used AAS, were asked to answer a questionnaire and provide blood samples following current AAS course completion. Hemoglobin, serum proteins, lipid profile and hematological parameters were measured. Meanwhile, the parameters of kidneys, liver, heart, and immune system function were monitored.

RESULTS

The subjects reported taking a 3-month course of an AAS comprising three compounds (testosterone enanthate, nandrolone decanoate and methandienone). A two-week gap separated every two courses, during which tamoxifen citrate (40 mg per day) and clomiphene citrate (10 mg per day) were taken to control serum testosterone levels. The intake of AAS one course had remarkable effects on some parameters related to kidney function. However, AAS three courses or more treatments showed abnormal liver and heart enzymes. Moreover, endogenous testosterone levels decreased dramatically with prolonged use of AAS (more than 10 courses). Alpha 2 protein increased by taking more than 10 courses, which might cause acute phase reactant of liver infection or inflammation.

CONCLUSIONS

AAS products must be controlled by Saudi ministry of health and should not be taken randomly without the supervision of the healthcare professional.

Genomic and non-genomic effects of androgens in the cardiovascular system: clinical implications

The principle steroidal androgens are testosterone and its metabolite 5α-dihydrotestosterone (DHT), which is converted from testosterone by the enzyme 5α-reductase. Through the classic pathway with androgens crossing the plasma membrane and binding to the androgen receptor (AR) or via mechanisms independent of the ligand-dependent transactivation function of nuclear receptors, testosterone induces genomic and non-genomic effects respectively. AR is widely distributed in several tissues, including vascular endothelial and smooth muscle cells. Androgens are essential for many developmental and physiological processes, especially in male reproductive tissues. It is now clear that androgens have multiple actions besides sex differentiation and sexual maturation and that many physiological systems are influenced by androgens, including regulation of cardiovascular function [nitric oxide (NO) release, Ca²⁺ mobilization, vascular apoptosis, hypertrophy, calcification, senescence and reactive oxygen species (ROS) generation]. This review focuses on evidence indicating that interplay between genomic and non-genomic actions of testosterone may influence cardiovascular function.

Structure-Based Approach To Identify 5-[4-Hydroxyphenyl]pyrrole-2-carbonitrile Derivatives as Potent and Tissue Selective Androgen Receptor Modulators

In an effort to find new and safer treatments for osteoporosis and frailty, we describe a novel series of selective androgen receptor modulators (SARMs). Using a structure-based approach, we identified compound 7, a potent AR (ARE EC₅₀ = 0.34 nM) and selective (N/C interaction EC₅₀ = 1206 nM) modulator. In vivo data, an AR LBD X-ray structure of 7, and further insights from modeling studies of ligand receptor interactions are also presented.

Effects of testosterone administration on liver structure and function in aging rats

Aging males have a decrease in testosterone levels, by which the testosterone treatment may influence in a negatively fashion the liver.

AIM

This study aimed to analyze the effects of aging with or without testosterone administration on the liver components of animals.

METHODS

Wistar rats were divided into three groups: 20 months' group (G20), 24 months' group (G24), group treated with testosterone for 16 weeks (GT). All groups were sacrificed at 24 months except for G20 that was sacrificed at 20 months.

RESULTS

Aging and testosterone treatment alters the body weight (BW), liver weight (LW) and relative liver weight. Besides, testosterone increased the mitogen capacity of hepatocytes. Nonetheless, we reinforce the negative effects of testosterone on old animals' liver as chronic hepatic congestion and/or cholestasis. In addition, we observed that testosterone plays an important role on hepatic glycogen stores.

CONCLUSIONS

Our study showed many implications for the knowledge about the effects of aging with or without testosterone administration on old animals' liver.

Normalization of Testosterone Levels After Testosterone Replacement Therapy Is Not Associated With Reduced Myocardial Infarction in Smokers

Objective

To examine the effect of cigarette smoking (CS) status and total testosterone (TT) levels after testosterone replacement therapy (TRT) on all-cause mortality, myocardial infarction (MI), and stroke in male smokers and nonsmokers without history of MI and stroke.

Participants and Methods

Data from 18,055 males with known CS status and low TT levels who received TRT at the Veterans Health Administration between December 1, 1999, and May 31, 2014, were grouped into (1) current smokers with normalized TT, (2) current smokers with nonnormalized TT, (3) nonsmokers with normalized TT, and (4) nonsmokers with nonnormalized TT. Combined effect of CS status and TT level normalization after TRT on all-cause mortality, MI, and stroke was compared using propensity score–weighted Cox proportional hazard models.

Results

Normalization of serum TT levels in nonsmokers was associated with a significant decrease in all-cause mortality (hazard ratio [HR]=0.526; 95% CI, 0.477-0.581; P<.001) and MI (HR=0.717; 95% CI, 0.522-0.986; P<.001). Among current smokers, normalization of serum TT levels was associated with a significant decrease in only all-cause mortality (HR=0.563; 95% CI, 0.488-0.649; P<.001) without benefit in MI (HR=1.096; 95% CI, 0.698-1.720; P=.69). Importantly, compared with nonsmokers with normalized TT, all-cause mortality (HR=1.242; 95% CI, 1.104-1.396; P<.001), MI (HR=1.706; 95% CI, 1.242-2.342; P=.001), and stroke (HR=1.590; 95% CI, 1.013-2.495; P=.04) were significantly higher in current smokers with normalized TT.

Conclusion

We conclude that active CS may negate the protective effect of testosterone level normalization on all-cause mortality and MI after TRT.

Male subfertility as a chronic illness: the role of adaptive challenges

Male factor infertility (MFI) is extremely common, often with several associated chronic health conditions. Because a man's fertility assessment may be their first contact with health services, the health care team has a responsibility to act as male health advocates to ensure comprehensive care. The diagnosis of subfertility allows a broader view of these men as patients with a chronic illness who have complex health needs. Because of the associated complexity of care following evaluation, there needs to be new approach in how men affected by MFI should be managed long term. In this commentary, we propose that the Adaptive Leadership Framework model for Chronic Illness is a suitable vehicle to use for management of the MFI patient's journey towards optimized health.

Protective effects of physiological testosterone on advanced glycation end product‑induced injury in human endothelial cells

The effect of testosterone, a sex steroid, on endothelial cells is controversial as it is uncertain if it has a protective effect on them. Whether physiological testosterone can inhibit the deleterious effects of advanced glycation end products (AGEs) on endothelial cells remains to be elucidated. The present study focused on elucidating the effect of testosterone on the injury of endothelial cells induced by AGEs. Human umbilical vein endothelial cells (HUVECs) were cultured in vitro and treated with AGEs in the presence or absence of various concentrations of testosterone. The cell viability in each group was measured using an MTS assay. Early-stage apoptosis was detected using flow cytometry with Annexin V-fluorescein isothiocyanate/propidium iodide double staining, and the expression levels of apoptosis-associated proteins, B cell lymphoma-2 (Bcl-2), Bcl-2-associated X protein (Bax) and caspase-3, were determined using western blot analysis. Oxidative stress and pro-inflammatory parameters in the medium were evaluated using an enzyme-linked immunosorbent assay. The MTS results showed that AGEs significantly decreased the proliferation of HUVECs, whereas a physiological concentration of testosterone alleviated this damage. Physiological concentrations of testosterone protected the HUVECs from AGE-induced apoptosis, mediated by caspase-3 and Bax/Bcl-2. In addition, treatment of the HUVECs with AGEs caused a significant decrease in anti-oxidative parameters, but increased the concentrations of malondialdehyde and tumor necrosis factor-α. The activation of Janus kinase 2 and signal transducer and activator of transcription 3 was significantly increased by incubation with AGEs. However, pre-incubation with a physiological concentration of testosterone attenuated these changes. Therefore, the data obtained in the present study established the potential role of physiological testosterone in ameliorating AGE-induced damage in HUVECs.

The Effect of Testosterone on Men With Andropause

BACKGROUND

Andropause is the gradual reduction of the male sex hormone (testosterone) with increasing age. Its symptoms are sexual dysfunction, weakness, fatigue, insomnia, loss of motivation, mood disorders and reduction of bone density. Treatment of andropause with testosterone has been recently considered.

OBJECTIVES

The aim of this study was to evaluate the effect of testosterone in the treatment of andropause in men.

PATIENTS AND METHODS

For men who met the inclusion criteria (50 years of age and older) laboratory tests and clinical examinations were conducted by an urologist in order to diagnose prostate cancer, prostate disease, urinary tract infection and active urinary retention. After obtaining consent, the patients were enrolled in the study. Data were analyzed using SPSS version 20. Descriptive statistics (frequency and percentage, mean, standard deviation) and the paired t-test were used to compare levels of testosterone. To determine the correlation between age and testosterone levels, the Pearson correlation was used. Finally, to compare the treatment processes during the treatment period the repeated measures ANOVA was used.

RESULTS

The mean age of patients was 56.57 ± 3.21 years. A total of 31 patients (39%) were smokers, among them 30% smoked daily, 2.5% weekly and 6% smoked for fun. The mean testosterone level before treatment was 240.6 ± 125.4 and at 1, 3 and 6 months after treatment the level was raised, so that at the end of the sixth months it was 578.7 ± 141.7. The level of increase was statistically significant (P = 0.0001).

CONCLUSIONS

Treatment with testosterone in men over 50 years with andropause will increase testosterone levels and also quality of life, sexual desire, erection, energy levels, ability to exercise and feel the joy of life more than before. Depression was decreased and they had sleepy feelings after dinner.

Dehydroepiandrosterone and 7-oxo-dehydroepiandrosterone in male reproductive health: Implications of differential regulation of human Sertoli cells metabolic profile

Dehydroepiandrosterone (DHEA) is a precursor of androgen synthesis whose action is partially exerted through its metabolites. 7-Oxo-dehydroepiandrosterone (7-oxo-DHEA) is a common DHEA metabolite, non-convertible to androgens, which constitutes a promising therapeutic strategy for multiple conditions. Sertoli cells (SCs) are responsible for the support of spermatogenesis, having unique metabolic characteristics strongly modulated by androgens. Consequently, disruptions in androgen synthesis compromise SCs function and hence male fertility. We aimed to evaluate the effects of DHEA and 7-oxo-DHEA in human SCs (hSCs) metabolism and oxidative profile. To do so, hSCs were exposed to increasing concentrations of DHEA and 7-oxo-DHEA (0.025, 1 and 50 μM) that revealed to be non-cytotoxic in these experimental conditions. We measured hSCs metabolites consumption/production by (1)H NMR, the protein expression levels of key players of the glycolytic pathway by Western blot as well as the levels of carbonyl groups, nitration and lipid peroxidation by Slot blot. The obtained data demonstrated that 7-oxo-DHEA is a more potent metabolic modulator than DHEA since it increased hSCs glycolytic flux. DHEA seem to redirect hSCs metabolism to the Krebs cycle, while 7-oxo-DHEA has some inhibitory effect in this path. The highest 7-oxo-DHEA concentrations (1 and 50 μM) also increased lactate production, which is of extreme relevance for the successful progression of spermatogenesis in vivo. None of these steroids altered the intracellular oxidative profile of hSCs, illustrating that, at the concentrations used they do not have pro- nor antioxidant actions in hSCs. Our study represents a further step in the establishment of safe doses of DHEA and 7-oxo-DHEA to hSCs, supporting its possible use in hormonal and non-hormonal therapies against male reproductive problems.

Infectious disease, injection practices, and risky sexual behavior among anabolic steroid users

Anabolic-androgenic steroids (AAS) and other performance-enhancing drugs (PEDs) are commonly misused to increase muscle size and strength, as well as improve physical appearance. Many AAS and certain PEDs are administered via injection and therefore pose a risk for transmission of infectious diseases such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and skin and soft tissue infections (SSTIs). Further, AAS users may be more likely to take part in high-risk sexual behaviors than non-AAS users. This review explores the prevalence of infectious diseases as well as risky injection practices and sexual behaviors of AAS users in the current literature. A comprehensive MEDLINE search (1984-17 April 2015) for English language reports was performed on AAS users. Ten studies analyzed the prevalence of HIV infection, 6 studies analyzed HBV infection, and 6 studies analyzed HCV infection; 20 studies analyzed injection practices and 7 studies analyzed high-risk sexual behaviors of AAS users. HIV, HBV, HCV, and SSTIs have been associated with AAS users. In particular, HIV infection seems much higher among homosexual male AAS users. AAS users also take part in high-risk injection practices but to a much lower extent than intravenous drug users. AAS users are also more likely to engage in high-risk sexual behaviors than the general population. Clinicians and health-policy leaders may utilize these findings to implement strategies to decrease the spread of infectious diseases.

The Use of HCG-Based Combination Therapy for Recovery of Spermatogenesis after Testosterone Use

INTRODUCTION AND AIM

About 3 million men take testosterone in the United States with many reproductive-age men unaware of the negative impact of testosterone supplementation on fertility. Addressing this population, we provide an early report on the use of human chorionic gonadotropin (HCG)-based combination therapy in the treatment of a series of men with likely testosterone-related azoospermia or severe oligospermia.

METHODS

We retrospectively reviewed charts from two tertiary care infertility clinics to identify men presenting with azoospermia or severe oligospermia (<1 million sperm/mL) while taking exogenous testosterone. All were noted to have been placed on combination therapy, which included 3,000 units HCG subcutaneously every other day supplemented with clomiphene citrate, tamoxifen, anastrozole, or recombinant follicle-stimulating hormone (or combination) according to physician preference.

MAIN OUTCOME MEASURE

Clinical outcomes, including hormone values, semen analyses, and clinical pregnancies, were tracked.

RESULTS

Forty-nine men were included in this case series. Return of spermatogenesis for azoospermic men or improved counts for men with severe oligospermia was documented in 47 men (95.9%), with one additional man (2.1%) having a documented pregnancy without follow-up semen analysis. The average time to return of spermatogenesis was 4.6 months with a mean first density of 22.6 million/mL. There was no significant difference in recovery by type of testosterone administered or supplemental therapy. No men stopped HCG or supplemental medications because of adverse events.

CONCLUSIONS

We here provide an early report of the feasibility of using combination therapy with HCG and supplemental medications in treating men with testosterone-related infertility. Future discussion and studies are needed to further characterize this therapeutic approach and document the presumed improved tolerability and speed of recovery compared with unaided withdrawal of exogenous testosterone.

Gynaecomastia--pathophysiology, diagnosis and treatment

Gynaecomastia (enlargement of the male breast tissue) is a common finding in the general population. Most cases of gynaecomastia are benign and of cosmetic, rather than clinical, importance. However, the condition might cause local pain and tenderness, could occasionally be the result of a serious underlying illness or a medication, or be inherited. Breast cancer in men is much less common than benign gynaecomastia, and the two conditions can usually be distinguished by a careful physical examination. Estrogens are known to stimulate the growth of breast tissue, whereas androgens inhibit it; most cases of gynaecomastia result from deficient androgen action or excessive estrogen action in the breast tissue. In some cases, such as pubertal gynaecomastia, the breast enlargement resolves spontaneously. In other situations, more active treatment might be required to correct an underlying condition (such as hyperthyroidism or a benign Leydig cell tumour of the testis) or medications that could cause breast enlargement (such as spironolactone) might need to be discontinued. For men with hypogonadism, administration of androgens might be helpful, as might antiestrogen therapy in men with endogenous overproduction of estrogens. Surgery to remove the enlarged breast tissue might be necessary when gynaecomastia does not resolve spontaneously or with medical therapy.

DNA replication-dependent induction of gene proximity by androgen

The male hormone androgen, working through the androgen receptor (AR), plays a major role in physiological process and disease development. Previous studies of AR mainly focus on its transcriptional activity. Here, we found that androgen-induced TMPRSS2 and ERG gene proximity is mediated by AR control of DNA replication rather than gene transcription. We demonstrate that, in both AR transactivation-positive and -negative prostate cells, androgen regulates DNA replication and androgen-induced gene proximity relies on both DNA replication-licensing and actual DNA replication activity. Androgen stimulation advances DNA replication timing of certain genomic regions, which may potentially increase gene proximity through sharing the same replication factory at a similar time. Therefore, we have revealed novel mechanisms of AR biological function, which will stimulate new research directions.