Growth hormone and sex steroid effects on bone metabolism and bone mineral density in healthy aged women and men

The effect of caponization on bone homeostasis of crossbred roosters. I. Analysis of tibia bone mineralization, densitometric, osteometric, geometric and biomechanical properties

The presented study focuses on assessing the effect of caponization on the densitometric, osteometric, geometric and biomechanical parameters of tibial bones in crossbred chickens. The study was carried out on 96 hybrids between Yellowleg Partridge hens (Ż-33) and Rhode Island Red cockerels (R-11) aged 16 weeks, 20 weeks and 24 weeks. Birds were randomly assigned to 2 groups-the control group (n = 48; which consisted of intact roosters) and the experimental group (n = 48, which consisted of individuals subjected to caponization at the age of 8 weeks). The caponization had no effect on the densitometric, osteometric and geometric parameters (except the horizontal internal diameter of 16-week-old individuals) of tibia bone, as well as the content of calcium (Ca), phosphorus (P) and the Ca/P ratio in the bone mineral fraction in all analyzed age groups of animals. However, it contributes to a lower percentage of ash in the bones of capons at 20 and 24 weeks of age compared to cockerels. On the contrary, some mechanical and material parameters show the negative effect of caponization. Ultimate load and bending moment decreased in capons in all of the analyzed age groups of animals and yield load, stiffness and ultimate stress also decreased but only in the group of 20-week-old and 24-week-old individuals. This can contribute to the weakening of the capon bones, and in the perspective of prolonged maintenance to their deformation and even fracture.

Bone health in ageing men

Osteoporosis does not only affect postmenopausal women, but also ageing men. The burden of disease is projected to increase with higher life expectancy both in females and males. Importantly, osteoporotic men remain more often undiagnosed and untreated compared to women. Sex steroid deficiency is associated with bone loss and increased fracture risk, and circulating sex steroid levels have been shown to be associated both with bone mineral density and fracture risk in elderly men. However, in contrast to postmenopausal osteoporosis, the contribution of relatively small decrease of circulating sex steroid concentrations in the ageing male to the development of osteoporosis and related fractures, is probably only minor. In this review we provide several clinical and preclinical arguments in favor of a 'bone threshold' for occurrence of hypogonadal osteoporosis, corresponding to a grade of sex steroid deficiency that in general will not occur in many elderly men. Testosterone replacement therapy has been shown to increase bone mineral density in men, however data in osteoporotic ageing males are scarce, and evidence on fracture risk reduction is lacking. We conclude that testosterone replacement therapy should not be used as a sole bone-specific treatment in osteoporotic elderly men.

The effects of testosterone on bone health in males with testosterone deficiency: a systematic review and meta-analysis

BACKGROUND

Testosterone deficiency (TD) may induce a series of clinical symptoms. Studies have shown that testosterone supplementation may prevent these unfavourable symptoms and improve patients' quality of life. Given the conflicting findings across studies, this systematic review aims to evaluate the effects and risks associated with testosterone supplementation in middle-aged or aging males with TD.

METHODS

Electronic databases (MEDLINE, EMBASE, PubMed, and Cochrane. Library were searched to December 2019. The risk of bias of individual included studies and the quality of the aggregate evidence were assessed using the GRADE approach. Our primary outcome was bone mineral density (BMD). Meta-analyses were performed. This systematic review was reported according to the PRISMA statement.

RESULTS

A total of 52 randomized controlled trials (RCTs) were included. When compared with placebo, testosterone supplementation did not increase total BMD (short-term: 1081 participants, MD - 0.01 g/cm², 95% CI - 0.02 g/cm² to 0.01 g/cm²; long-term: 156 participants, MD 0.04 g/cm², 95% CI - 0.07 g/cm² to 0.14 g/cm²), lumbar spine, hip, or femur neck BMD. Furthermore, testosterone supplementation did not decrease the risk of falling or fracture. Lastly, it was found that testosterone supplementation did not increase the risk of cardiovascular events (1374 participants, RR 1.28, 95% CI 0.62 to 2.64), all-cause mortality (729 participants, RR 0.55, 95% CI 0.29 to 1.04), or prostatic events. However, testosterone supplementation may improve sexual function and quality of life (1328 participants, MD -1.32, 95% CI - 2.11 to - 0.52).

CONCLUSIONS

The effect of testosterone supplementation on BMD and the risk of falls or fracture remains inconclusive. However, supplementation may benefit patients in the areas of sexual function and quality of life without increasing the risk of cardiovascular events, all-cause mortality, or prostatic events. RCTs with a longer follow-up period are still required.

TRIAL REGISTRATION

We registered our protocol in PROSPERO (CRD42018109738).

Testosterone treatment in older men: clinical implications and unresolved questions from the Testosterone Trials

A decrease in the concentration of circulating testosterone in many older men is a biomarker and possibly a rectifiable contributing factor to ill health. Low circulating testosterone concentration has been associated with cardiovascular disease, reduced cognition, fracture risk, and anaemia. However, randomised placebo-controlled trials are essential to clarify the benefits and possible risks of testosterone treatment in men without hypothalamic, pituitary, or testicular disease. The Testosterone Trials (T-Trials) were a coordinated set of trials that, following a screening-to-enrolment ratio of 65:1, randomly assigned 790 men aged 65 years or older who had a baseline testosterone concentration of less than 9·54 nmol/L and symptoms consistent with hypogonadism, but no recognisable hypothalamic-pituitary-testicular axis pathology, to daily transdermal testosterone or placebo for 12 months. In the main trial, testosterone treatment resulted in a modest benefit for sexual function, whereas the other primary outcomes of vitality and physical function were not met. Data from concomitant substudies raised a possible concern over changes in coronary plaque volume, showed a neutral effect on memory and other cognitive functions, and revealed improvements in volumetric bone mineral density and anaemia. Although insufficient to alter the existing clinical equipoise, the T-Trials provided substantial new data on organ-specific outcomes for testosterone treatment in older men. Further clinical trials are necessary to determine whether testosterone treatment will translate into patient-valued health outcomes and to clarify effects on the cardiovascular system.

Effects of testosterone replacement therapy on hypogonadal men with osteopenia or osteoporosis: a subanalysis of a prospective randomized controlled study in Japan (EARTH study)

OBJECTIVE

We investigated the effects of testosterone replacement therapy (TRT) on bone mineral density (BMD) among hypogonadal men with osteopenia/osteoporosis.

METHODS

From our previous EARTH study population, 74 patients with a clinical diagnosis of osteopenia or osteoporosis and hypogonadism were included in this study, as the TRT (n = 35) and control (n = 34) groups. The TRT group was administered 250 mg of testosterone enanthate injection every 4 weeks for 12 months. The BMD, waist circumference, body mass index, body fat percentage, and muscle volume were measured at baseline and at 12 months. Blood biochemical data, including total cholesterol, triglycerides, HDL-cholesterol, hemoglobin A1c, and adiponectin values were also evaluated.

RESULTS

At the 12-month visit, BMD significantly increased in both groups. However, comparisons on changes of parameter values from baseline to the 12-month visit between the TRT and control groups were significantly different in BMD (5.0 ± 5.0 vs. 3.0 ± 3.2; p = .0434) and in adiponectin value (-0.90 ± 3.33 vs. 0.10 ± 2.04; p = .0192). There were no significant changes in other parameters.

CONCLUSIONS

TRT for 12 months could improve BMD with a decrease in adiponectin levels among hypogonadal men with osteopenia/osteoporosis.

Effects of Recombinant Human Growth Hormone for Osteoporosis: Systematic Review and Meta-Analysis

Our objective was to evaluate the efficacy of recombinant human growth hormone (GH) on bone mineral density (BMD) in persons age 50 and older, with normal pituitary function, with or at risk for developing osteoporosis. We systematically reviewed randomized clinical trials (RCTs), searching six databases, and conducted meta-analyses to examine GH effects on BMD of the lumbar spine and femoral neck. Data for fracture incidence, bone metabolism biomarkers, and adverse events were also extracted and analysed. Thirteen RCTs met the eligibility criteria. Pooled effect sizes suggested no significant GH effect on BMD. Pooled effect sizes were largest, but nonsignificant, when compared to placebo. GH had a significant effect on several bone metabolism biomarkers. A significantly higher rate of adverse events was observed in the GH groups. Meta-analysis of RCTs suggests that GH treatment for persons with or at risk for developing osteoporosis results in very small, nonsignificant increases in BMD.

Estrogens and Androgens in Skeletal Physiology and Pathophysiology

Estrogens and androgens influence the growth and maintenance of the mammalian skeleton and are responsible for its sexual dimorphism. Estrogen deficiency at menopause or loss of both estrogens and androgens in elderly men contribute to the development of osteoporosis, one of the most common and impactful metabolic diseases of old age. In the last 20 years, basic and clinical research advances, genetic insights from humans and rodents, and newer imaging technologies have changed considerably the landscape of our understanding of bone biology as well as the relationship between sex steroids and the physiology and pathophysiology of bone metabolism. Together with the appreciation of the side effects of estrogen-related therapies on breast cancer and cardiovascular diseases, these advances have also drastically altered the treatment of osteoporosis. In this article, we provide a comprehensive review of the molecular and cellular mechanisms of action of estrogens and androgens on bone, their influences on skeletal homeostasis during growth and adulthood, the pathogenetic mechanisms of the adverse effects of their deficiency on the female and male skeleton, as well as the role of natural and synthetic estrogenic or androgenic compounds in the pharmacotherapy of osteoporosis. We highlight latest advances on the crosstalk between hormonal and mechanical signals, the relevance of the antioxidant properties of estrogens and androgens, the difference of their cellular targets in different bone envelopes, the role of estrogen deficiency in male osteoporosis, and the contribution of estrogen or androgen deficiency to the monomorphic effects of aging on skeletal involution.

Hif1α is required for osteoclast activation and bone loss in male osteoporosis

The number of osteoporosis patients is increasing not only in women but in men. Male osteoporosis occurs due to aging or androgen depletion therapies, leading to fractures. However, molecular mechanisms underlying male osteoporosis remain unidentified. Here, we show that hypoxia inducible factor 1 alpha (Hif1α) is required for development of testosterone deficiency-induced male osteoporosis. We found that in mice Hif1α protein accumulates in osteoclasts following orchidectomy (ORX) in vivo. In vitro, Hif1α protein accumulated in osteoclasts cultured in hypoxic conditions, but Hif1α protein rather than mRNA levels were suppressed by testosterone treatment, even in hypoxia. Administration of a Hif1α inhibitor to ORX mice abrogated testosterone deficiency-induced osteoclast activation and bone loss but did not alter osteoclast activities or bone phenotypes in sham-operated, testosterone-sufficient animals. We conclude that Hif1α protein accumulation due to testosterone-deficiency promotes development of male osteoporosis. Thus Hif1α protein could be targeted to inhibit pathologically-activated osteoclasts under testosterone-deficient conditions to treat male osteoporosis patients.

Osteoporosis and Low Bone Mineral Density in Men with Testosterone Deficiency Syndrome

INTRODUCTION

Testosterone deficiency syndrome (TDS) is a risk factor for low bone mineral density (BMD) and osteoporosis. Knowledge of the relationship between TDS and bone health, as well as the practical aspects of how to diagnose and treat low BMD, is therefore of practical importance to sexual medicine practitioners.

AIM

The aim of this study was to review the physiologic basis and clinical evidence of the relationship between TDS and bone health; and to provide a practical, evidence-based algorithm for the diagnosis and management of low BMD in men with TDS.

METHODS

Method used was a review of relevant publications in PubMed.

MAIN OUTCOME MEASURES

Pathophysiology of low BMD in TDS, morbidity, and mortality of osteoporosis in men, association between TDS and osteoporosis, indications for dual X-ray absorptiometry (DXA) scanning in TDS, evidence for testosterone replacement therapy (TRT) in men with osteoporosis, treatment for osteoporosis in the setting of TDS.

RESULTS

Sex hormones play a pleomorphic role in maintenance of BMD. TDS is associated with increased risk of osteoporosis and osteopenia, both of which contribute to morbidity and mortality in men. DXA scanning is indicated in men older than 50 years with TDS, and in younger men with longstanding TDS. Men with TDS and osteoporosis should be treated with anti-osteoporotic agents and TRT should be highly considered. Men with osteopenia should be stratified by fracture risk. Those at high risk should be treated with anti-osteoporotic agents with strong consideration of TRT; while those at low risk should be strongly considered for TRT, which has a beneficial effect on BMD.

CONCLUSION

Low BMD is a prevalent and treatable cause of morbidity and mortality in men with TDS. Utilization of a practical, evidence-based approach to diagnosis and treatment of low BMD in men with TDS enables sexual medicine practitioners to make a meaningful impact on patient quality of life and longevity. Gaffney CD, Pagano MJ, Kuker AP, Stember DS, and Stahl PJ. Osteoporosis and low bone mineral density in men with testosterone deficiency syndrome.

Osteoporosis in men

Osteoporotic fractures in older men (>50 years of age) are common and associated with considerable mortality and morbidity, but osteoporosis in men is under-recognized and undertreated. Secondary osteoporosis is also common in men, and causes include androgen deprivation therapy for prostate cancer, glucocorticoid treatment and alcohol excess. Clinical trials have demonstrated the efficacy of pharmacological osteoporosis treatments in men in terms of increasing BMD and decreasing levels of bone turnover markers; however, few trials have included fracture reduction end points. This Review will consider the pathophysiology of osteoporosis in men and the evidence for testing and treatment. The aims of the Review are to inform clinical practice, to discuss the current evidence base and to highlight the 2012 Endocrine Society clinical practice guidelines on osteoporosis in men.

Adult growth hormone deficiency - benefits, side effects, and risks of growth hormone replacement

Deficiency of growth hormone (GH) in adults results in a syndrome characterized by decreased muscle mass and exercise capacity, increased visceral fat, impaired quality of life, unfavorable alterations in lipid profile and markers of cardiovascular risk, decrease in bone mass and integrity, and increased mortality. When dosed appropriately, GH replacement therapy (GHRT) is well tolerated, with a low incidence of side effects, and improves most of the alterations observed in GH deficiency (GHD); beneficial effects on mortality, cardiovascular events, and fracture rates, however, remain to be conclusively demonstrated. The potential of GH to act as a mitogen has resulted in concern over the possibility of increased de novo tumors or recurrence of pre-existing malignancies in individuals treated with GH. Though studies of adults who received GHRT in childhood have produced conflicting reports in this regard, long-term surveillance of adult GHRT has not demonstrated increased cancer risk or mortality.

Is androgen therapy indicated in men with osteoporosis?

Male osteoporosis is not rare, and its management is a public health issue. The clinical evaluation must include investigations for one or more etiological factors such as hypogonadism, which is found in 5% to 15% of men with osteoporosis. Gradual development of moderate hypogonadism is the most common situation, and the prevalence of hypogonadism increases with advancing age. The wealth of scientific data establishing a major role for sex hormones in growth, bone turnover, and the osteoporotic fracture risk is in striking contrast to the paucity of therapeutic trials. Androgen therapy did not consistently produce bone mass gains, and no data on potential anti-fracture effects are available. Androgen therapy was not associated with significant increases in mortality, prostate disorders, or cardiovascular events, but few data were obtained in patients older than 75 years. In practice, in a male patient with osteoporosis, a diagnosis of marked and persistent hypogonadism requires investigations for treatable causes. In patients younger than 75 years of age, androgen replacement therapy should be started, in collaboration with an endocrinologist. A history of fractures indicates a need for additional osteoporosis pharmacotherapy. The risk/benefit ratio of androgen therapy is unclear in men older than 75 years, in whom a reasonable option consists in combining fall-prevention measures, vitamin D supplementation, and a medication proven to decrease the risk of proximal femoral fractures.

A model for estimating body shape biological age based on clinical parameters associated with body composition

BACKGROUND

To date, no studies have attempted to estimate body shape biological age using clinical parameters associated with body composition for the purposes of examining a person's body shape based on their age.

OBJECTIVE

We examined the relations between clinical parameters associated with body composition and chronological age, and proposed a model for estimating the body shape biological age.

METHODS

The study was conducted in 243,778 subjects aged between 20 and 90 years who received a general medical checkup at health promotion centers at university and community hospitals in Korea from 2004 to 2011.

RESULTS

In men, the clinical parameters with the highest correlation to age included the waist- to-hip ratio (r = 0.786, P < 0.001), hip circumference (r = -0.448, P < 0.001), and height (r = -0.377, P < 0.001). In women, the clinical parameters with the highest correlation to age include the waist-to-hip ratio (r = 0.859, P < 0.001), waist circumference (r = 0.580, P < 0.001), and hip circumference (r = 0.520, P < 0.001). To estimate the optimal body shape biological age based on clinical parameters associated with body composition, we performed a multiple regression analysis. In a model estimating the body shape biological age, the coefficient of determination (R(2)) was 0.71 in men and 0.76 in women.

CONCLUSION

Our model for estimating body shape biological age might be a novel approach to variation in body shape that is due to aging. We assume that our estimation model would be used as an adjunctive measure in easily predicting differences in body shape with the use of clinical parameters that are commonly used to assess the status of obesity in a clinical setting.

Hormone replacement therapy and physical function in healthy older men. Time to talk hormones?

Improving physical function and mobility in a continuously expanding elderly population emerges as a high priority of medicine today. Muscle mass, strength/power, and maximal exercise capacity are major determinants of physical function, and all decline with aging. This contributes to the incidence of frailty and disability observed in older men. Furthermore, it facilitates the accumulation of body fat and development of insulin resistance. Muscle adaptation to exercise is strongly influenced by anabolic endocrine hormones and local load-sensitive autocrine/paracrine growth factors. GH, IGF-I, and testosterone (T) are directly involved in muscle adaptation to exercise because they promote muscle protein synthesis, whereas T and locally expressed IGF-I have been reported to activate muscle stem cells. Although exercise programs improve physical function, in the long-term most older men fail to comply. The GH/IGF-I axis and T levels decline markedly with aging, whereas accumulating evidence supports their indispensable role in maintaining physical function integrity. Several studies have reported that the administration of T improves lean body mass and maximal voluntary strength in healthy older men. On the other hand, most studies have shown that administration of GH alone failed to improve muscle strength despite amelioration of the detrimental somatic changes of aging. Both GH and T are anabolic agents that promote muscle protein synthesis and hypertrophy but work through separate mechanisms, and the combined administration of GH and T, albeit in only a few studies, has resulted in greater efficacy than either hormone alone. Although it is clear that this combined approach is effective, this review concludes that further studies are needed to assess the long-term efficacy and safety of combined hormone replacement therapy in older men before the medical rationale of prescribing hormone replacement therapy for combating the sarcopenia of aging can be established.

Osteoporosis in men: an Endocrine Society clinical practice guideline

OBJECTIVE

The aim was to formulate practice guidelines for management of osteoporosis in men.

EVIDENCE

We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and evidence quality.

CONSENSUS PROCESS

Consensus was guided by systematic evidence reviews, one in-person meeting, and multiple conference calls and e-mails. Task Force drafts were reviewed successively by The Endocrine Society's Clinical Guidelines Subcommittee and Clinical Affairs Core Committee; representatives of ASBMR, ECTS, ESE, ISCD; and members at large. At each stage, the Task Force received written comments and incorporated needed changes. The reviewed document was approved by The Endocrine Society Council before submission for peer review.

CONCLUSIONS

Osteoporosis in men causes significant morbidity and mortality. We recommend testing higher risk men [aged ≥70 and men aged 50-69 who have risk factors (e.g. low body weight, prior fracture as an adult, smoking, etc.)] using central dual-energy x-ray absorptiometry. Laboratory testing should be done to detect contributing causes. Adequate calcium and vitamin D and weight-bearing exercise should be encouraged; smoking and excessive alcohol should be avoided. Pharmacological treatment is recommended for men aged 50 or older who have had spine or hip fractures, those with T-scores of -2.5 or below, and men at high risk of fracture based on low bone mineral density and/or clinical risk factors. Treatment should be monitored with serial dual-energy x-ray absorptiometry testing.

Osteoporosis in Men

The prevalence of osteoporosis is estimated to be 18% in men, but 30% of all fractures occur in men. With age, men experience a gradual decline in testosterone production and bone density. The rate of trabecular bone loss in the lumbar spine in men over age 50 can be double the rate of loss in men under age 50. Endogenous testosterone, estradiol, and their metabolites play a role in maintaining bone health, but their specific effects on bone turnover have been difficult to elucidate. Recently, large cohort studies have provided more detailed information confirming estrogen’s associations and further characterizing the effect of endogenous testosterone and its metabolites on bone mineral density and fractures. Very few clinical trials have assessed the impact of testosterone replacement therapy (TRT) on bone density and fractures in men. The few studies that have been conducted are generally small and not robust enough to show the true treatment effect of TRT and adequately determine its safety. In the absence of data on patient outcomes, it is important for pharmacists to understand the impact of drug therapy on biomarkers and surrogate markers of disease for optimal pharmacotherapy selection and monitoring.

Hyperostosis frontalis interna: what does it tell us about our health?

OBJECTIVES

To examine whether the prevalence and severity of hyperostosis frontalis interna (HFI) has significantly changed during the past 100 years.

METHODS

Two female populations, 100 years apart, were studied; 992 historic and 568 present day females. Detection of HFI was carried out via direct observation or CT images (Brilliance 64, Philips Medical Systems, Cleveland, Ohio). HFI was graded according to Hershkovitz et al.’s (1999) 4-scale definition and according May et al.’s (2010c) 3-scale definition.

RESULTS

Following correction for age, present day females manifested a significantly higher HFI prevalence compared with historic females (P < 0.05). The risk of developing HFI was found to be approximately 2.5 times greater in present day females compared with females living 100 years ago (P < 0.05). In the young age cohort, present day females manifested a significantly higher prevalence of HFI type B (P < 0.05), whereas in the old age cohort, a significant difference in the prevalence of HFI types C and D was noted between the two groups (P < 0.05). HFI tended to appear at a younger age in the present population. The last two decades has witnessed an increase in HFI prevalence(from 55.6% to 75%).

CONCLUSIONS

HFI prevalence has increased during the last century, especially among young individuals, possibly indicating a profound change in human fertility patterns, together with the introduction of various hormonal treatments) and new dietary habits.

A pilot study of copper supplementation effects on plasma F2alpha isoprostanes and urinary collagen crosslinks in young adult women

Marginal copper deficiency has been proposed to occur frequently, but the benefits of correction remain largely uncharacterized. Two benefits could be reduced oxidant stress and better crosslinking of collagen in bone. Copper intake was increased in 8 female university students by supplementation with copper glycinate (2 mg copper/day) for 8 weeks. Supplementation improved copper status based on serum activity of two copper enzymes, ceruloplasmin and diamine oxidase (9% and 75% mean increase, respectively). No effect was seen for erythrocyte copper-zinc superoxide dismutase. Supplementation produced a 39% mean decrease in plasma for F(2alpha)-isoprostanes (a marker of oxidant stress), and gave a 62% increase in the urine ratio of collagen crosslinks to a measure of total collagen. None of the supplementation effects were duplicated for 8 women given placebo. In conclusion, this pilot study found that in young adult women, increased copper intake can alter biochemical parameters relevant to copper function.

Is consensus in anti-aging medical intervention an elusive expectation or a realistic goal?

One of the biggest scandals of the recent history of medicine is the conflict of views between the gerontological establishment and the American Academy of Anti-Aging Medicine (A4M). The style used in that discussion was really rough and unusual. On the one hand, according to some representatives of the American Medical Associations (AMA), the use of human growth hormone (hGH) for anti-aging medical interventions is illegal, criminal, and requires persecution. On the other hand, A4M is of the opinion that all this is "...filled with incorrect, misplaced references and studies, and multiple basic scientific errors, in an apparent attempt to damage the anti-aging medical profession...". It is evident that in the frame of a short article is impossible to treat all the relevant aspects of this complicated story. Nevertheless, this Editorial attempts to point out the main results obtained so far, together with the most important issues of theoretical feasibility of the hGH replacement therapy (hGHRT). The comprehensive explanation of the aging process called "membrane hypothesis of aging" (MHA) offers a solid basis for the interpretation of the observed beneficial effects of the hGH through its practically ubiquitous membrane receptors, and the species specificity of this peptide hormone. The specific activation of these receptors stimulates the membrane transport functions, rehydrates the intracellular colloids, allowing to speed up the protein synthesis and turnover, and activates a great number of cellular functions, all observed so far. The facts known about the adult growth hormone deficiency (AGHD) syndrome, and the beneficial effects of hGHRT in all aspects of this pathology suggest that aging may generally be considered as an AGHD syndrome. If this concept is accepted by most of the gerontologists, we can resolve practically all problems involved in the above outlined controversies. All this requires an independent, open-minded approach to the problem, and pushes us to a better understanding of the results of theoretical aging research. This approach may open a new, realistic way to the development of efficient anti-aging medical interventions.

Testosterone treatment in elderly men

Testosterone has been used in testicular and hypothalamo-pituitary diseases since the 1940s. There is growing interest in the use of testosterone in aging men, and this has stimulated research into the benefits of male hormone replacement. Testosterone treatment of men with hypogonadism might have beneficial effects on body composition, muscle strength, sexual function, and cognition. There are several modes of administration of the male hormone, with injectable testosterone esters and implanted testosterone pellets being the mainstay of treatment until recently. These preparations are increasingly being replaced by transdermal patches, gels, and long-acting parenteral preparations. Testosterone patches and gels are ideally for elderly men. Treatment with the male hormone is relatively safe, if patients are selected appropriately and monitored carefully. The most important adverse effects are on the prostate. In this review, we briefly discuss the indications, contraindications, and benefits of testosterone treatment. Further, we list the adverse effects, advantages, and disadvantages of various testosterone preparations in elderly men.

Additional beneficial effects of recombinant growth hormone in alendronate-treated patients with idiopathic osteoporosis

In order to study the benefit of adding recombinant human growth hormone (rhGH) to antiresorptive therapy, six patients with idiopathic osteoporosis (IO) receiving alendronate plus calcium and vitamin D were started on daily subcutaneous injections of rhGH 2.0 IU for one year. Fasting morning urine and serum samples were collected for N telopeptide of type-1 collagen (NTX), serum bone-specific alkaline phosphatase (BSAP) and insulin-like growth factor 1 (IGF-1) during the study. Bone mineral density (BMD) was determined by dual-energy x-ray absorptiometry at baseline and 01 year. The effect of rhGH was evaluated comparing the percentage changes in BMD during the last year on ALN with the results obtained with the combined therapy. Serum IGF-1 increased in all patients but variations were not significant (p=0.266). Serum BSAP did not significantly change (p=0.078) but median NTX increased at 45 days from 12.3 to 19.8 nMBCE/mMCr (p=0.012) and tended to return to baseline values at 12 months (15.2 nMBCE/mMCr). Comparing with isolated ALN therapy, a beneficial effect on bone density was observed in 2/3 of the patients at lumbar spine, and percentage change (median and quartiles) varied from -0.65% (-2.33 and 2.23) on ALN to 0.70% (-0.35 and 3.03) on ALN+GH. Although no bone gain occurred at the femoral neck, our data point to a positive effect of rhGH in patients with idiopathic osteoporosis.

Testosterone replacement therapy in hypogonadal men: assessing benefits, risks, and best practices

Hypogonadism is a common condition, especially among older men, but often goes undiagnosed and untreated. It can be associated with a number of signs and symptoms that affect health and quality of life, including feelings of low energy and fatigue; decreased sex drive and performance; decreased muscle mass and strength; decreased bone mineral density; and increased body fat, particularly abdominal fat, a putative risk factor for metabolic syndrome and type 2 diabetes mellitus. The evidence supporting testosterone replacement therapy (TRT) in improving these and related conditions is strong and consistent for body composition and sexual function; moderately consistent for bone mineral density; inconsistent for insulin sensitivity, glycemic control, and lipid profiles; and weak and inconsistent for mood and cognitive function. The concern of some physicians about the potential for TRT to stimulate prostate cancer is not supported by decades of data accumulated to date, though studies of longer duration (eg, 10 years or more) would be even more convincing. Other research needs are discussed. As the front line of health care delivery, primary care physicians need to be vigilant in diagnosing and treating symptomatic hypogonadism. Based on current guidelines, we recommend assessing testosterone levels when an adult man exhibits signs of hypogonadism, and as part of normal medical screening in men starting at age 40 to 50 years, to establish a baseline. A physician should discuss the possibility of TRT with symptomatic patients who have a serum total testosterone level < 300 ng/dL. If TRT is initiated, a patient's response and adverse events should be assessed every 3 to 6 months, and therapy adjusted accordingly.

Biochemical assessment of bone turnover and bone fragility in men

Osteoporosis in men is less studied than in women. Few data concern biochemical bone turnover markers (BTM) in men and their potential use.

METHODOLOGY

We evaluated papers concerning BTM in men cited on Medline. Selection of studies were based on the number of subjects, age range, group homogeneity, follow-up duration, number of BTM.

RESULTS

BTM levels are high in young men, then decrease with age. In elderly men, bone resorption increases with age more than bone formation. Variability of individual values is high and their significance is unclear. In elderly men, BTM levels correlate negatively with bone mineral density suggesting that accelerated bone turnover underlies age-related bone loss. Data on the prediction of accelerated bone loss and fractures by BTM in men are scant. Testosterone treatment induces a decrease in bone resorption followed by a decrease in bone formation. Bisphosphonates and calcitonin decrease BTM levels in osteoporotic men. Parathyroid hormone 1-34 and growth hormone induce a rapid increase in bone turnover followed by a progressive slowdown.

CONCLUSIONS

Few studies concern BTM in men. Currently available data are not sufficient to suggest guidelines for the practical use of BTM in the clinical management of the osteoporosis in elderly men.

Bone mineral density in patients with growth hormone deficiency: does a gender difference exist?

OBJECTIVE

The aim of the study was to clarify whether a gender difference exists with respect to bone mineral density (BMD) and bone mineral content (BMC) in adult patients with growth hormone deficiency (GHD).

DESIGN

A case-control design.

METHODS

Blood sampling for measurements of calcium, phosphate, creatinine, PTH, vitamin D, IGF-1, markers of bone formation and bone resorption, and dual energy X-ray absorptiometry (DEXA), to determine BMD and BMC of the lumbar spine, hip, distal arm and total body, were performed in 34 patients with GHD (19 females) and 34 sex-, age- and weight-matched healthy control subjects. The patients were well substituted on all pituitary axes, apart from GH.

RESULTS

GH-deficient males had significantly lower BMD in the lumbar spine (P = 0.02), hip (P = 0.01) and total body (P = 0.003) than healthy males while GH-deficient females compared to healthy females had identical BMD values at all regions. This gender difference was even more obvious when BMD values were expressed as Z-scores or as three-dimensional BMD of the total body. The bone formation and bone resorption markers, as well as calcium and vitamin D, were all at the same levels in GH-deficient and healthy males, indicating identical bone turnover. The GH-deficient females, however, had significantly lower levels of bone markers compared to healthy females, indicating a reduced bone turnover. Oestrogen substitution of the GH-deficient females could explain this difference.

CONCLUSIONS

Compared to healthy control subjects GH-deficient males had, in contrast to GH-deficient females, significantly reduced BMD and BMC. This obvious gender difference seems to be caused by the oestrogen substitution given to the females, compensating for the lack of GH, an effect testosterone does not seem to possess.

Adverse events associated with testosterone replacement in middle-aged and older men: a meta-analysis of randomized, placebo-controlled trials

BACKGROUND

We performed a meta-analysis of randomized clinical trials to determine the risks of adverse events associated with testosterone replacement in older men.

METHODS

The MEDLINE database was searched from 1966 to April 2004, using testosterone as the indexing term; limits included human, male, > or =45 years old, and randomized controlled trial. Of the 417 studies thus identified, 19 met the inclusion criteria: testosterone replacement for at least 90 days, men > or =45 years old with low or low-normal testosterone level, randomized controlled trial, and medically stable men. Odds ratios (ORs) were pooled using a random effects model, assuming heterogeneous results across studies, and were weighted for sample size.

RESULTS

In the 19 studies that met eligibility criteria, 651 men were treated with testosterone and 433 with placebo. The combined rate of all prostate events was significantly greater in testosterone-treated men than in placebo-treated men (OR = 1.78, 95% confidence interval [CI], 1.07-2.95). Rates of prostate cancer, prostate-specific antigen (PSA) >4 ng/ml, and prostate biopsies were numerically higher in the testosterone group than in the placebo group, although differences between the groups were not individually statistically significant. Testosterone-treated men were nearly four times as likely to have hematocrit >50% as placebo-treated men (OR = 3.69, 95% CI, 1.82-7.51). The frequency of cardiovascular events, sleep apnea or death was not significantly different between the two groups.

CONCLUSIONS

Testosterone replacement in older men was associated with a significantly higher risk of detection of prostate events and of hematocrit >50% than was placebo; hematocrit increase was the most frequent adverse event associated with testosterone replacement. These data reaffirm the need to monitor hematocrit, PSA, and digital examination of the prostate during testosterone replacement in older men.

The decline of androgen levels in elderly men and its clinical and therapeutic implications

Aging in men is accompanied by a progressive, but individually variable decline of serum testosterone production, more than 20% of healthy men over 60 yr of age presenting with serum levels below the range for young men. Albeit the clinical picture of aging in men is reminiscent of that of hypogonadism in young men and decreased testosterone production appears to play a role in part of these clinical changes in at least some elderly men, the clinical relevancy of the age-related decline in sex steroid levels in men has not been unequivocally established. In fact, minimal androgen requirements for elderly men remain poorly defined and are likely to vary between individuals. Consequently, borderline androgen deficiency cannot be reliably diagnosed in the elderly, and strict differentiation between "substitutive" and "pharmacological" androgen administration is not possible. To date, only a few hundred elderly men have received androgen therapy in the setting of a randomized, controlled study, and many of these men were not androgen deficient. Most consistent effects of treatment have been on body composition, but to date there is no evidence-based documentation of clinical benefits of androgen administration to elderly men with normal or moderately low serum testosterone in terms of diminished morbidity or of improved survival or quality of life. Until the long-term risk-benefit ratio for androgen administration to elderly is established in adequately powered trials of longer duration, androgen administration to elderly men should be reserved for the minority of elderly men who have both clear clinical symptoms of hypogonadism and frankly low serum testosterone levels.

Effects of testosterone on body composition, bone metabolism and serum lipid profile in middle-aged men: a meta-analysis

OBJECTIVES

Ageing in men is associated with a gradual decline in serum testosterone levels and a concomitant loss of muscle mass, accumulation of central adiposity, impaired mobility and increased risk of bone fractures. Whether androgen treatment might be beneficial in these subjects is still under debate. We have carried out a systematic review of randomized controlled trials (RCTs) evaluating the effects of testosterone (T) administration to middle-aged and ageing men on body composition, muscle strength, bone density, markers of bone metabolism and serum lipid profile.

DATA SOURCE

A comprehensive search of all published randomized clinical trials was performed using the MEDLINE, Cochrane Library, EMBASE and Current Contents databases.

REVIEW METHODS

Guided by prespecified criteria, software-assisted data abstraction and quality assessed by two independent reviewers, 29 RCTs were found to be eligible. For each investigated variable, we reported the results of pooled estimates of testosterone treatment using the random effect model of meta-analysis. Heterogeneity, reproducibility and consistency of the findings across studies were explored using sensitivity and meta-regression analysis.

RESULTS

Overall, 1,083 subjects were evaluated, 625 randomized to T, 427 to placebo and 31 to observation (control group). Weighted mean age was 64.5 years (range 49.9--77.6) and mean serum testosterone was 10.9 nmol/l (range 7.8--19). Testosterone treatment produced: (i) a reduction of 1.6 kg (CI: 2.5--0.6) of total body fat, corresponding to -6.2% (CI: 9.2--3.3) variation of initial body fat, (ii) an increase in fat free mass of 1.6 kg (CI: 0.6--2.6), corresponding to +2.7% (CI: 1.1--4.4) increase over baseline and (iii) no change in body weight. The effects of T on muscle strength were heterogeneous, showing a tendency towards improvement only at the leg/knee extension and handgrip of the dominant arm (pooled effect size=0.3 standard mean difference (SMD), CI: -0.0 to 0.6). Testosterone improved bone mineral density (BMD) at the lumbar spine by +3.7% (CI: 1.0--6.4%) compared to placebo, but not at the femoral neck, and produced a consistent reduction in bone resorption markers (pooled effect size = -0.6 SMD, CI: -1.0 to -0.2). Testosterone also reduced total cholesterol by 0.23 mmol/l (CI: -0.37 to -0.10), especially in men with lower baseline T concentrations, with no change in low density lipoprotein (LDL)-cholesterol. A significant reduction of high density lipoprotein (HDL)-cholesterol was found only in studies with higher mean T-values at baseline (-0.085 mmol/l, CI: -0.017 to -0.003). Sensitivity and meta-regression analysis revealed that the dose/type of T used, in particular the possibility of aromatization, explained the heterogeneity in findings observed on bone density and HDL-cholesterol among studies.

CONCLUSION

The present analysis provides an estimate of the average treatment effects of testosterone therapy in middle-aged men. Our findings are sufficiently strong to justify further interventional studies focused on alternative targets of androgenic treatment carrying more stringent clinical implications, in particular the cardiovascular, metabolic and neurological systems.

Andropause: Is Androgen Replacement Therapy Indicated for the Aging Male?

The number of men in the United States > or =65 years of age is projected to increase from 14,452,000 in 2000 to 31,343,000 in 2030. Approximately 30% of men 60-70 years of age and 70% of men 70-80 years of age have low bioavailable or free testosterone levels. Symptoms and findings of testosterone deficiency are similar to those associated with aging. They include loss of energy, depressed mood, decreased libido, erectile dysfunction, decreased muscle mass and strength, increased fat mass, frailty, osteopenia, and osteoporosis. Several small clinical trials indicate that testosterone replacement therapy can improve many of these findings; however, the studies have not been powered to assess potential risks, such as the need for invasive treatment of benign prostatic hyperplasia, development of a clinical prostate cancer, or cardiovascular events. Thus, the benefit/risk ratio of testosterone replacement therapy in aging men is not known.

Androgens and the ageing male

Serum testosterone levels peak in early adulthood in men and fall progressively with age. Since sex hormone binding globulin increases with age, the unbound forms of testosterone (free and bioavailable testosterone) fall more steeply than total testosterone levels. Serum testosterone levels below the normal range for young healthy adult males provide chemical evidence of androgen deficiency independent of the age of the patient. When accompanied by signs or symptoms that are compatible with androgen deficiency, treatment with testosterone should be considered in older men without evidence of prostate or breast cancer. While such therapy for younger hypogonadal men has shown benefit on libido, mood, muscle mass, muscle strength, bone mineral density and haematocrit, similar benefits in older men have not been as adequately assessed. While there is no convincing evidence that testosterone treatment in older men will increase the risk of cardiovascular or prostate cancer, long-term, well-controlled studies are lacking and needed. Treatment options for older men include injectable, transdermal and transbuccal testosterone preparations.

Anti-aging medicine--the good, the bad, and the ugly

Complementary and alternative medicine has flourished since the beginning of time because of a human need to postpone the aging process and to reverse disease. Complementary and alternative medicine sells, because in some cases it works as well or better than mainstream medicine. In addition, many practitioners of complementary medicine understand Hippocrates' aphorism: "It is more important to know the person that has the disease than the disease the person has." It is important to recognize that spending time with the patient is often as therapeutic as drugs. CAM offers patients the time, touch, attention, and level of personal interaction that are increasingly uncommon in contemporary medical care. There is a major need for large and appropriately designed studies to test the effectiveness of complementary techniques. As in other areas of health care, studies in the elderly are consistently lacking. With the growing interest in CAM, it is important for medical providers to keep an open mind--to both the potential benefits and potential harms of alternative treatments. When treatments are shown to be dangerous or ineffective, we must educate the public and work to remove these therapies from the market place. When treatments are proven effective, Western and Eastern medical providers must work together with patients to provide the most appropriate and comprehensive health care.

Hormonal fountains of youth

Any hope of a fountain of youth to stop people from getting older is a long way off, with science just beginning to understand the complex genetic, physical, and hormonal causes of aging. Clearly, modem research has demonstrated that the concept of a hormonal fountain of youth is predominantly mythology. The best evidence supporting use of hormonal replacement is vitamin D and estrogen replacement to prevent hip fractures. Other than that, treatment should be limited to hormone replacement in persons who have endocrine disease.

Insulin-like growth factor I is a determinant of hip bone mineral density in men less than 60 years of age: MINOS study

Several studies show that in elderly men bone mineral density (BMD) is not correlated with the insulin-like growth factor (IGF-I) level, but data are scanty in young men. Results of studies correlating insulin-like growth factor binding protein 3 (IGFBP-3) and BMD in men are discordant. As different hypotheses can explain the discordant results, we evaluated the correlation of BMD with serum IGF-I, IGFBP-3, and IGF-I/IGFBP-3 index in a large cohort of 721 men aged 19-85 years taking into account age, body weight, 17beta-estradiol, free testosterone, and parathyroid hormone. Serum IGF-I and IGFBP-3 decreased with age (r = -0.44 and r = -0.36, P = 0.0001). After adjustment for confounding variables, IGF-I correlated weakly positively with BMD and with bone mineral apparent density (BMAD) of hip as well as with cortical thickness of femoral neck, both of which are determined mainly by bone resorption, but not with bone size determined by periosteal apposition. IGF-I correlated weakly positively with BMD at the whole body and at the third lumbar vertebra IGFBP-3 and IGF-I/IGFBP-3 index did not correlate with densitometric parameters. In men aged 19-60 years, IGF-I correlated with BMD and BMAD of total hip and with cortical thickness of femoral neck positively and more strongly than in the entire cohort but not with the size of proximal femur. BMD of total hip was 6% higher in men in the highest quartile of IGF-I than in men in the lowest quartile. IGF-I, IGFBP-3, and IGF-I/IGFBP-3 index did not correlate with densitometric parameters of other sites. In the men aged more than 60 years, neither IGF-I nor IGFBP-3 nor IGF-I/IGFBP-3 index correlated with BMD, BMAD, or bone size. In men aged 19-60 years, the most significant hormonal determinants of BMD and BMAD of the hip and of the cortical thickness of femoral neck were 17beta-estradiol and IGF-I (P < 0.05-0.0001). In men aged more than 60 years, the most significant determinants of hip BMD were 17beta-estradiol and PTH. In conclusion, IGF-I seems to contribute to the inhibition of bone resorption and to maintaining bone mass of the proximal femur during the phase of slow bone loss in men aged less than 60 years. IGFBP-3 and IGF-I/IGFBP-3 index were not correlated with BMD or bone size.

The endocrine pharmacology of testosterone therapy in men

The review starts off by outlining the history of the discovery of the male sex hormone testosterone and the historical background to the various, often dubious, approaches to the treatment of age-related endocrine disorders in older men. A discussion of congenital androgen deficiency in young men is followed by methods of diagnosing hypogonadism in older men. Among therapeutic options, the alternatives to direct testosterone replacement are discussed, although none of them have proved to be particularly successful in clinical practice. For testosterone replacement itself, various routes of administration and pharmaceutical formulations are now available, facilitating good monitoring and individualized therapy.

Andropause:

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

Hormones and the aging process

For more than a century, it has been suggested that failure of the secretions of the ductless glands leads to aging. Replacement of these hormones has been suggested as a method of slowing the aging process. Clearly, modern research has demonstrated that the concept of a "hormonal fountain of youth" is predominantly mythology. The best evidence for hormonal replacement is vitamin D and estrogen replacement to prevent hip fractures. Other than that, treatment should be limited to hormone replacement in persons who have endocrine disease.

Growth hormone therapy in adults

Growth hormone (GH) is classically linked with linear growth in childhood but continues to have important metabolic actions throughout life. GH deficiency in adulthood causes a distinct syndrome with significant morbidities. These include increased total and visceral fat, decreased muscle mass and aerobic capacity, affective disturbances, abnormal lipids, and increased vascular mortality, all of which are ameliorated with GH replacement. The possibility of adult GH deficiency (AGHD) should always be considered in individuals with a history of childhood GH deficiency or significant hypothalamic-pituitary damage, and the diagnosis should then be confirmed by biochemical testing. Adult GH dosing is much lower than that in pediatric practice, as appropriate for physiologic reconstitution. Hormonal side effects are minimized by stepwise dose titration. Lingering concerns remain regarding the possibility of increased cancer risk with long-term treatment, but this hazard has not been unequivocally demonstrated. Compared with AGHD, there is much less information about GH replacement in other diseases or in normal aging, or about the use of supraphysiologic GH doses to treat catabolic states. In critical illness, high-dose GH therapy has proven clearly harmful, and the balance of risks and benefits of GH administration in most adult contexts other than AGHD has not been defined.

Androgen treatment of male hypogonadism in older males

The treatment of primary and secondary hypogonadism with testosterone is well established. Recently, there has been increased awareness that low testosterone levels also occur in chronically ill persons and aging males. Because of sex hormone binding globulin changes, it is more appropriate to make the diagnosis using either free or bioavailable testosterone. A small number of controlled studies have suggested that testosterone replacement in older men improves libido, quality of erections, some aspects of cognition, muscle mass, muscles strength, and bone mineral density. It also decreases fat mass and leptin levels. A number of screening questionnaires for the andropause have been developed. Insufficient numbers of older men have been treated with testosterone to characterize the true incidence of side effects. There is a desperate need for well designed, large controlled trials to establish the value or otherwise of testosterone treatment in older males.

An integrative review on current evidence of testosterone replacement therapy for the andropause

OBJECTIVES

This paper examines the evidence supporting testosterone replacement in aging males. Confounding factors contributing to low testosterone levels and challenges to diagnosis of the andropause will also be considered.

METHODS

A thorough review using an integrative approach citing published literature and the ongoing work of the authors. A search was performed using National Library of Medicine PubMed. Electronic and print journals available at the Texas Medical Center library were also considered.

RESULTS

Information based on collective trials in older men has added to evidence for benefits and side effects of testosterone replacement inferred from studies in younger hypogonadal patients and animal models. In general, most investigators agree with short-term safety but long-term safety is unknown. Testosterone therapy in aging males improves body composition, certain domains of brain function and may also decrease cardiovascular risk in biological models. Measurable clinical effects are less apparent. Potential risks include erythrocytosis, edema, gynecomastia, and prostate stimulation. The possibility of increased risk of clinically significant prostate cancer and cardiovascular disease has been considered.

CONCLUSION

The search continues for an ideal replacement androgen and larger long-term studies are needed. At this time, androgen replacement is on a case-by-case basis and prostate cancer screening should be completed prior to instituting therapy. Routine androgen replacement therapy for aging males will have significant economic implications, and is not currently recommended.

Testosterone supplementation therapy for older men: potential benefits and risks

Serum testosterone levels decline gradually and progressively with aging in men. Many manifestations associated with aging in men, including muscle atrophy and weakness, osteoporosis, reduced sexual functioning, and increased fat mass, are similar to changes associated with testosterone deficiency in young men. These similarities suggest that testosterone supplementation may prevent or reverse the effects of aging. A MEDLINE search was performed to identify studies of testosterone supplementation therapy in older men. A structured, qualitative review was performed of placebo-controlled trials that included men aged 60 and older and evaluated one or more physical, cognitive, affective, functional, or quality-of-life outcomes. Studies focusing on patients with severe systemic diseases and hormone deficiencies related to specific diseases were excluded. In healthy older men with low-normal to mildly decreased testosterone levels, testosterone supplementation increased lean body mass and decreased fat mass. Upper and lower body strength, functional performance, sexual functioning, and mood were improved or unchanged with testosterone replacement. Variable effects on cognitive function were reported, with improvements in some cognitive domains (e.g., spatial, working, and verbal memory). Testosterone supplementation improved exercise-induced coronary ischemia in men with coronary heart disease, whereas angina pectoris was improved or unchanged. In a few studies, men with low testosterone levels were more likely to experience improvements in lumbar bone mineral density, self-perceived functional status, libido, erectile function, and exercise-induced coronary ischemia with testosterone replacement than men with less marked testosterone deficiency. No major unfavorable effects on lipids were reported, but hematocrit and prostate specific antigen levels often increased. Based on these results, testosterone supplementation cannot be recommended at this time for older men with normal or low-normal testosterone levels and no clinical manifestations of hypogonadism. However, testosterone replacement may be warranted in older men with markedly decreased testosterone levels, regardless of symptoms, and in men with mildly decreased testosterone levels and symptoms or signs suggesting hypogonadism. The long-term safety and efficacy of testosterone supplementation remain uncertain. Establishment of evidence-based indications will depend on further demonstrations of favorable clinical outcomes and symptomatic, functional, and quality-of-life benefits in carefully performed, long-term, randomized, placebo-controlled clinical trials.