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Groti Antonič K, Zitzmann M. Novel perspectives of testosterone therapy in men with functional hypogonadism: traversing the gaps of knowledge. Aging Male 2024; 27:2296460. [PMID: 38149634 DOI: 10.1080/13685538.2023.2296460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/13/2023] [Indexed: 12/28/2023] Open
Abstract
INTRODUCTION In the past decade, there has been a significant augmentation in the corpus of evidence pertaining to functional hypogonadism. Despite this, prevailing clinical guidelines continue to advise against the universal screening for hypogonadism in middle-aged and elderly males. FINDINGS Numerous randomized controlled trials have scrutinized the effects of testosterone therapy in males afflicted with type 2 diabetes and/or obesity. However, these guidelines uniformly assert that lifestyle modifications and weight reduction should be the primary intervention strategies in overweight and obese males, relegating testosterone therapy to a secondary, selective option. It is extensively documented that testosterone therapy can yield substantial improvements in various metabolic parameters as well as ameliorate symptoms of erectile dysfunction. Moreover, recent studies have demonstrated the potential of testosterone therapy in reversing type 2 diabetes in males with low-normal testosterone levels who are at elevated risk for this condition, in comparison to the outcomes achievable through lifestyle modifications alone. CONCLUSION This focused review article aims to present a comprehensive update on the latest data concerning the innovative aspects of testosterone therapy in males with functional hypogonadism, particularly in the context of type 2 diabetes and/or obesity. Additionally, it will delve into the cardiovascular safety of such interventions within this high-risk demographic, with a special emphasis on insights gleaned from the TRAVERSE trial.
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Affiliation(s)
- Kristina Groti Antonič
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Michael Zitzmann
- Centre for Reproductive Medicine and Andrology, Münster University Hospital, Münster, Germany
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Theodorakis N, Feretzakis G, Vamvakou G, Verykios VS, Polymeris A, Nikolaou M. Testosterone therapy for functional hypogonadism in middle-aged and elderly males: current evidence and future perspectives. Hormones (Athens) 2024:10.1007/s42000-024-00587-2. [PMID: 39060901 DOI: 10.1007/s42000-024-00587-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024]
Abstract
Population aging is a global phenomenon driving research focus toward preventing and managing age-related disorders. Functional hypogonadism (FH) has been defined as the combination of low testosterone levels, typically serum total testosterone below 300-350 ng/dL, together with manifestations of hypogonadism, in the absence of an intrinsic pathology of the hypothalamic-pituitary-testicular (HPT) axis. It is usually seen in middle-aged or elderly males as a product of aging and multimorbidity. This age-related decline in testosterone levels has been associated with numerous adverse outcomes. Testosterone therapy (TTh) is the mainstay of treatment for organic hypogonadism with an identifiable intrinsic pathology of the HPT axis. Current guidelines generally make weak recommendations for TTh in patients with FH, mostly in the presence of sexual dysfunction. Concerns about long-term safety have historically limited TTh use in middle-aged and elderly males with FH. However, recent randomized controlled trials and meta-analyses have demonstrated safe long-term outcomes regarding prostatic and cardiovascular health, together with decreases in all-cause mortality and improvements in various domains, including sexual function, body composition, physical strength, bone density, and hematopoiesis. Furthermore, there are numerous insightful studies suggesting additional benefits of TTh, for instance in cardio-renal-metabolic conditions. Specifically, future trials should investigate the role of TTh in improving symptoms and prognosis in various clinical contexts, including sarcopenia, frailty, dyslipidemia, arterial hypertension, diabetes mellitus, fracture risk, heart failure, stable angina, chronic kidney disease, mood disorders, and cognitive dysfunction.
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Affiliation(s)
- Nikolaos Theodorakis
- Department of Cardiology & 65+ Clinic, Sismanogleio-Amalia Fleming General Hospital, 14, 25th Martiou Str, Melissia, 15127, Greece
- School of Medicine, National and Kapodistrian University of Athens, 75 Mikras Asias, Athens, 11527, Greece
| | - Georgios Feretzakis
- School of Science and Technology, Hellenic Open University, 18 Aristotelous Str, Patras, 26335, Greece.
| | - Georgia Vamvakou
- Department of Cardiology & 65+ Clinic, Sismanogleio-Amalia Fleming General Hospital, 14, 25th Martiou Str, Melissia, 15127, Greece
| | - Vassilios S Verykios
- School of Science and Technology, Hellenic Open University, 18 Aristotelous Str, Patras, 26335, Greece
| | - Antonis Polymeris
- Department of Endocrinology, Metabolism and Diabetes Mellitus, Sismanogleio-Amalia Fleming General Hospital, 14, 25th Martiou Str, Melissia, 15127, Greece
| | - Maria Nikolaou
- Department of Cardiology & 65+ Clinic, Sismanogleio-Amalia Fleming General Hospital, 14, 25th Martiou Str, Melissia, 15127, Greece
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Kim HY, Kwon HS, Lim JO, Jang HJ, Muthamil S, Shin UC, Lyu JH, Park YJ, Nam HH, Lee NY, Oh HJ, Yun SI, Jin JS, Park JH. Gonadal efficacy of Thymus quinquecostatus Celakovski: Regulation of testosterone levels in aging mouse models. Biomed Pharmacother 2024; 175:116700. [PMID: 38703505 DOI: 10.1016/j.biopha.2024.116700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/29/2024] [Accepted: 05/01/2024] [Indexed: 05/06/2024] Open
Abstract
Late-onset hypogonadism (LOH) is an age-related disease in men characterized by decreased testosterone levels with symptoms such as decreased libido, erectile dysfunction, and depression. Thymus quinquecostatus Celakovski (TQC) is a plant used as a volatile oil in traditional medicine, and its bioactive compounds have anti-inflammatory potential. Based on this knowledge, the present study aimed to investigate the effects of TQC extract (TE) on LOH in TM3 Leydig cells and in an in vivo aging mouse model. The aqueous extract of T. quinquecostatus Celakovski (12.5, 25, and 50 µg/mL concentrations) was used to measure parameters such as cell viability, testosterone level, body weight, and gene expression, via in vivo studies. Interestingly, TE increased testosterone levels in TM3 cells in a dose-dependent manner without affecting cell viability. Furthermore, TE significantly increased the expression of genes involved in the cytochrome P450 family (Cyp11a1, Cyp17a1, Cyp19a1, and Srd5a2), which regulate testosterone biosynthesis. In aging mouse models, TE increased testosterone levels without affecting body weight and testicular tissue weight tissue of an aging animal group. In addition, the high-dose TE-treated group (50 mg/kg) showed significantly increased expression of the cytochrome p450 enzymes, similar to the in vitro results. Furthermore, HPLC-MS analysis confirmed the presence of caffeic acid and rosmarinic acid as bioactive compounds in TE. Thus, the results obtained in the present study confirmed that TQC and its bioactive compounds can be used for LOH treatment to enhance testosterone production.
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Affiliation(s)
- Hyun-Yong Kim
- Herbal Medicine Resources Research Center, Korea Institute of Oriental Medicine, Naju, Jeollanam-do 58245, Republic of Korea
| | - Hyuck Se Kwon
- R&D Team, Food & Supplement Health Claims, Vitech, #602 Giyeon B/D 141 Anjeon-ro, Iseo-myeon, Wanju-gun, Jeollabuk-do 55365, Republic of Korea; Department of Food Science and Technology, College of Agriculture and Life Sciences, Jeonbuk National University, Jeonju 54896, Republic of Korea
| | - Je-Oh Lim
- Herbal Medicine Resources Research Center, Korea Institute of Oriental Medicine, Naju, Jeollanam-do 58245, Republic of Korea
| | - Hyun-Jun Jang
- Herbal Medicine Resources Research Center, Korea Institute of Oriental Medicine, Naju, Jeollanam-do 58245, Republic of Korea
| | - Subramanian Muthamil
- Herbal Medicine Resources Research Center, Korea Institute of Oriental Medicine, Naju, Jeollanam-do 58245, Republic of Korea
| | - Ung Cheol Shin
- Herbal Medicine Resources Research Center, Korea Institute of Oriental Medicine, Naju, Jeollanam-do 58245, Republic of Korea
| | - Ji-Hyo Lyu
- Herbal Medicine Resources Research Center, Korea Institute of Oriental Medicine, Naju, Jeollanam-do 58245, Republic of Korea
| | - Yeo Jin Park
- Korean Medicine (KM) Application Center, Korea Institute of Oriental Medicine, Daegu 41062, Republic of Korea
| | - Hyeon-Hwa Nam
- Herbal Medicine Resources Research Center, Korea Institute of Oriental Medicine, Naju, Jeollanam-do 58245, Republic of Korea
| | - Na-Young Lee
- R&D Team, Food & Supplement Health Claims, Vitech, #602 Giyeon B/D 141 Anjeon-ro, Iseo-myeon, Wanju-gun, Jeollabuk-do 55365, Republic of Korea
| | - Hyun-Jeong Oh
- R&D Team, Food & Supplement Health Claims, Vitech, #602 Giyeon B/D 141 Anjeon-ro, Iseo-myeon, Wanju-gun, Jeollabuk-do 55365, Republic of Korea
| | - Soon-Il Yun
- Department of Food Science and Technology, College of Agriculture and Life Sciences, Jeonbuk National University, Jeonju 54896, Republic of Korea; Department of Agricultural Convergence Technology, College of Agriculture and Life Sciences, Jeonbuk National University, Jeonju 54896, Republic of Korea
| | - Jong-Sik Jin
- Department of Oriental Medicine Resources, Jeonbuk National University, 79 Gobong-ro, Iksan, Jeollabuk-do 54596, Republic of Korea
| | - Jun Hong Park
- Herbal Medicine Resources Research Center, Korea Institute of Oriental Medicine, Naju, Jeollanam-do 58245, Republic of Korea; University of Science & Technology (UST), KIOM Campus, Korean Convergence Medicine Major, Daejeon 34054, Republic of Korea.
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De Vincentis S, Greco C, Fanelli F, Decaroli MC, Diazzi C, Mezzullo M, Milic J, De Santis MC, Roli L, Pagotto U, Guaraldi G, Rochira V. Sarcopenic obesity and reduced BMD in young men living with HIV: body composition and sex steroids interplay. J Endocrinol Invest 2024:10.1007/s40618-024-02375-6. [PMID: 38643322 DOI: 10.1007/s40618-024-02375-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/09/2024] [Indexed: 04/22/2024]
Abstract
PURPOSE Sex steroids play a key role on male bone homeostasis and body composition (BC), their role in men living with HIV (MLWH) is less recognized. This study aimed at investigating the prevalence of low BMD, sarcopenia, and sarcopenic obesity (SO) and their relationship with sex steroids in MLWH aged < 50. METHODS Prospective, cross-sectional, observational study on MLWH younger than 50 (median age 47.0 years). BC and BMD were evaluated with DXA. Two different definitions of sarcopenia were applied: appendicular lean mass/height2 (ALMI) < 7.26 kg/m2 or appendicular lean mass/body weight (ALM/W) < 28.27%. Low BMD was defined for Z-score < -2.0. Sarcopenia coupled with obesity identified SO. Serum total testosterone (T) and estradiol (E2) were measured by LC-MS/MS; free testosterone (cFT) was calculated by Vermeulen equation. RESULTS Sarcopenia was detected in 107 (34.9%) and 44 (14.3%) out of 307 MLWH according to ALMI and ALM/W, respectively. The prevalence of SO was similar by using both ALMI (11.4%) and ALM/W (12.4%). Sarcopenic and SO MLWH had lower total T and cFT in both the definition for sarcopenia. BMD was reduced in 43/307 (14.0%). Serum E2 < 18 pg/mL was an independent contributing factor for sarcopenia, SO, and low BMD. CONCLUSIONS T and E2 are important determinants of BC even in MLWH. This is among the first studies investigating the distribution of obesity phenotypes and the prevalence of SO among MLWH showing that SO is present in 11-12% of enrolled MLWH regardless of the definition used. However, deep differences emerged using two different diagnostic definitions.
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Affiliation(s)
- S De Vincentis
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via Giardini, 1355, 41126, Modena, Italy.
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy.
| | - C Greco
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via Giardini, 1355, 41126, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - F Fanelli
- Endocrinology Research Group, Department of Medical and Surgical Sciences, Center for Applied Biomedical Research, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - M C Decaroli
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via Giardini, 1355, 41126, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - C Diazzi
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - M Mezzullo
- Endocrinology Research Group, Department of Medical and Surgical Sciences, Center for Applied Biomedical Research, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - J Milic
- Multidisciplinary Metabolic Clinic, Unit of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - M C De Santis
- Department of Laboratory Medicine and Pathology, Azienda USL of Modena, Modena, Italy
| | - L Roli
- Department of Laboratory Medicine and Pathology, Azienda USL of Modena, Modena, Italy
| | - U Pagotto
- Endocrinology Research Group, Department of Medical and Surgical Sciences, Center for Applied Biomedical Research, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - G Guaraldi
- Multidisciplinary Metabolic Clinic, Unit of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - V Rochira
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via Giardini, 1355, 41126, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
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Kanakis GA, Pofi R, Goulis DG, Isidori AM, Armeni E, Erel CT, Fistonić I, Hillard T, Hirschberg AL, Meczekalski B, Mendoza N, Mueck AO, Simoncini T, Stute P, van Dijken D, Rees M, Lambrinoudaki I. EMAS position statement: Testosterone replacement therapy in older men. Maturitas 2023; 178:107854. [PMID: 37845136 DOI: 10.1016/j.maturitas.2023.107854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Late-onset hypogonadism is the clinical entity characterised by low testosterone concentrations associated with clinical symptoms in the absence of organic disease in ageing men. It has been associated with metabolic syndrome, reduced bone mineral density, and increased cardiovascular morbidity and mortality risk. Although testosterone replacement therapy (TRT) reverses most of these conditions in young hypogonadal men, the risk/benefit ratio of TRT in older men is debatable. AIM To update the 2015 EMAS statement on TRT in older men with new research on late-onset hypogonadism and TRT. MATERIALS AND METHODS Literature review and consensus of expert opinion. SUMMARY RECOMMENDATIONS TRT should be offered only to symptomatic older men with confirmed low testosterone concentrations after explaining the uncertainties regarding the long-term safety of this treatment. TRT may be offered to men with severe hypogonadism and erectile dysfunction to improve sexual desire, erectile, and orgasmic function. It should also be considered in hypogonadal men with severe insulin resistance or pre-diabetes mellitus. TRT may also be considered, in combination with proven treatment strategies, for osteoporosis, or for selected patients with persistent mild depressive symptoms and/or low self-perceived quality of life, combined with standard medical care for each condition. TRT is contraindicated in hypogonadal men actively seeking fertility treatment. Due to a lack of data, TRT should not be routinely used in older men to improve exercise capacity/physical function, improve cognitive function, or prevent cognitive decline. TRT must be avoided in older, frail men with known breast cancer or untreated prostate cancer and all men who have had myocardial infarction or stroke within the last four months, and those with severe or decompensated heart failure. The quality of evidence regarding patients with previous prostate cancer or cardiovascular disease is too low to draw definitive conclusions. Any limits on duration of use are arbitrary, and treatment should continue for as long as the man feels the benefits outweigh the risks for him, and decisions must be made on an individual basis. Withdrawal should be considered when hypogonadism is reversed after the resolution of underlying disorder. Short-acting transdermal preparations should be preferred for TRT initiation in older men, but injectable forms may be considered subsequently. Older men on TRT should be monitored at 3, 6, and 12 months after initiation and at least yearly thereafter, or earlier and more frequently if indicated. Evaluation should include assessment of the clinical response, and measurement of total testosterone, haematocrit, and prostate-specific antigen (PSA) concentrations. Bone density and/or quality should also be assessed. Obese and overweight patients should be encouraged to undergo lifestyle modifications, including exercise and weight loss, to increase endogenous testosterone.
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Affiliation(s)
- George A Kanakis
- Department of Endocrinology & IVF Unit, Athens Naval and Veteran Affairs Hospital, Athens, Greece.
| | - Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Greece
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Eleni Armeni
- Second Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Greece; Royal Free Hospital, London, UK
| | - C Tamer Erel
- İstanbul-Cerrahpaşa University, Cerrahpaşa School of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
| | - Ivan Fistonić
- Faculty for Health Studies, University of Rijeka, Rijeka, Croatia
| | - Timothy Hillard
- Department of Obstetrics & Gynaecology, University Hospitals Dorset, Poole, UK
| | - Angelica-Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Blazej Meczekalski
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, Poznan, Poland
| | - Nicolás Mendoza
- Department of Obstetrics and Gynecology, University of Granada, Spain
| | - Alfred O Mueck
- Department of Women's Health, University Hospital Tuebingen, Germany; Beijing OB/GYN Hospital, Capital Medical University, China
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56100 Pisa, Italy
| | - Petra Stute
- Department of Obstetrics and Gynecology, University Clinic Inselspital, Bern, Switzerland
| | - Dorenda van Dijken
- Department of Obstetrics and Gynecology, OLVG Hospital, Amsterdam, the Netherlands
| | - Margaret Rees
- Women's Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Irene Lambrinoudaki
- Second Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Greece
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Facondo P, Delbarba A, Pezzaioli LC, Ferlin A, Cappelli C. Osteoporosis in men with hypogonadism because of ApoA-I Leu75Pro amyloidosis under long-term testosterone therapy. Andrology 2023; 11:1077-1085. [PMID: 36624081 DOI: 10.1111/andr.13376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/11/2022] [Accepted: 12/22/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Apo A-I Leu75Pro amyloidosis is a rare systemic hereditary disease, whose hallmark and earliest involvement is testicular impairment, characterized by hypogonadism and macrorchidism; renal and hepatic involvement are the other characteristics. OBJECTIVE To evaluate for the first time the prevalence of osteopenia, osteoporosis and vertebral fractures (VFs) in men with this form of amyloidosis affected by hypogonadism and under long-term testosterone replacement therapy (TRT). MATERIALS AND METHODS Retrospective study on 50 men >50 years (median age 64.5) with dual-energy X-ray absorptiometry (DXA), hormonal, and biochemical data available at least 3 years after the start of TRT. Serum gonadal hormones and bone markers, lumbar and femoral DXA-scan with morphometric assay for evaluation of VFs were assessed. RESULTS At 7.5 years from start of TRT, lumbar and/or femoral osteopenia and osteoporosis were found in 54% and 10% of patients, respectively. Of the men who had the morphometric assay performed, five of 34 (14.7%) had VFs. Compared to patients with normal bone mineral density, men with osteopenia and osteoporosis were older, had lower body mass index, higher sex hormone binding globulin and showed more frequently renal involvement. Multiorgan involvement, without different TRT dosage, was associated with lower testosterone levels. DISCUSSION AND CONCLUSION Men with hypogonadism because of Apo A-I Leu75Pro amyloidosis under long-term TRT had a high burden of low bone mass (64%) and VFs (almost 15%). Osteopenia-osteoporosis was more frequently observed in older patients with multi-organ disease, which might contribute to impair bone health beyond hypogonadism.
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Affiliation(s)
- Paolo Facondo
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Andrea Delbarba
- Unit of Endocrinology and Metabolism, ASST Spedali Civili, Brescia, Italy
| | | | - Alberto Ferlin
- Unit of Andrology and Reproductive Medicine, Department of Medicine, University of Padova, Brescia, Italy
| | - Carlo Cappelli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Unit of Endocrinology and Metabolism, ASST Spedali Civili, Brescia, Italy
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De Vincentis S, Rochira V. Update on acquired hypogonadism in men living with HIV: pathogenesis, clinic, and treatment. Front Endocrinol (Lausanne) 2023; 14:1201696. [PMID: 37455928 PMCID: PMC10338827 DOI: 10.3389/fendo.2023.1201696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/08/2023] [Indexed: 07/18/2023] Open
Abstract
Hypogonadism is a frequent finding among men living with HIV (MLWH) and it seems to occur earlier in comparison with the general male population. Although the prevalence of hypogonadism in MLWH has significantly lowered thanks to advancements in medical management, it remains high if compared with age-matched HIV-uninfected men, ranging from 13% to 40% in the age group of 20-60 years. Signs and symptoms of low serum testosterone (T) in MLWH are cause of concern since they are non-specific, of mild-to-moderate degree, and often overlapping with those of infection per se. For these reasons, hypogonadism can be underestimated in the absence of targeted laboratory blood examinations. With regard to the etiological factors involved in the T decrease, emerging evidence has suggested the functional nature of hypogonadism in MLWH, pointing out the mutual relationship between sex steroids, health status, comorbidities, and HIV-related factors. In agreement with this hypothesis, a therapeutic approach aiming at improving or reversing concomitant diseases through lifestyle changes (e.g. physical activity) rather than pharmacological T treatment should be theoretically considered. However, considering both patient's barriers to lifestyle changes to be maintained overtime and the lack of evidence-based data on the efficacy of lifestyle changes in normalizing serum T in MLWH, T therapy remains an option when other non-pharmacological interventions are ineffective as well as for all other functional forms of hypogonadism. From this perspective, the traditional therapeutic management of male hypogonadism in MLWH, especially the role of T supplementation, should be revised in the light of the probable functional nature of hypogonadism by considering a good balance between benefits and harmful. This narrative review presents an overview of current knowledge on hypogonadism in MLWH, deepening the factors driving and taking part in T decrease, providing advice for the clinical approach, and underlining the importance of individualized treatment aiming at optimizing non-gonadal comorbidities and thus avoiding over-, or even unnecessary, treatment with T.
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Affiliation(s)
- Sara De Vincentis
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Vincenzo Rochira
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
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8
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Devlin MJ, Eick GN, Snodgrass JJ. The utility of dried blood spot measurement of bone turnover markers in biological anthropology. Am J Hum Biol 2022; 34:e23816. [PMID: 36214251 PMCID: PMC9787861 DOI: 10.1002/ajhb.23816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Bone is a dynamic organ under continual turnover influenced by life history stage, energy dynamics, diet, climate, and disease. Bone turnover data have enormous potential in biological anthropology for testing evolutionary and biocultural hypotheses, yet few studies have integrated these biomarkers. In the present article we systematically review the current availability, future viability, and applicability of measuring bone turnover markers (BTMs) in dried blood spot (DBS) samples obtained from finger prick whole blood. METHODS Our review considers clinical and public health relevance, biomarker stability in DBS, assay availability, and cost. We consider biomarkers of bone formation such as osteocalcin (bone matrix protein), PINP (N-terminal propeptide of type I collagen), and alkaline phosphatase (osteoblast enzyme), as well as biomarkers of bone resorption such as CTX (marker of collagen breakdown) and TRACP5b (tartrate-resistant acid phosphatase 5b; osteoclast enzyme). RESULTS Two BTMs have been validated for DBS: osteocalcin (formation) and TRACP5b (resorption). Prime candidates for future development are CTX and PINP, the formation and resorption markers used for clinical monitoring of response to osteoporosis treatment. CONCLUSION BTMs are a field-friendly technique for longitudinal monitoring of skeletal biology during growth, reproduction and aging, combining minimized risk to study participants with maximized ease of sample storage and transport. This combination allows new insights into the effects of energy availability, disease, and physical activity level on bone, and questions about bone gain and loss across life history and in response to environmental factors; these issues are important in human biology, paleoanthropology, bioarchaeology, and forensic anthropology.
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Affiliation(s)
- Maureen J. Devlin
- Department of AnthropologyUniversity of MichiganAnn ArborMichiganUSA
| | - Geeta N. Eick
- Global Health Biomarker Laboratory, Department of AnthropologyUniversity of OregonEugeneOregonUSA
| | - J. Josh Snodgrass
- Global Health Biomarker Laboratory, Department of AnthropologyUniversity of OregonEugeneOregonUSA,Center for Global HealthUniversity of OregonEugeneOregonUSA,Invited Faculty, Global Station for Indigenous Studies & Cultural DiversityHokkaido UniversitySapparoHokkaidoJapan
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9
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高山 賢. [Recent advances in the sex steroid hormone action involved in the development of dementia and frailty]. Nihon Ronen Igakkai Zasshi 2022; 59:430-445. [PMID: 36476689 DOI: 10.3143/geriatrics.59.430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- 賢一 高山
- 東京都健康長寿医療センター研究所老化機構研究チームシステム加齢医学
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Suboptimal Plasma Vitamin C Is Associated with Lower Bone Mineral Density in Young and Early Middle-Aged Men: A Retrospective Cross-Sectional Study. Nutrients 2022; 14:nu14173556. [PMID: 36079812 PMCID: PMC9459983 DOI: 10.3390/nu14173556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background: This study was conducted to evaluate associations between bone mineral density (BMD) and four selected circulating nutrients, particularly vitamin C, among adults aged 20−49 years. Methods: In this retrospective cross-sectional study, the lumbar spine BMD of 866 men and 589 women were measured by dual-energy X-ray absorptiometry and divided into tertiles, respectively. Logistic regressions were used to identify the predictors of low BMD by comparing subjects with the highest BMD to those with the lowest. Results: Multivariate logistic regressions identified suboptimal plasma vitamin C (adjusted odds ratio (AOR) 1.64, 95% confidence interval (CI) 1.16, 2.31), suboptimal serum vitamin B12 (AOR 2.05, 95% CI 1.02, 4.12), and low BMI (BMI < 23) (AOR 1.68, 95% CI 1.12, 2.53) as independent predictors for low BMD in men. In women, low BMI was the only independent predictor for low BMD. Plasma vitamin C, categorized as suboptimal (≤8.8 mg/L) and sufficient (>8.8 mg/L), was positively significantly correlated with the lumbar spine BMD in men, but there was no association in women. Conclusions: Plasma vitamin C, categorized as suboptimal and sufficient, was positively associated with the lumbar spine BMD in young and early middle-aged men. A well-designed cohort study is needed to confirm the findings.
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11
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Corona G, Vena W, Pizzocaro A, Giagulli VA, Francomano D, Rastrelli G, Mazziotti G, Aversa A, Isidori AM, Pivonello R, Vignozzi L, Mannucci E, Maggi M, Ferlin A. Testosterone supplementation and bone parameters: a systematic review and meta-analysis study. J Endocrinol Invest 2022; 45:911-926. [PMID: 35041193 DOI: 10.1007/s40618-021-01702-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/01/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The role of testosterone (T) replacement therapy (TRT) in subjects with late onset hypogonadism is still the object of an intense debate. METHODS All observational studies and placebo-controlled or -uncontrolled randomized trials (RCTs) comparing the effect of TRT on different bone parameters were considered. RESULTS Out of 349 articles, 36 were considered, including 3103 individuals with a mean trial duration of 66.6 weeks. TRT improves areal bone mineral density (aBMD) at the spine and femoral neck levels in observational studies, whereas placebo-controlled RTCs showed a positive effect of TRT only at lumber spine and when trials included only hypogonadal patients at baseline (total testosterone < 12 nM). The effects on aBMD were more evident in subjects with lower T levels at baseline and increased as a function of trial duration and a higher prevalence of diabetic subjects. Either T or estradiol increase at endpoint contributed to aBMD improvement. TRT was associated with a significant reduction of bone resorption markers in observational but not in controlled studies. CONCLUSION TRT is able to inhibit bone resorption and increase bone mass, particularly at the lumbar spine level and when the duration is long enough to allow the anabolic effect of T and estrogens on bone metabolism to take place.
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Affiliation(s)
- G Corona
- Endocrinology Unit, Medical Department, Azienda Usl, Maggiore-Bellaria Hospital, Bologna, Italy
| | - W Vena
- Unit of Endocrinology, Diabetology and Medical Andrology, IRCSS, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - A Pizzocaro
- Unit of Endocrinology, Diabetology and Medical Andrology, IRCSS, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - V A Giagulli
- Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - D Francomano
- Unit of Internal Medicine and Endocrinology, Madonna Delle Grazie Hospital, Velletri, Rome, Italy
| | - G Rastrelli
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Mario Serio Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - G Mazziotti
- Unit of Endocrinology, Diabetology and Medical Andrology, IRCSS, Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - A Aversa
- Department of Experimental and Clinical Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome-Policlinico Umberto I Hospital, Rome, Italy
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e della Sessualità Maschile e Femminile, Università Federico II di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - L Vignozzi
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Mario Serio Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - E Mannucci
- Department of Diabetology, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - M Maggi
- Endocrinology Unit, Mario Serio Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy.
| | - A Ferlin
- Department of Medicine, Unit of Andrology and Reproductive Medicine, University of Padova, Padova, Italy
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12
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Yang J, Kong G, Yao X, Zhu Z. Association between Serum Total Testosterone Level and Bone Mineral Density in Middle-Aged Postmenopausal Women. Int J Endocrinol 2022; 2022:4228740. [PMID: 36034179 PMCID: PMC9402345 DOI: 10.1155/2022/4228740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/31/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hormone status strongly affects women's health and quality of life. To date, studies investigating the association between total testosterone (T) level and bone mineral density (BMD) in women are limited and have yielded contradictory conclusions. The aim of our study was to examine the association between serum total T level and lumbar BMD in postmenopausal women aged 40-59 years. METHODS The study group included 1,058 women from the 2011-2016 National Health and Nutrition Examination Survey. Multiple regression analyses were used to evaluate the association between serum total T level and lumbar BMD. RESULTS After adjusting for covariates, there was a positive association between the serum total T level and lumbar BMD (β, 1.07; 95% confidence interval, 0.17-1.97). A non-linearity in this association was identified, with a point of inflection at 30 ng/dL. CONCLUSIONS Serum total T level was positively associated with lumbar BMD in middle-aged postmenopausal women up to a T level >30 ng/dL. Therefore, increasing T level in women with a low serum total T level may have beneficial outcomes on bone health.
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Affiliation(s)
- JinXiao Yang
- Department of Urology, The First People's Hospital of Xiaoshan District, Xiaoshan Affiliated Hospital of Wenzhou Medical University, Hangzhou, Zhejiang 311200, China
| | - Guofei Kong
- Department of Osteoporosis Care and Control, The First People's Hospital of Xiaoshan District, Xiaoshan Affiliated Hospital of Wenzhou Medical University, Hangzhou, Zhejiang 311200, China
| | - Xiaocong Yao
- Department of Osteoporosis Care and Control, The First People's Hospital of Xiaoshan District, Xiaoshan Affiliated Hospital of Wenzhou Medical University, Hangzhou, Zhejiang 311200, China
| | - Zhongxin Zhu
- Department of Osteoporosis Care and Control, The First People's Hospital of Xiaoshan District, Xiaoshan Affiliated Hospital of Wenzhou Medical University, Hangzhou, Zhejiang 311200, China
- Department of Clinical Research, The First People's Hospital of Xiaoshan District, Xiaoshan Affiliated Hospital of Wenzhou Medical University, Hangzhou, Zhejiang 311200, China
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13
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de Paiva Gonçalves V, Cabrera-Ortega AA, Carvalho JDS, Ramadan D, Spolidorio LC. Physiological testosterone replacement effects on male aged rats with orchiectomy-induced osteoporosis in advanced stage: a tomographic and biomechanical pilot study. Aging Male 2021; 24:139-147. [PMID: 34647515 DOI: 10.1080/13685538.2021.1990256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Aim: This study aimed to evaluate the effect of physiological testosterone replacement on male aged rats with orchiectomy-induced osteoporosis in advanced stage.Methods: Thirty male rats (Rattus norvegicus albinus, Holtzman lineage) were randomly distributed into 3 groups (n = 10): 1-sham, 2-orchiectomy (OCX), 3-OCX + testosterone replacement (OCX + T). On day 0, a sham or orchiectomy surgery was performed according to the groups. Thirty and sixty days after surgeries, the animals from OCX + T group received testosterone intramuscularly, and the rats in all groups were euthanized on day 77. The femurs were removed for micro-CT scanning and biomechanical test.Results: Orchiectomy resulted in a marked trabecular bone damage (p < 0.05), which was not reversed with testosterone treatment (OCX + T group). The femoral strength was lower in orchiectomized animals (p < 0.05), while the bone strength in OCX + T group was similar to that observed in the sham animals (p > 0.05) and correlated to this parameter the deformation of rupture was smaller in OCX + T group.Conclusion: In conclusion, testosterone depletion induced by orchiectomy established an osteoporotic environment, mainly affecting the trabecular bone. Moreover, even though testosterone treatment did not enhance these variables, the hormonal replacement improved the femoral fracture strength and promoted beneficial effects on the biomechanical parameters compromised by castration in femoral bone.
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Affiliation(s)
- Vinícius de Paiva Gonçalves
- Department of Physiology and Pathology, Araraquara School of Dentistry, University of São Paulo State, UNESP, Araraquara, Brazil
| | - Adriana Alicia Cabrera-Ortega
- School of Dentistry, Center of Advanced Research and Study in Dentistry, Autonomous University of State of Mexico, Toluca, Mexico
| | - Jhonatan de Souza Carvalho
- Department of Diagnosis and Surgery, Araraquara School of Dentistry, University of São Paulo State, UNESP, Araraquara, Brazil
| | - Dania Ramadan
- Department of Diagnosis and Surgery, Araraquara School of Dentistry, University of São Paulo State, UNESP, Araraquara, Brazil
| | - Luís Carlos Spolidorio
- Department of Physiology and Pathology, Araraquara School of Dentistry, University of São Paulo State, UNESP, Araraquara, Brazil
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Abstract
Over the past two decades several large cohort studies have been performed to disclose the changes of sex hormone in elderly and their clinical significance. Beyond the decline of total testosterone, aging is accompanied by a sex hormone binding globulin (SHBG) increase, a steeper free testosterone decline, while gonadotropins may be increased or inappropriately normal, with important contribution of comorbidities (e.g., obesity) to these changes. Actually, it has become firm the concept that the biochemical finding of testosterone deficiency alone is not sufficient for diagnosing hypogonadism in older men. The definition of late-onset hypogonadism (LOH) includes low serum testosterone levels coupled with signs and symptoms related to hypogonadism. Indeed, the combination of multiple factors all contributing to the testosterone decline, with other concurrent comorbidities further overlapping, makes the clinical correlates of LOH highly heterogeneous. For all these reasons both the diagnosis and the therapeutic management of LOH, especially the decision about starting testosterone replacement treatment, remain challenging.
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15
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Casale M, Forni GL, Cassinerio E, Pasquali D, Origa R, Serra M, Campisi S, Peluso A, Renni R, Cattoni A, De Michele E, Allò M, Poggi M, Ferrara F, Di Concilio R, Sportelli F, Quarta A, Putti MC, Notarangelo LD, Sau A, Ladogana S, Tartaglione I, Picariello S, Marcon A, Sturiale P, Roberti D, Lazzarino AI, Perrotta S. Risk factors for endocrine complications in transfusion-dependent thalassemia patients on chelation therapy with deferasirox: a risk assessment study from a multicentre nation-wide cohort. Haematologica 2021; 107:467-477. [PMID: 33406815 PMCID: PMC8804575 DOI: 10.3324/haematol.2020.272419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Indexed: 01/19/2023] Open
Abstract
Transfusion-dependent patients typically develop iron-induced cardiomyopathy, liver disease, and endocrine complications. We aimed to estimate the incidence of endocrine disorders in transfusiondependent thalassemia (TDT) patients during long-term iron-chelation therapy with deferasirox (DFX). We developed a multi-center follow-up study of 426 TDT patients treated with once-daily DFX for a median duration of 8 years, up to 18.5 years. At baseline, 118, 121, and 187 patients had 0, 1, or ≥2 endocrine diseases respectively. 104 additional endocrine diseases were developed during the follow-up. The overall risk of developing a new endocrine complication within 5 years was 9.7% (95% Confidence Interval [CI]: 6.3–13.1). Multiple Cox regression analysis identified three key predictors: age showed a positive log-linear effect (adjusted hazard ratio [HR] for 50% increase 1.2, 95% CI: 1.1–1.3, P=0.005), the serum concentration of thyrotropin showed a positive linear effect (adjusted HR for 1 mIU/L increase 1.3, 95% CI: 1.1–1.4, P<0.001) regardless the kind of disease incident, while the number of previous endocrine diseases showed a negative linear effect: the higher the number of diseases at baseline the lower the chance of developing further diseasess (adjusted HR for unit increase 0.5, 95% CI: 0.4–0.7, P<0.001). Age and thyrotropin had similar effect sizes across the categories of baseline diseases. The administration of levothyroxine as a covariate did not change the estimates. Although in DFX-treated TDT patients the risk of developing an endocrine complication is generally lower than the previously reported risk, there is considerable risk variation and the burden of these complications remains high. We developed a simple risk score chart enabling clinicians to estimate their patients’ risk. Future research will look at increasing the amount of variation explained from our model and testing further clinical and laboratory predictors, including the assessment of direct endocrine magnetic resonance imaging.
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Affiliation(s)
- Maddalena Casale
- Department of Women, Child and General and Specialized Surgery, University " Luigi Vanvitelli", via Luigi De Crecchio n. 4, 80138, Naples.
| | - Gian Luca Forni
- Center of Microcitemia and Congenital Anemias, Galliera Hospital, Mura delle Cappuccine 14 16128, Genoa
| | - Elena Cassinerio
- Rare Diseases Center, General Medicine Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
| | - Daniela Pasquali
- Endocrinology, Department of Advanced Medical and Surgical Sciences, University " Luigi Vanvitelli", Naples
| | - Raffaella Origa
- Thalassemia Centre, Pediatric Hospital A CAO, AOG Brotzu, Cagliari
| | - Marilena Serra
- Thalassemia Centre, Department of Internal Medicine, Hospital "V. Fazzi", Lecce
| | | | - Angelo Peluso
- Centre of Microcitemia, POC SS.Annunziata - ASL TA, Taranto
| | - Roberta Renni
- Thalassemia Centre, Department of Internal Medicine, Hospital F.Ferrari, Casarano
| | - Alessandro Cattoni
- Department of Pediatrics, Università degli Studi di Milano Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma, Azienda Ospedaliera San Gerardo, Monza
| | - Elisa De Michele
- Immunotransfusion Medicine Unit, AOU OO.RR. S. Giovanni di Dio e Ruggi d'Aragona, Salerno
| | | | | | | | | | | | - Antonella Quarta
- Center for Microcythemia, Iron Metabolism disorders, Gaucher disease-Hematology and Transplantation Unit, "A. Perrino" Hospital, Brindisi
| | | | | | - Antonella Sau
- Department of Pediatric Hematology and Oncology, Hospital "Spirito Santo", Pescara
| | - Saverio Ladogana
- Pediatric Oncohematology Unit, "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo
| | - Immacolata Tartaglione
- Department of Women, Child and General and Specialized Surgery, University " Luigi Vanvitelli", via Luigi De Crecchio n. 4, 80138, Naples
| | - Stefania Picariello
- Department of Women, Child and General and Specialized Surgery, University " Luigi Vanvitelli", via Luigi De Crecchio n. 4, 80138, Naples
| | - Alessia Marcon
- Rare Diseases Center, General Medicine Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
| | | | - Domenico Roberti
- Department of Women, Child and General and Specialized Surgery, University " Luigi Vanvitelli", via Luigi De Crecchio n. 4, 80138, Naples
| | - Antonio Ivan Lazzarino
- EPISTATA - Agency for Clinical Research and Medical Statistics, London E8 3SY, United Kingdom
| | - Silverio Perrotta
- Department of Women, Child and General and Specialized Surgery, University " Luigi Vanvitelli", via Luigi De Crecchio n. 4, 80138, Naples
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16
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Corona G, Krausz C. Late‐onset hypogonadism a challenging task for the andrology field. Andrology 2020; 8:1504-1505. [DOI: 10.1111/andr.12917] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Giovanni Corona
- Endocrinology Unit Medical Department Maggiore‐Bellaria HospitalAzienda‐Usl Bologna Bologna Italy
| | - Csilla Krausz
- Andrology Female Endocrinology and Gender Incongruence Unit Department of Experimental, Clinical and Biomedical Sciences University of Florence Florence Italy
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