Treating exercise-associated low testosterone and its related symptoms

Original investigation: manipulating energy availability in male endurance runners: a randomised controlled trial

This study investigated the effect of 4 days low energy availability (LEA) on physiological markers and mood states in male endurance runners. Twelve participants (mean (standard deviation); age: 25.8 (3.8) years; fat-free mass (FFM): 52.8 (5.5) kg) completed three 4-day conditions: adequate energy availability (AEA): 45 kcal/kg FFM/day; LEA1: 30 kcal/kg FFM/day; and LEA2: 15 kcal/kg FFM/day, in a randomized order. Participants ran on a treadmill at 65% of V̇O2max until they expended 15 kcal/kg FFM/day of energy. Energy intake was adjusted to achieve the desired energy availability. Pre- and post-measurements of bone turnover, metabolism, testosterone and estradiol (plasma), resting metabolic rate (indirect calorimetry), and mood states (Brunel Mood Scale) were assessed. The results reported a significant decrease in testosterone (condition × time interaction, p = 0.03) occurred on LEA2 (Pre: 23.8 (7.0) nmol/L vs. Post: 20.3 (7.7) nmol/L) compared with AEA (Pre: 22.9 (5.5) nmol/L vs. Post: 23.3 (6.1) nmol/L) or LEA1 (Pre: 23.6 (8.6) nmol/L vs. Post: 20.9 (8.8) nmol/L). Fatigue level significantly increased (condition × time interaction, p = 0.02) in LEA2 (Pre: 3.5 (1.7) vs. Post: 6.5 (2.9)) but did not change in AEA (Pre: 2.8 (1.5) vs. Post: 2.5 (2.7)) or LEA1 (Pre: 2.8(2.4) vs. Post: 2.9 (2.0)). Other measures were unaffected by the interventions. In conclusion, this study suggests that testosterone and fatigue may serve as early indicators of LEA in male runners. However, other physiological markers and mood states appeared largely unaffected, aligning with existing literature indicating minimal disruption of physiological functions during acute LEA in male athletes. Study registration: Australian New Zealand Clinical Trials Registry (Trial No.: 381278).

Dose-response association between 24-hour total movement activity and testosterone deficiency in adult males

Background and objectives

Previous studies on the relationship between physical activity and testosterone are limited and controversial. Hence we investigated whether high level of physical activity is associated with a low risk of testosterone deficiency (TD).

Methods

This cross-sectional analysis was conducted in a representative sample of US adult males who participated in the 2011-2014 cycle of the National Health and Nutrition Examination Survey (NHANES). We used the monitor independent movement summary (MIMS) to assess activity intensity, a novel physical activity metrics developed using raw data collected by accelerometers. Multivariable regression and smooth curve fitting was used to describe the relationships between physical activity and TD, and segmented regression model were used to analyze the threshold effect between them. Sensitivity analysis was conducted using interaction and stratified analysis.

Results

A U-shaped relationship between daily MIMS units and risk of TD was observed. The optimal value of daily MIMS units for the lowest risk of TD was 14.77 (×103), the risk of TD decreased by 5% in patients per unit increase of daily MIMS units when daily MIMS units <14.77 (×103) (adjusted OR = 0.95, 95%CI: 0.91, 0.99), but increased by 12% per unit increase of daily MIMS units when daily MIMS units ≥14.77 (×103) (adjusted OR = 1.12, 95%CI: 1.01, 1.23). In sensitivity analyses, the threshold effect was also similar according to baseline characteristics (P-interaction >0.05).

Conclusion

In a nationally representative sample of US adult males, light to moderate intensity physical activity is associated with a lower odds of TD, while high-intensity physical activity is associated with a higher risk of TD.

Sea cucumber peptides positively regulate sexual hormones in male mice with acute exhaustive swimming: possibly through the Ca2+/PKA signaling pathway

Sea cucumber peptides (SCPs) have been proven to have many active functions; however, their impact on testosterone synthesis and the corresponding mechanism are not yet clear. This study attempts to explore the effects of SCPs on sex hormone regulation in acute exhaustive swimming (AES) male mice and the possible mechanisms. In the present study, SCP intervention significantly prolonged exhaustive swimming time and reduced exercise metabolite accumulation. The reproductive ability-related parameters including penile index, mating ability, testicular morphology, and sperm storage were dramatically improved by SCP intervention. Notably, SCPs markedly reversed the AES-induced decrease in serum testosterone (T), estradiol (E2), and follicle-stimulating hormone (FSH) levels. Moreover, treatment with a high dose of SCP (0.6 mg per g bw) significantly enhanced the expression of testosterone synthesis-related proteins in testis, meanwhile markedly increasing the gene expression of StAR, Hsd17b3, Hsd17b2, Ldlr, and Cyp19a1. Serum metabolomics results indicated that SCP intervention notably upregulated the expression of 1-stearoyl-2-arachidonoyl-sn-glycerol but downregulated the concentrations of succinate and DL-lactate. Furthermore, serum metabolomics combined with testicular transcriptome, western blot, and correlation analyses demonstrated that SCPs may regulate testosterone synthesis via the Ca2+/PKA signaling pathway. This study indicated that the SCP could be a potential dietary supplement to improve the symptoms of decreased sex hormones related to exercise fatigue.

Signs of low energy availability in elite male volleyball athletes but no association with risk of bone stress injury and patellar tendinopathy

Relative Energy Deficiency in Sport (RED-S) syndrome is associated with undesirable health and performance outcomes. The aetiology of RED-S syndrome is low energy availability (LEA). LEA has been reported in male athletes in various sports, but there is little information in team sports. Therefore, the aims of this study were to assess the point-prevalence of surrogate markers of LEA in elite male volleyball players and examine the association between low and normal total-testosterone (TES) on endocrine markers, resting metabolic rate, bone mineral density (BMD), and history of injury/illness. Using a cross-sectional design, 22 elite male volleyball players underwent anthropometric, dual-energy X-ray absorptiometry (DEXA or DXA) and resting metabolic rate testing, bloodwork, dietary analysis, the three-factor eating questionnaire-R18, injury/illness questionnaire and Victorian Institute of Sport Assessment - patellar tendon questionnaire. The primary finding of this investigation was that 36% of athletes had ≥2 surrogate markers of LEA. Although fasted insulin was lower and cortisol was higher in players with low-total TES, low BMD, low RMR and various other endocrine markers linked to LEA were not observed. More research is required to define surrogate markers of LEA in male athletes.HIGHLIGHTS Thirty-six percent of volleyball players had ≥2 surrogate markers of LEA.The Cunningham, 1991 predictive RMR equation and/or the cut-off point (<0.9) may be unsuitable for detecting energy conservation associated with LEA in large male athletes.There was no association between total-TES and risk of bone stress injury, illness and patellar tendinopathy.

Review of the scientific rationale, development and validation of the International Olympic Committee Relative Energy Deficiency in Sport Clinical Assessment Tool: V.2 (IOC REDs CAT2)-by a subgroup of the IOC consensus on REDs

Relative Energy Deficiency in Sport (REDs) has various different risk factors, numerous signs and symptoms and is heavily influenced by one's environment. Accordingly, there is no singular validated diagnostic test. This 2023 International Olympic Committee's REDs Clinical Assessment Tool-V.2 (IOC REDs CAT2) implements a three-step process of: (1) initial screening; (2) severity/risk stratification based on any identified REDs signs/symptoms (primary and secondary indicators) and (3) a physician-led final diagnosis and treatment plan developed with the athlete, coach and their entire health and performance team. The CAT2 also introduces a more clinically nuanced four-level traffic-light (green, yellow, orange and red) severity/risk stratification with associated sport participation guidelines. Various REDs primary and secondary indicators have been identified and 'weighted' in terms of scientific support, clinical severity/risk and methodological validity and usability, allowing for objective scoring of athletes based on the presence or absence of each indicator. Early draft versions of the CAT2 were developed with associated athlete-testing, feedback and refinement, followed by REDs expert validation via voting statements (ie, online questionnaire to assess agreement on each indicator). Physician and practitioner validity and usability assessments were also implemented. The aim of the IOC REDs CAT2 is to assist qualified clinical professionals in the early and accurate diagnosis of REDs, with an appropriate clinical severity and risk assessment, in order to protect athlete health and prevent prolonged and irreversible outcomes of REDs.

2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs)

Relative Energy Deficiency in Sport (REDs) was first introduced in 2014 by the International Olympic Committee's expert writing panel, identifying a syndrome of deleterious health and performance outcomes experienced by female and male athletes exposed to low energy availability (LEA; inadequate energy intake in relation to exercise energy expenditure). Since the 2018 REDs consensus, there have been >170 original research publications advancing the field of REDs science, including emerging data demonstrating the growing role of low carbohydrate availability, further evidence of the interplay between mental health and REDs and more data elucidating the impact of LEA in males. Our knowledge of REDs signs and symptoms has resulted in updated Health and Performance Conceptual Models and the development of a novel Physiological Model. This Physiological Model is designed to demonstrate the complexity of either problematic or adaptable LEA exposure, coupled with individual moderating factors, leading to changes in health and performance outcomes. Guidelines for safe and effective body composition assessment to help prevent REDs are also outlined. A new REDs Clinical Assessment Tool-Version 2 is introduced to facilitate the detection and clinical diagnosis of REDs based on accumulated severity and risk stratification, with associated training and competition recommendations. Prevention and treatment principles of REDs are presented to encourage best practices for sports organisations and clinicians. Finally, methodological best practices for REDs research are outlined to stimulate future high-quality research to address important knowledge gaps.

Methodology for studying Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the International Olympic Committee (IOC) consensus on REDs

In the past decade, the study of relationships among nutrition, exercise and the effects on health and athletic performance, has substantially increased. The 2014 introduction of Relative Energy Deficiency in Sport (REDs) prompted sports scientists and clinicians to investigate these relationships in more populations and with more outcomes than had been previously pursued in mostly white, adolescent or young adult, female athletes. Much of the existing physiology and concepts, however, are either based on or extrapolated from limited studies, and the comparison of studies is hindered by the lack of standardised protocols. In this review, we have evaluated and outlined current best practice methodologies to study REDs in an attempt to guide future research.This includes an agreement on the definition of key terms, a summary of study designs with appropriate applications, descriptions of best practices for blood collection and assessment and a description of methods used to assess specific REDs sequelae, stratified as either Preferred, Used and Recommended or Potential Researchers can use the compiled information herein when planning studies to more consistently select the proper tools to investigate their domain of interest. Thus, the goal of this review is to standardise REDs research methods to strengthen future studies and improve REDs prevention, diagnosis and care.

Primary, secondary and tertiary prevention of Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the IOC consensus on REDs

Relative Energy Deficiency in Sport (REDs) is common among female and male athletes representing various sports at different performance levels, and the underlying cause is problematic low energy availability (LEA). It is essential to prevent problematic LEA to decrease the risk of serious health and performance consequences. This narrative review addresses REDs primary, secondary and tertiary prevention strategies and recommends best practice prevention guidelines targeting the athlete health and performance team, athlete entourage (eg, coaches, parents, managers) and sport organisations. Primary prevention of REDs seeks to minimise exposure to and reduce behaviours associated with problematic LEA. Some of the important strategies are educational initiatives and de-emphasising body weight and leanness, particularly in young and subelite athletes. Secondary prevention encourages the early identification and management of REDs signs or symptoms to facilitate early treatment to prevent development of more serious REDs outcomes. Recommended strategies for identifying athletes at risk are self-reported screening instruments, individual health interviews and/or objective assessment of REDs markers. Tertiary prevention (clinical treatment) seeks to limit short-term and long-term severe health consequences of REDs. The cornerstone of tertiary prevention is identifying the source of and treating problematic LEA. Best practice guidelines to prevent REDs and related consequences include a multipronged approach targeting the athlete health and performance team, the athlete entourage and sport organisations, who all need to ensure a supportive and safe sporting environment, have sufficient REDs knowledge and remain observant for the early signs and symptoms of REDs.

New perspectives in functional hypogonadotropic hypogonadism: beyond late onset hypogonadism

Functional hypogonadotropic hypogonadism (FHH) is an increasingly frequent condition, whose pathological mechanisms are not yet fully clarified. The concept of FHH has now completely replaced that of late onset hypogonadism, that only concerned the ageing man. FHH is the result of an impairment of the hypothalamic-pituitary gonadal axis (HPG-A) function, resulting in decreased testosterone concentrations associated with low or inappropriately normal gonadotropin levels and infertility; it can be diagnosed once organic causes of hypogonadism are excluded. The growing occurrence of FHH derives from its association with widespread conditions, such as obesity and diabetes mellitus, but also to the increasing ease and frequency of use of several drugs, such as opioids, glucocorticoids, and sex steroids. Moreover, given the tendency of many subjects to excessive physical activity and drastic reduction in caloric intake, FHH may also be secondary to low energy availability. Finally, the association with HIV infection should not be overlooked. Therefore, there is an important variability in the diseases that can lead to FHH. Despite the heterogeneity of the underlying pathologies, the mechanisms leading to FHH would seem quite similar, with the initial event represented by the impairment at the HPG-A level. Nevertheless, many different biological pathways are involved in the pathogenesis of FHH, therefore the aim of the current paper is to provide an overview of the main relevant mechanisms, through a detailed analysis of the literature, focusing specifically on pathogenesis and clinical, diagnostic and therapeutic aspects.

Effects of Bushen Yiyuan recipe on testosterone synthesis in Leydig cells of rats with exercise-induced low serum testosterone levels

CONTEXT

Bushen Yiyuan recipe (BYR) is an effective Chinese prescription with antifatigue and antioxidation effects.

OBJECTIVE

The effects of BYR on testosterone synthesis in rat Leydig cells with exercise-induced low serum testosterone levels (EILST) are assessed.

MATERIALS AND METHODS

Thirty-two Sprague-Dawley rats were chronically trained for 6 weeks to establish an EILST model. EILST rats were divided into model (physiological saline), EFE (700 mg/kg ethanol extract of Epimedii folium, the dried leaves of Epimedium brevicornu Maxim [Berberidaceae]), and BYR groups (350 and 700 mg/kg) for 6 weeks. Expression of HMG-CoA, LDL-R, SR-BI, STAR and CYP11A1 were quantified by RT qPCR and Western blots.

RESULTS

Compared with the model group (115.52 ± 13.05 μg/dL; 67.83 ± 14.29; 0.32 ± 0.04; 0.33 ± 0.02; 0.38 ± 0.01), serum testosterone, testosterone/cortisol ratio, HMG-CoA, STAR and CYP11A1 relative protein expression significantly increased in low-dose BYR (210.60 ± 5.08 μg/dL; 119.38 ± 13.02; 0.47 ± 0.01; 0.46 ± 0.03; 0.46 ± 0.02), high-dose BYR (220.57 ± 14.71 μg/dL; 124.26 ± 14.79; 0.49 ± 0.02; 0.42 ± 0.03; 0.51 ± 0.02), and EFE groups (206.83 ± 5.54 μg/dL; 119.53 ± 25.04; 0.45 ± 0.02; 0.42 ± 0.02; 0.41 ± 0.02) (all p < 0.01, except for CYP11A1 in EFE group). HMG-CoA, STAR and CYP11A1 mRNA relative expression significantly increased in low-dose and high-dose BYR group compared to model group (all p < 0.01).

CONCLUSIONS

BYR affects endogenous cholesterol synthesis and testosterone synthesis to prevent and treat EILST levels in rats. It can improve the body's sports ability.

Functional hypogonadism among patients with obesity, diabetes, and metabolic syndrome

Testosterone deficiency, defined as low total testosterone combined with physical, cognitive, and sexual signs and/or symptoms, is a common finding in adult men. Functional hypogonadism (FH) is defined as borderline low testosterone (T) secondary to aging and/or comorbid conditions such as diabetes, obesity, and/or metabolic syndrome. The relationship between FH and metabolic disorders is multifactorial and bidirectional, and associated with a disruption of the hypothalamic-pituitary-gonadal axis. Resolution of FH requires the correct diagnosis and treatment of the underlying condition(s) with lifestyle modifications considered first-line therapy. Normalization of T levels through dietary modifications such as caloric restriction and restructuring of macronutrients have recently been explored. Exercise and sleep quality have been associated with T levels, and patients should be encouraged to practice resistance training and sleep seven to nine hours per night. Supplementation with vitamin D and Trigonella foenum-graecum may also be considered when optimizing T levels. Ultimately, treatment of FH requires a multidisciplinary approach and personalized patient care.

Circulating testosterone and dehydroepiandrosterone are associated with individual motor unit features in untrained and highly active older men

Long-term exercise training has been considered as an effective strategy to counteract age-related hormonal declines and minimise muscle atrophy. However, human data relating circulating hormone levels with motor nerve function are scant. The aims of the study were to explore associations between circulating sex hormone levels and motor unit (MU) characteristics in older men, including masters athletes competing in endurance and power events. Forty-three older men (mean ± SD age: 69.9 ± 4.6 years) were studied based on competitive status. The serum concentrations of dehydroepiandrosterone (DHEA), total testosterone (T) and estradiol were quantified using liquid chromatography mass spectrometry. Intramuscular electromyographic signals were recorded from vastus lateralis (VL) during 25% of maximum voluntary isometric contractions and processed to extract MU firing rate (FR), and motor unit potential (MUP) features. After adjusting for athletic status, MU FR was positively associated with DHEA levels (p = 0.019). Higher testosterone and estradiol were associated with lower MUP complexity; these relationships remained significant after adjusting for athletic status (p = 0.006 and p = 0.019, respectively). Circulating DHEA was positively associated with MU firing rate in these older men. Higher testosterone levels were associated with reduced MUP complexity, indicating reduced electrophysiological temporal dispersion, which is related to decreased differences in conduction times along axonal branches and/or MU fibres. Although evident in males only, this work highlights the potential of hormone administration as a therapeutic interventional strategy specifically targeting human motor units in older age.

Collegiate Male Athletes Exhibit Conditions of the Male Athlete Triad

The primary purpose of this study was to determine prevalence of the Male Athlete Triad (MAT) conditions: low energy availability (EA), low bone mineral density (BMD), and low testosterone in male collegiate athletes from different sports. Participants included 44 collegiate male athletes (age, 20.4 ± 0.2 yr; BMI, 25.3 ± 1.3 kg/m2) from seven sports (cross country, soccer, basketball, wrestling, track, golf, and baseball). Resting metabolic rate, three-day food intake, seven-day exercise energy expenditure, body composition, and reproductive and metabolic hormones were assessed. Of the total participants, 15% had low EA, 0% had low BMD, 28% had low total testosterone (TT), and 80% had low calculated free testosterone (cFT). There were no significant correlations between EA, BMD, TT, and cFT. Insulin and sex hormone binding globulin (SHBG) were below and on the upper end of the reference range for healthy male adults, respectively. Insulin was negatively correlated with total (r = -0.330, p = 0.043) and lumbar spine BMD z-scores (r = -0.413, p = 0.010). Low TT and low cFT were the most prevalent MAT conditions among all athletes. Further research should investigate the relationship between insulin and SHBG and the role of these hormones in the MAT. Novelty Bullets • Assessment of energy availability alone is not sufficient to identify physiological disturbances in collegiate male athletes. • Low total and/or free testosterone may be present in some collegiate male athletes, regardless of BMD status. • Low insulin and high SHBG concentration may portray the presence of conditions of the MAT in male collegiate athletes.

Dysregulation of the Hypothalamic-Pituitary-Testicular Axis due to Energy Deficit

CONTEXT

Although gonadal axis dysregulation from energy deficit is well recognized in women, the effects of energy deficit on the male gonadal axis have received much less attention.

EVIDENCE ACQUISITION

To identify relevant articles, we conducted PubMed searches from inception to May 2021.

EVIDENCE SYNTHESIS

Case series and mechanistic studies demonstrate that energy deficit (both acutely over days or chronically over months) either from inadequate energy intake and/or excessive energy expenditure can lower serum testosterone concentration as a result of hypothalamic-pituitary-testicular (HPT) axis dysregulation in men. The extent to which this has clinical consequences that can be disentangled from the effects of nutritional insufficiency, concomitant endocrine dysregulation (eg, adrenal and thyroid axis), and coexisting comorbidities (eg, depression and substance abuse) is uncertain. HPT axis dysfunction is primarily the result of loss of GnRH pulsatility resulting from a failure of leptin to induce kisspeptin signaling. The roles of neuroendocrine consequences of depression, hypothalamic-pituitary-adrenal axis activation, proinflammatory cytokines, Ghrelin, and genetic susceptibility remain unclear. In contrast to hypogonadism from organic pathology of the HPT axis, energy deficit-associated HPT dysregulation is functional, and generally reversible by restoring energy balance.

CONCLUSIONS

The clinical management of such men should aim to restore adequate nutrition and achieve and maintain a healthy body weight. Psychosocial comorbidities must be identified and addressed. There is no evidence that testosterone treatment is beneficial. Many knowledge gaps regarding epidemiology, pathophysiology, and treatment remain and we highlight several areas that require future research.

Association of total testosterone status with bone mineral density in adults aged 40-60 years

Objective

Evidence linking total testosterone and bone mineral density (BMD) in adults is very limited. According to our review of the literature, only a few reports have focused on the relationship between total testosterone and bone mineral density in adults. Therefore, the purpose of this study was to determine the relationship between total testosterone and total bone mineral density in adults aged 40–60 years.

Methods

We used a cross-sectional study of a non-institutionalized U.S. population sample from the National Health and Nutrition Examination Survey. A weighted multivariate linear regression model was used to evaluate the relationship between total testosterone and total bone mineral density. Subgroup analyses were further performed.

Results

In multiple regression models adjusted for potential confounders, total testosterone levels were inversely associated with total bone mineral density. However, in the sex-stratified subgroup analysis, the association between total testosterone levels and total bone mineral density was not significant in female adolescents. There was no negative association between total testosterone and total BMD among men, adults 40 to 60 years of age, and other racial/ethnic groups. There is a negative association between total testosterone and total bone mineral density when total testosterone concentration is greater than 500 ng/dL among Non-Hispanic black.

Conclusion

Our statistical results show that the association between total testosterone levels and total bone mineral density varies by gender and race. Elevated total testosterone levels below 500 ng/dL have adverse effects on bone health. Total testosterone concentrations below 500 ng/dL may have no effect on bone health.

Manipulation of Dietary Intake on Changes in Circulating Testosterone Concentrations

Elevations in the circulating concentration of androgens are thought to have a positive effect on the anabolic processes leading to improved athletic performance. Anabolic-androgenic steroids have often been used by competitive athletes to augment this effect. Although there has been concerted effort on examining how manipulating training variables (e.g., intensity and volume of training) can influence the androgen response to exercise, there has been much less effort directed at understanding how changes in both macronutrient and micronutrient intake can impact the androgen response. Thus, the focus of this review is to examine the effect that manipulating energy and nutrient intake has on circulating concentrations of testosterone and what the potential mechanism is governing these changes.

Effects of Aerobic Exercise on Rats with Hyperandrogenic Polycystic Ovarian Syndrome

Hyperandrogenism is a key pathologic characteristic of polycystic ovarian syndrome (PCOS), and exercise can alleviate the accompanying inflammation and decrease the high androgen levels, but the mechanism is still unclear, so the purpose of this study is to explore the pathophysiologic characteristics of hyperandrogenic PCOS and the mechanism underlying its amelioration with aerobic exercise. Thirty-two female rats were randomly allocated to a normal control group (NC, n = 8), exercise control group (EC, n = 8), PCOS group (PC, n = 8), and PCOS plus exercise group (PE, n = 8). The PC and PE groups were injected with a dehydroepiandrosterone (DHEA) solution to induce the hyperandrogenic PCOS rat model. The EC and PE groups underwent a Masashi swimming protocol (120 min per session, 6 days/week, for 15 days). Results indicated that the concentrations of leptin (LP) in the EC group were significantly lower than those in the NC group (p < 0.05). Compared with the NC group, the levels of testosterone (T), estradiol (E2), follicle-stimulating hormone (FSH), LP, anti-Müllerian hormone (AMH), tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and free fatty acids (FFA) were all significantly augmented in the PC group (all p < 0.05). In addition, compared with the NC group, the levels of adiponectin (ADP) were significantly decreased (p < 0.05), and the expression of aromatase cytochrome P450 (P450arom) in ovarian tissue was significantly elevated in the PC group (p < 0.05). The levels of T, FSH, LP, and FFA were also significantly increased in the PE group (p < 0.05). Compared with the PC group, the levels of T and LP in the PE group were significantly diminished (p < 0.05), and the levels of ADP were significantly increased in the PE group (p < 0.05). T was positively correlated with E2, FSH, AMH, LP, TNF-α, IL-6, and FFA levels, while ADP was negatively correlated with LP and E2. These results showed that hyperandrogenism, chronic low-grade inflammation, and leptin resistance may interact to influence the occurrence and development of PCOS. Aerobic exercise can alleviate the internal inflammation by relieving leptin resistance and may mitigate the sex hormone disorder and hyperandrogenism in rats with PCOS by affecting the hypothalamic-pituitary-ovarian axis.

The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part II: Diagnosis, Treatment, and Return-To-Play

ABSTRACT

The Male Athlete Triad is a medical syndrome most common in adolescent and young adult male athletes in sports that emphasize a lean physique, especially endurance and weight-class athletes. The 3 interrelated conditions of the Male Athlete Triad occur on spectrums of energy deficiency/low energy availability (EA), suppression of the hypothalamic-pituitary-gonadal axis, and impaired bone health, ranging from optimal health to clinically relevant outcomes of energy deficiency/low EA with or without disordered eating or eating disorder, functional hypogonadotropic hypogonadism, and osteoporosis or low bone mineral density with or without bone stress injury (BSI). Because of the importance of bone mass acquisition and health concerns in adolescence, screening is recommended during this time period in the at-risk male athlete. Diagnosis of the Male Athlete Triad is best accomplished by a multidisciplinary medical team. Clearance and return-to-play guidelines are recommended to optimize prevention and treatment. Evidence-based risk assessment protocols for the male athlete at risk for the Male Athlete Triad have been shown to be predictive for BSI and impaired bone health and should be encouraged. Improving energetic status through optimal fueling is the mainstay of treatment. A Roundtable on the Male Athlete Triad was convened by the Female and Male Athlete Triad Coalition in conjunction with the 64th Annual Meeting of the American College of Sports Medicine in Denver, Colorado, in May of 2017. In this second article, the latest clinical research to support current models of screening, diagnosis, and management for at-risk male athlete is reviewed with evidence-based recommendations.

Blood and performance adaptations to individual training load in professional soccer: a team study

PURPOSE

The aim of this study was to describe seasonal changes in iron storage, hormonal status and functional capacity in relation to accumulated training load in a professional male soccer team.

METHODS

Resting blood samples, countermovement jump (CMJ) and aerobic capacity (45-15 test) were collected over a 6-month period from the start of the preparatory period to the middle-season (E1 to E4) in a professional male soccer team (n=15 outfield players). External training load was regularly quantified using a wearable 10-Hz global positioning system.

RESULTS

One player systematically showed reduced iron storage throughout the season (ferritin<110 μg·l-1, hemoglobin<14 g·dl-1). No significant differences in blood and performance parameters were observed throughout the season (P>0.05). However, accumulated total distance and high-intensity distance (above maximal aerobic speed) from E1 to E3 were negatively correlated to changes in haematocrit, hemoglobin and red blood cells (r=-0.85 to -0.67; P<0.05) and positively to changes in ferritin (r=0.63-0.69; P<0.05). Additionally, high-intensity distance covered between E1 and E3 was negatively correlated to changes in testosterone concentrations (r [95%CI]=-0.71 [-0.93; -0.15]; P=0.021).

CONCLUSIONS

Resting blood parameters and functional capacity of male soccer players appeared to be stable throughout the early competitive period. However, iron storage and hormonal status are likely to be affected by accumulated high-intensity activity performed during practice and competition. Practitioners involved with GPS-based TL monitoring could consider the accumulated amount of high-intensity activity to inform medical staffs about possible changes in oxygen-carrying capacity and anaerobic overtraining.

Relationship between inflammatory biomarkers and testosterone levels in male master athletes and non-athletes

BACKGROUND

Aging is often associated with low-grade systemic inflammation and reduced anabolic hormone levels. To investigate whether lifelong exercise training can decrease the age-related low-grade inflammation and anabolic hormone levels, we examined hormonal and inflammatory parameters among highly-trained male masters athletes and age-matched non-athletes.

METHODS

From 70 elite power and endurance master athletes - EMA (51.3 ± 8.0 yr), 32 young controls - YC (23.7 ± 3.9 yr) and 24 untrained age-matched controls - MAC (47.2 ± 8.0 yr) venous blood was drawn to measure inflammatory parameters (interleukin-6 [IL-6], tumor necrosis factor-α [TNF-α] and interleukin-10 [IL-10]) and circulating hormones (luteinizing hormone [LH], total testosterone, estradiol, sex hormone-binding globulin [SHBG] and free androgen index [FAI]).

RESULTS

EMA showed a better anti-inflammatory status than MAC (higher IL-10 and IL-10/IL-6 ratio and lower IL-6), but a lower anti-inflammatory status than YC (higher TNF-α) (p < 0.05). The MAC group had lower testosterone levels compared to the YC and EMA group (p < 0.05), and lower estradiol levels and testosterone/LH ratio compared to YC (p < 0.05). In the control groups (MAC and YC), testosterone correlated negatively with age and proinflammatory parameters, and positively with anti-inflammatory parameters.

CONCLUSION

Elite master athletics elevated levels of anti-inflammatory cytokines above that seen in non-athlete peers and mitigated the age-related reduction in testosterone levels.

Testosterone Boosters Intake in Athletes: Current Evidence and Further Directions

“Testosterone boosters” (TB)—are supplements that are claimed to increase testosterone levels in the human body. While the consumption of TB may be popular among athletes, there is insufficient evidence both about the safety and the real efficacy of TB. In our review, we searched MEDLINE/PubMed and Cochrane Library for studies on the effects of 15 substances that are claimed to increase testosterone levels Anacyclus pyrethrum; Bulbine natalensis; Epimedium (horny goat weed); L-arginine; L-carnitine; magnesium; Mucuna pruriens; pantothenic acid; selenium; shilajit Eurycoma longifolia (Tongkat Ali); Serenoa repens (saw palmetto); boron; Withania somnifera (ashwagandha); and Trigonella foenum-graecum (fenugreek) in athletes and healthy adults under 55 years of age. We found such studies regarding 10 out of 15 substances: L-arginine (3 studies); L-carnitine (2); magnesium (1); selenium (2); shilajit (1); Tongkat Ali (2); Serenoa repens (1); boron (3); ashwagandha root (2); and fenugreek (7). Many of them fail to prove the efficacy of these substances to increase testosterone levels. Tongkat Ali, ashwagandha, and fenugreek were the substances with the strongest evidence. The positive effect of magnesium and shilajit on testosterone concentration was shown in single studies. Conflicting data found that L-arginine, L-carnitine, Serenoa repens, selenium and boron do not appear to increase testosterone levels. There are almost no data on the safety profile of various TB components; however, certain TB components may be linked to coagulation, and pancreatic and hepatic disorders. Based on the review, the authors conclude that at present TB cannot be recommended for use by athletes due to insufficient data on their efficacy and safety.

Reasons for and Consequences of Low Energy Availability in Female and Male Athletes: Social Environment, Adaptations, and Prevention

Low energy availability (LEA) represents a state in which the body does not have enough energy left to support all physiological functions needed to maintain optimal health. When compared to the normal population, athletes are particularly at risk to experience LEA and the reasons for this are manifold. LEA may result from altered dietary behaviours that are caused by body dissatisfaction, the belief that a lower body weight will result in greater performance, or social pressure to look a certain way. Pressure can also be experienced from the coach, teammates, and in this day and age through social media platforms. While LEA has been extensively described in females and female athletes have started fighting against the pressure to be thin using their social media platforms, evidence shows that male athletes are at risk as well. Besides those obvious reasons for LEA, athletes engaging in sports with high energy expenditure (e.g. rowing or cycling) can unintentionally experience LEA; particularly, when the athletes' caloric intake is not matched with exercise intensity. Whether unintentional or not, LEA may have detrimental consequences on health and performance, because both short-term and long-term LEA induces a variety of maladaptations such as endocrine alterations, suppression of the reproductive axis, mental disorders, thyroid suppression, and altered metabolic responses. Therefore, the aim of this review is to increase the understanding of LEA, including the role of an athlete's social environment and the performance effects related to LEA.

Self-reported reproductive health of athletic and recreationally active males in Ireland: potential health effects interfering with performance

Introduction: The syndrome of Relative Energy Deficiency in Sport (RED-S) consensus statements recognise that male athletes might have impaired fertility in terms of the Exercise Hypogonodal Male Condition (ExHMC). Thus, the aims of this study were to (1) identify risk of ExHMC in active males in various sports and (2) determine if associations between risk of ExHMC and health problems interfering with training and competition exist. Methods: A questionnaire was distributed online (November 2018-January 2019) using questions derived from the "Androgen Deficiency in the Aging Male Questionnaire" (ADAM-Q) to assess risk of ExHMC. Additional questions were included to collect information on participant demographics, injury and illness history and dietary habits. Logistic regression analyses explored differences between groups. Results: Risk of ExHMC was identified in 23.3% (n = 185) of 794 questionnaire participants. Following multivariate analyses, risk of ExHMC was independently associated with a lower than normal sex drive rating within the last month (OR 7.62, 95%CI 4.99-11.63) and less than three morning erections per week within the last month (OR: 4.67, 95%CI 3.23-6.76). Risk of ExHMC was associated with 15-21 days absence from training or competition during the previous 6 months due to overload injuries in the univariate analysis (OR = 2.69, 95% CI = 1.24-5.84). Conclusion: Risk of ExHMC and associated symptoms in this heterogeneous sample may be indicative of RED-S. Confounding factors such as over-training, medication use, fatigue and psychological stress need to be considered. Identification of male athletes exhibiting physiological symptoms associated with RED-S requires more research.

Hypogonadism in Exercising Males: Dysfunction or Adaptive-Regulatory Adjustment?

For decades researchers have reported men who engaged in intensive exercise training can develop low resting testosterone levels, alterations in their hypothalamic-pituitary-gonadal (HPG) axis, and display hypogonadism. Recently there is renewed interest in this topic since the International Olympic Committee (IOC) Medical Commission coined the term "Relative Energy Deficiency in Sports" (RED-S) as clinical terminology to address both the female-male occurrences of reproductive system health disruptions associated with exercise. This IOC Commission action attempted to move beyond the sex-specific terminology of the "Female Athlete Triad" (Triad) and heighten awareness/realization that some athletic men do have reproductive related physiologic disturbances such as lowered sex hormone levels, HPG regulatory axis alterations, and low bone mineral density similar to Triad women. There are elements in the development and symptomology of exercise-related male hypogonadism that mirror closely that of women experiencing the Triad/RED-S, but evidence also exists that dissimilarities exist between the sexes on this issue. Our research group postulates that the inconsistency and differences in the male findings in relation to women with Triad/RED-S are not just due to sex dimorphism, but that there are varying forms of exercise-related reproductive disruptions existing in athletic men resulting in them displaying a relative hypogonadism condition. Specifically, such conditions in men may derive acutely and be associated with low energy availability (Triad/RED-S) or excessive training load (overtraining) and appear transient in nature, and resolve with appropriate clinical interventions. However, manifestations of a more chronic based hypogonadism that persists on a more permanent basis (years) exist and is termed the "Exercise Hypogonadal Male Condition." This article presents an up-to-date overview of the various types of acute and chronic relative hypogonadism found in athletic, exercising men and proposes mechanistic models of how these various forms of exercise relative hypogonadism develop.

Low energy availability assessed by a sport-specific questionnaire and clinical interview indicative of bone health, endocrine profile and cycling performance in competitive male cyclists

Objectives

To evaluate the efficacy of a sport-specific energy availability (EA) questionnaire, combined with clinical interview, for identifying male athletes at risk of developing bone health, endocrine and performance consequences of relative energy deficiency in sports (RED-S).

Methods

Fifty competitive male road cyclists, recruited through links of participants in a pilot study, were assessed by a newly developed sport-specific questionnaire and clinical interview (SEAQ-I) and received dual energy X-ray absorptiometry (DXA) bone mineral density (BMD) and body composition scans and blood tests for endocrine markers.

Results

Low EA as assessed using the SEAQ-I, was observed in 28% of cyclists. Low lumbar spine BMD (Z-score<−1.0) was found in 44% of cyclists. EA was the most significant determinant of lumbar spine BMD Z-score (p<0.001). Among low EA cyclists, lack of previous load-bearing sport was associated with the lowest BMD (p=0.013). Low EA was associated with reduced total percentage fat (p<0.019). The 10 cyclists with chronic low EA had lower levels of testosterone compared with those having adequate EA (p=0.024). Mean vitamin D concentration was below the level recommended for athletes (90  nmol/L). Training loads were positively associated with power-to-weight ratios, assessed as 60  min functional threshold power (FTP) per kg (p<0.001). Percentage body fat was not significantly linked to cycling performance.

Conclusions

This study demonstrates that a SEAQ-I is effective for identifying male road cyclists with acute intermittent and chronic sustained low EA. Cyclists with low EA, particularly in the long-term, displayed adverse quantifiable measures of bone, endocrinology and performance consequences of RED-S.