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De Silva NL, Papanikolaou N, Grossmann M, Antonio L, Quinton R, Anawalt BD, Jayasena CN. Male hypogonadism: pathogenesis, diagnosis, and management. Lancet Diabetes Endocrinol 2024:S2213-8587(24)00199-2. [PMID: 39159641 DOI: 10.1016/s2213-8587(24)00199-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/09/2024] [Accepted: 07/09/2024] [Indexed: 08/21/2024]
Abstract
Organic male hypogonadism due to irreversible hypothalamic-pituitary-testicular (HPT) pathology is easily diagnosed and treated with testosterone-replacement therapy. However, controversy surrounds the global practice of prescribing testosterone to symptomatic men with low testosterone and non-gonadal factors reducing health status, such as obesity, type 2 diabetes, and ageing (ie, functional hypogonadism), but without identifiable HPT axis pathology. Health optimisation remains the gold-standard management strategy. Nevertheless, in the last decade large clinical trials and an individual patient data meta-analysis of smaller clinical trials confirmed that testosterone therapy induces modest, yet statistically significant, improvements in sexual function without increasing short-term to medium-term cardiovascular or prostate cancer risks in men with functional hypogonadism. Although testosterone improves bone mineral density and insulin sensitivity in these men, trials from the last decade suggest insufficient evidence to determine the safety and effectiveness of use of this hormone for the prevention of fractures or type 2 diabetes. This Review discusses the pathogenesis and diagnosis of male hypogonadism and appraises the evidence underpinning the management of this condition.
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Affiliation(s)
- Nipun Lakshitha De Silva
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK; Faculty of Medicine, General Sir John Kotelawala Defence University, Colombo, Sri Lanka
| | - Nikoleta Papanikolaou
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Mathis Grossmann
- Department of Medicine (Austin Health), The University of Melbourne, Melbourne, VIC, Australia; Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
| | - Leen Antonio
- Department of Chronic Diseases and Metabolism (CHROMETA), Laboratory of Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium; Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Richard Quinton
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK; Northern Regional Gender Dysphoria Service, Cumbria Northumberland Tyne & Wear NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Bradley David Anawalt
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Channa N Jayasena
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK.
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De Alcubierre D, Feola T, Cozzolino A, Pofi R, Galea N, Catalano C, Auriemma RS, Pirchio R, Pivonello R, Isidori AM, Giannetta E. The spectrum of cardiac abnormalities in patients with acromegaly: results from a case-control cardiac magnetic resonance study. Pituitary 2024; 27:416-427. [PMID: 38847918 PMCID: PMC11289141 DOI: 10.1007/s11102-024-01403-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2024] [Indexed: 07/31/2024]
Abstract
PURPOSE Cardiac abnormalities are common in patients with acromegaly, contributing to the increased morbidity and mortality. Cardiac magnetic resonance (CMR) is the gold standard for measuring cardiac morpho-functional changes. This study aims to detect cardiac alterations in acromegaly through CMR, even when the disease is adequately controlled. METHODS In this, multicentre, case-control study, we compared consecutive patients with acromegaly, cured after surgery or requiring medical treatment, with matched controls recruited among patients harbouring non-functioning adrenal incidentalomas. RESULTS We included 20 patients with acromegaly (7 females, mean age 50 years) and 17 controls. Indexed left ventricular-end-diastolic volume (LV-EDVi) and LV-end-systolic volume (LV-ESVi) were higher in patients than in controls (p < 0.001), as were left ventricular mass (LVMi) (p = 0.001) and LV-stroke volume (LV-SVi) (p = 0.028). Right ventricle (RV) EDVi and ESVi were higher, whereas RV-ejection fraction (RV-EF) was lower (p = 0.002) in patients than in controls (p < 0.001). No significant differences were observed in the prevalence of cardiometabolic comorbidities, including hypertension, glucose and lipid metabolism impairment, obstructive sleep apnoea syndrome, and obesity. IGF1 x upper limit of normal significantly predicted LVMi (b = 0.575; p = 0.008). Subgroup analysis showed higher LVMi (p = 0.025) and interventricular septum thickness (p = 0.003) in male than female patients, even after adjusting cardiac parameters for confounding factors. CONCLUSIONS The CMR analysis reveals a cluster of biventricular structural and functional impairment in acromegaly, even when the biochemical control if achieved. These findings appear specifically triggered by the exposure to GH-IGF1 excess and show sex-related differences advocating a possible interaction with sex hormones in cardiac disease progression.
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Affiliation(s)
- Dario De Alcubierre
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, Rome, 00161, Italy
- Neuroendocrinology, Neuromed Institute, IRCCS, Pozzilli, Italy
| | - Tiziana Feola
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, Rome, 00161, Italy
- Neuroendocrinology, Neuromed Institute, IRCCS, Pozzilli, Italy
| | - Alessia Cozzolino
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, Rome, 00161, Italy
| | - Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology, and Metabolism, Churchill hospital, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - Nicola Galea
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Carlo Catalano
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Renata Simona Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Università Federico II di Napoli, Naples, Italy
| | - Rosa Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Università Federico II di Napoli, Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Università Federico II di Napoli, Naples, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, Rome, 00161, Italy.
- Centre for Rare Diseases (ENDO-ERN accredited), Policlinico Umberto I, Rome, Italy.
| | - Elisa Giannetta
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, Rome, 00161, 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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Isidori AM, Aversa A, Calogero A, Ferlin A, Francavilla S, Lanfranco F, Pivonello R, Rochira V, Corona G, Maggi M. Adult- and late-onset male hypogonadism: the clinical practice guidelines of the Italian Society of Andrology and Sexual Medicine (SIAMS) and the Italian Society of Endocrinology (SIE). J Endocrinol Invest 2022; 45:2385-2403. [PMID: 36018454 PMCID: PMC9415259 DOI: 10.1007/s40618-022-01859-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/29/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE To provide the evidence-based recommendations on the role of testosterone (T) on age-related symptoms and signs remains. METHODS The Italian Society of Andrology and Sexual Medicine (SIAMS) and the and the Italian Society of Endocrinology (SIE) commissioned an expert task force to provide an updated guideline on adult-onset male hypogonadism. Derived recommendations were based on Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. RESULTS Clinical diagnosis of adult-onset hypogonadism should be based on a combination of clinical and biochemical parameters. Testosterone replacement therapy (TRT) should be offered to all symptomatic subjects with hypogonadism after the exclusion of possible contraindications. T gels and the long-acting injectable T are currently available preparations showing the best efficacy/safety profile. TRT can improve all aspects of sexual function, although its effect is limited in more complicated patients. Body composition (reducing fat mass and increasing lean mass) is improved after TRT, either in subjects with or without metabolic syndrome or type 2 diabetes. Conversely, the role of TRT in improving glycometabolic control is more conflicting. TRT can result in increasing bone mineral density, particularly at lumbar site, but no information on fracture risk is available. Limited data support the use of TRT for improving other outcomes, including mood frailty and mobility. CONCLUSIONS TRT can improve sexual function and body composition particularly in less complicated adult and in aging subjects with hypogonadism. When hypogonadism is adequately diagnosed, T appropriately prescribed and subjects correctly followed up, no short-term increased risk of adverse events is observed. Longer and larger studies are advisable to better clarify TRT long-term efficacy/safety profile.
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Affiliation(s)
- A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome - Policlinico Umberto I Hospital, Rome, Italy
| | - A Aversa
- Department of Experimental and Clinical Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - A Calogero
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - A Ferlin
- Unit of Andrology and Reproductive Medicine, Department of Medicine, University of Padova, Padua, Italy
| | - S Francavilla
- Andrology Unit, Department of Clinical Medicine, Public Health, Life and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - F Lanfranco
- Division of Endocrinology, Andrology and Metabolism, Humanitas Gradenigo, Department of Medical Sciences, University of Turin, Turin, 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
- Staff of UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - V Rochira
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - G Corona
- Endocrinology Unit, Medical Department, Azienda Usl Bologna Maggiore-Bellaria Hospital, Largo Nigrisoli, 2, 40133, Bologna, Italy.
| | - M Maggi
- Endocrinology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
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Abstract
Sexual function, and testosterone (T) levels, progressively decline in aging men. Associated morbidities and metabolic disorders can accelerate the phenomenon. The specific contribution of low T to sexual function impairment in aging men has still not been completely clarified. Similarly, the role of T replacement therapy (TRT), as well as the combination of TRT with phosphodiesterase type 5 inhibitors (PDE5i) for patients with erectile dysfunction (ED), is still conflicting. Here we aim to summarize and critically discuss all available data supporting the contribution of low T to sexual impairment observed with aging as well as the possible role of TRT. Available data on men with sexual dysfunction show that reduced sexual desire is the most important correlate of male hypogonadism. Conversely, aging and associated morbidities substantially attenuate the relationship between ED and T. TRT is effective in improving sexual function in middle-aged and older subjects but its role is small and extremely variable. Lifestyle interventions can result in similar outcomes to those of TRT. In conclusion, it is our opinion that PDE5i along with lifestyle measures should be considered the first approach for treating ED even in subjects with milder T deficiency. When these interventions fail or are difficult to apply, TRT should be considered.
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Affiliation(s)
- Giovanni Corona
- Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Azienda Usl, Bologna, Italy
| | - Mario Maggi
- Endocrinology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Mario Serio, Italy.
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Testosterone replacement therapy and cardiovascular disease. Int J Impot Res 2022; 34:685-690. [PMID: 34999717 DOI: 10.1038/s41443-021-00516-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 01/23/2023]
Abstract
The use of testosterone therapy has a complex history of apprehension and questions regarding its safety. Despite an eventual consensus that testosterone therapy was safe and effective, several studies relating to cardiovascular risks emerged in the last decade, rekindling skepticism regarding the safety of testosterone therapy. Given the utility of testosterone therapy in treating the symptoms of hypogonadism, it remains crucial to closely examine the safety of testosterone therapy. The present article synthesizes the current evidence regarding cardiovascular risks that may be associated with testosterone therapy, the potential mechanisms regarding testosterone's efficacy, and future directions in evaluating the safety of its use.
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Defeudis G, Maddaloni E, Rossini G, Di Tommaso AM, Mazzilli R, Di Palma P, Pozzilli P, Napoli N. Glycemic Variability in Subjects with Diabetes and Hypogonadism during Testosterone Replacement Treatment: A Pilot Study. J Clin Med 2022; 11:jcm11185333. [PMID: 36142982 PMCID: PMC9505941 DOI: 10.3390/jcm11185333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/02/2022] [Accepted: 09/06/2022] [Indexed: 11/16/2022] Open
Abstract
Background: This is a proof of concept, as a pilot study, with the aim to evaluate continuous glucose monitoring metrics (CGM) in subjects with type 2 diabetes (T2DM), treated with nutritional therapy and metformin, before and after testosterone replacement therapy (TRT). Methods: In this longitudinal observational study, subjects affected by T2DM and starting TRT for documented ED and hypogonadism were enrolled. All subjects mounted a CGM system during the v0 visit, one week before the beginning of the TRT (week−1), during v2, four weeks after the start of TRT (week 4), and v4 (week 12). CGM was worn for about 144 h after each visit. Results: A total of seven patients, referring to our clinic for erectile dysfunction (ED), were studied (aged 63.3 ± 2.3 years). Mean (± standard deviation) total testosterone level was 2.3 ± 0.6 ng/mL at baseline. After TRT, total testosterone level was 4.6 ± 3.04 ng/mL at week 4 and 3.93 ± 4.67 ng/mL at week 12. No significant differences were observed in TIR, TAR, TBR, estimated HbA1c, AUC below, and AUC above limit during the intervention period. Conclusions: This is the first study evaluating the effects of TRT on daily glucose excursions in subjects with T2DM and hypogonadism. Though we did not find any significant difference in key CGM metrics during the 12 weeks of TRT, this study confirms the glycometabolic safety of the TRT even on the most novel standardized glycemic targets.
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Affiliation(s)
- Giuseppe Defeudis
- Unit of Endocrinology and Diabetes, Department of Medicine, University Campus Bio-Medico di Roma, 00128 Rome, Italy
- Correspondence: or
| | - Ernesto Maddaloni
- Department of Experimental Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Giovanni Rossini
- Unit of Endocrinology and Diabetes, Department of Medicine, University Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Alfonso Maria Di Tommaso
- Unit of Endocrinology and Diabetes, Department of Medicine, University Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Rossella Mazzilli
- Endocrinology Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant’Andrea Hospital, 00189 Rome, Italy
| | - Paolo Di Palma
- Unit of Urology, Hospital of Frosinone, ASL Frosinone, 03100 Frosinone, Italy
| | - Paolo Pozzilli
- Unit of Endocrinology and Diabetes, Department of Medicine, University Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Nicola Napoli
- Unit of Endocrinology and Diabetes, Department of Medicine, University Campus Bio-Medico di Roma, 00128 Rome, Italy
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Di Lodovico E, Facondo P, Delbarba A, Pezzaioli LC, Maffezzoni F, Cappelli C, Ferlin A. Testosterone, Hypogonadism, and Heart Failure. Circ Heart Fail 2022; 15:e008755. [PMID: 35392658 DOI: 10.1161/circheartfailure.121.008755] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Male hypogonadism is defined as low circulating testosterone level associated with signs and symptoms of testosterone deficiency. Although the bidirectional link between hypogonadism and cardiovascular disease has been clarified, the association between testosterone and chronic heart failure (HF) is more controversial. Herein, we critically review published studies relating to testosterone, hypogonadism, and HF and provide practical clinical information on proper diagnosis and treatment of male hypogonadism in patients with HF. In general, published studies are extremely heterogeneous, frequently have not adhered to hypogonadism guidelines, and suffer from many intrinsic methodological inaccuracies; therefore, data provide only low-quality evidence. Nevertheless, by selecting the few methodologically robust studies, we show the prevalence of testosterone deficiency (30%-50%) and symptomatic hypogonadism (15%) in men with HF is significant. Low testosterone correlates with HF severity, New York Heart Association class, exercise functional capacity, and a worse clinical prognosis and mortality. Interventional studies on testosterone treatment in men with HF are inconclusive but do suggest beneficial effects on exercise capacity, New York Heart Association class, metabolic health, and cardiac prognosis. We suggest that clinicians should measure testosterone levels in men with HF who have symptoms of a testosterone deficiency and conditions that predispose to hypogonadism, such as obesity and diabetes. These patients-if diagnosed as hypogonadal-may benefit from the short- and long-term effects of testosterone replacement therapy, which include improvements in both cardiac prognosis and systemic outcomes. Further collaborative studies involving both cardiologists and endocrinologists are warranted.
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Affiliation(s)
- Elena Di Lodovico
- Department of Clinical and Experimental Sciences, University of Brescia, Italy (E.D.L., P.F., L.C.P., C.C., A.F.)
| | - Paolo Facondo
- Department of Clinical and Experimental Sciences, University of Brescia, Italy (E.D.L., P.F., L.C.P., C.C., A.F.)
| | - Andrea Delbarba
- Unit of Endocrinology and Metabolism, ASST Spedali Civili, Brescia, Italy (A.D., F.M., C.C., A.F.)
| | - Letizia Chiara Pezzaioli
- Department of Clinical and Experimental Sciences, University of Brescia, Italy (E.D.L., P.F., L.C.P., C.C., A.F.)
| | - Filippo Maffezzoni
- Unit of Endocrinology and Metabolism, ASST Spedali Civili, Brescia, Italy (A.D., F.M., C.C., A.F.)
| | - Carlo Cappelli
- Department of Clinical and Experimental Sciences, University of Brescia, Italy (E.D.L., P.F., L.C.P., C.C., A.F.).,Unit of Endocrinology and Metabolism, ASST Spedali Civili, Brescia, Italy (A.D., F.M., C.C., A.F.)
| | - Alberto Ferlin
- Department of Clinical and Experimental Sciences, University of Brescia, Italy (E.D.L., P.F., L.C.P., C.C., A.F.).,Unit of Endocrinology and Metabolism, ASST Spedali Civili, Brescia, Italy (A.D., F.M., C.C., A.F.).,Now with Department of Medicine, Unit of Andrology and Reproductive Medicine, University of Padova, Italy (A.F.)
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9
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Defeudis G, Mazzilli R, Tenuta M, Rossini G, Zamponi V, Olana S, Faggiano A, Pozzilli P, Isidori AM, Gianfrilli D. Erectile dysfunction and diabetes: A melting pot of circumstances and treatments. Diabetes Metab Res Rev 2022; 38:e3494. [PMID: 34514697 PMCID: PMC9286480 DOI: 10.1002/dmrr.3494] [Citation(s) in RCA: 73] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 09/03/2021] [Indexed: 02/06/2023]
Abstract
Diabetes mellitus (DM), a chronic metabolic disease characterised by elevated levels of blood glucose, is among the most common chronic diseases. The incidence and prevalence of DM have been increasing over the years. The complications of DM represent a serious health problem. The long-term complications include macroangiopathy, microangiopathy and neuropathy as well as sexual dysfunction (SD) in both men and women. Erectile dysfunction (ED) has been considered the most important SD in men with DM. The prevalence of ED is approximately 3.5-fold higher in men with DM than in those without DM. Common risk factors for the development of DM and its complications include sedentary lifestyle, overweight/obesity and increased caloric consumption. Although lifestyle changes may help improve sexual function, specific treatments are often needed. This study aims to review the definition and prevalence of ED in DM, the impact of DM complications and DM treatment on ED and, finally, the current and emerging therapies for ED in patients with DM.
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Affiliation(s)
- Giuseppe Defeudis
- Unit of Endocrinology and DiabetesDepartment of MedicineUniversity Campus Bio‐Medico di RomaRomeItaly
| | - Rossella Mazzilli
- Department of Clinical and Molecular MedicineSapienza University of RomeRomeItaly
| | - Marta Tenuta
- Department of Experimental MedicineSapienza University of RomeRomeItaly
| | - Giovanni Rossini
- Unit of Endocrinology and DiabetesDepartment of MedicineUniversity Campus Bio‐Medico di RomaRomeItaly
| | - Virginia Zamponi
- Department of Clinical and Molecular MedicineSapienza University of RomeRomeItaly
| | - Soraya Olana
- Department of Clinical and Molecular MedicineSapienza University of RomeRomeItaly
| | - Antongiulio Faggiano
- Department of Clinical and Molecular MedicineSapienza University of RomeRomeItaly
| | - Paolo Pozzilli
- Unit of Endocrinology and DiabetesDepartment of MedicineUniversity Campus Bio‐Medico di RomaRomeItaly
| | - Andrea M. Isidori
- Department of Experimental MedicineSapienza University of RomeRomeItaly
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10
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Carlomagno F, Pozza C, Tenuta M, Pofi R, Tarani L, Sesti F, Minnetti M, Gianfrilli D, Isidori AM. Testicular Microvascular Flow Is Altered in Klinefelter Syndrome and Predicts Circulating Testosterone. J Clin Endocrinol Metab 2022; 107:e236-e245. [PMID: 34407199 DOI: 10.1210/clinem/dgab605] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Indexed: 01/20/2023]
Abstract
CONTEXT Experimental studies on Klinefelter syndrome (KS) reported increased intratesticular testosterone (T) levels coexisting with reduced circulating levels. Abnormalities in testicular microcirculation have been claimed; however, no studies investigated in vivo testicular blood flow dynamics in humans with KS. OBJECTIVE To analyze the testicular microcirculation in KS by contrast-enhanced ultrasonography (CEUS) and correlate vascular parameters with endocrine function. DESIGN AND SETTING Prospective study. University setting. PATIENTS Sixty-eight testicular scans, 34 testes from 19 T-naïve subjects with KS and 34 testes from age-matched eugonadal men (control) who underwent CEUS for incidental nonpalpable testicular lesions. MAIN OUTCOMES CEUS kinetic parameters. RESULTS CEUS revealed slower testicular perfusion kinetics in subjects with KS than in age-matched controls. Specifically, the wash-in time (P = 0.018), mean transit time (P = 0.035), time to peak (P < 0.001), and wash-out time (P = 0.004) were all prolonged. Faster testicular blood flow was associated with higher total T levels. Principal component analysis and multiple linear regression analyses confirmed the findings and supported a role for reduced venous blood flow as independent predictor of total T levels. CONCLUSIONS Testicular venous blood flow is altered in KS and independently predicts T peripheral release.
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Affiliation(s)
- Francesco Carlomagno
- Department of Experimental Medicine, Sapienza University of Rome, 00161, Rome, Italy
| | - Carlotta Pozza
- Department of Experimental Medicine, Sapienza University of Rome, 00161, Rome, Italy
| | - Marta Tenuta
- Department of Experimental Medicine, Sapienza University of Rome, 00161, Rome, Italy
| | - Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, 00161, Rome, Italy
| | - Luigi Tarani
- Department of Pediatrics, Sapienza University of Rome, 00161, Rome, Italy
| | - Franz Sesti
- Department of Experimental Medicine, Sapienza University of Rome, 00161, Rome, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, 00161, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, 00161, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, 00161, Rome, Italy
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11
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Lunenfeld B, Mskhalaya G, Zitzmann M, Corona G, Arver S, Kalinchenko S, Tishova Y, Morgentaler A. Recommendations on the diagnosis, treatment and monitoring of testosterone deficiency in men. Aging Male 2021; 24:119-138. [PMID: 34396893 DOI: 10.1080/13685538.2021.1962840] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
The relative proportional increase of the elderly population within many countries will become one of the most significant social transformations of the twenty-first century and, for the first time in history, persons aged 65 or above outnumbered children under five years of age globally. One in four persons living in Europe and Northern America will be aged 65 or over. One of the goals of ISSAM is to raise awareness of the special health needs of older men. Since a significant number of aging men will eventually become testosterone deficient, the Hypogonadism panel of ISSAM updates its guidelines.
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Affiliation(s)
- Bruno Lunenfeld
- Faculty of Life Sciences, Bar-Ilan University, Ramat Gan, Israel
| | | | - Michael Zitzmann
- Center for Reproductive Medicine and Andrology/Clinical and Surgical Andrology, University Hospital of Münster, Münster, Germany
| | - Giovanni Corona
- Medical Department, Endocrinology Unit, Maggiore Bellaria Hospital, Bologna, Italy
| | - Stefan Arver
- Department of Medicine/Huddinge Karolinska Institutet and ANOVA, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Kalinchenko
- Department of Endocrinology, People's Friendship University of Russia, Moscow, Russia
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12
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Alwani M, Yassin A, Talib R, Al-Qudimat A, Aboumarzouk O, Al-Zoubi RM, Saad F, Haider KS, Al Ansari A. Cardiovascular Disease, Hypogonadism and Erectile Dysfunction: Early Detection, Prevention and the Positive Effects of Long-Term Testosterone Treatment: Prospective Observational, Real-Life Data. Vasc Health Risk Manag 2021; 17:497-508. [PMID: 34465997 PMCID: PMC8403087 DOI: 10.2147/vhrm.s309714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/30/2021] [Indexed: 12/22/2022] Open
Abstract
Purpose Erectile dysfunction (ED) is associated with testosterone deficiency and is a symptom of functional hypogonadism. A correlation between ED and cardiovascular disease (CVD) has been recognized, and ED has been proposed as an early marker of CVD. However, the relationship between ED and CVD risk in hypogonadism requires clarification and whether testosterone therapy (TTh) can be a beneficial treatment strategy, but long-term data are limited. This study investigates long-term TTh in men with hypogonadism and ED with a history of CVD. Methods Seventy-seven patients with a history of CVD and diagnosed with functional hypogonadism and erectile dysfunction (erectile function domain score <21 on the International Index of Erectile Function questionnaire (IIEF questions 1–5)) were enrolled and TTh effects on anthropometric and metabolic parameters investigated for a maximum duration of 12 years. All men received long-acting injections of testosterone undecanoate at 3-monthly intervals. Eight-year data were analysed. Data collection registry started in November 2004 till January 2015. Results In hypogonadal men receiving TTh, IIEF increased by 5.4 (p<0.001). Total weight loss was 23.6 ± 0.6 kg after 8 years. HbA1c had declined by an average of 2.0% (P<0.0001). Total cholesterol levels significantly declined following TTh after only 1 year (P<0.0001), and HDL increased from 1.6±0.5 at baseline to 2±0.5 mmol/L following 8 years of TTh (P<0.0001). SBP decreased from 164±14 at baseline to 133±9 mmHg, signifying a reduction of 33±1 mmHg (P<0.0001). Conclusion In hypogonadal men with a history of CVD, TTh improves and preserves erectile function over prolonged periods with concurrent sustained improvements in cardiometabolic risk factors. Measuring ED and testosterone status may serve as an important male health indicator predicting subsequent CVD-related events and mortality and TTh may be an effective add-on treatment in secondary prevention of cardiovascular events in hypogonadal men with a history of CVD.
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Affiliation(s)
- Mustafa Alwani
- Jordan University of Science and Technology, School of Medicine, Irbid, Jordan.,Hamad Medical Corporation, Department of Surgery, Division of Urology/Andrology and Section of Surgical Research, Doha, Qatar
| | - Aksam Yassin
- Hamad Medical Corporation, Department of Surgery, Division of Urology/Andrology and Section of Surgical Research, Doha, Qatar.,Weill Cornell Medical College, New York, NY, USA.,Weill Cornell Medical College, Doha, Qatar
| | - Raidh Talib
- Hamad Medical Corporation, Department of Surgery, Division of Urology/Andrology and Section of Surgical Research, Doha, Qatar
| | - Ahmad Al-Qudimat
- Hamad Medical Corporation, Department of Surgery, Division of Urology/Andrology and Section of Surgical Research, Doha, Qatar
| | - Omar Aboumarzouk
- Hamad Medical Corporation, Department of Surgery, Division of Urology/Andrology and Section of Surgical Research, Doha, Qatar
| | - Raed M Al-Zoubi
- Hamad Medical Corporation, Department of Surgery, Division of Urology/Andrology and Section of Surgical Research, Doha, Qatar.,Jordan University of Science and Technology, Department of Chemistry, Irbid, Jordan
| | - Farid Saad
- Dresden International University, Center of Medicine and Health Sciences, Dresden, Germany
| | - Karim S Haider
- Klinikum Bremen-Mitte, Department of Urology, Bremen, Germany
| | - Abdulla Al Ansari
- Hamad Medical Corporation, Department of Surgery, Division of Urology/Andrology and Section of Surgical Research, Doha, Qatar
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13
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Caliber M, Saad F. Testosterone therapy for prevention and reversal of type 2 diabetes in men with low testosterone. Curr Opin Pharmacol 2021; 58:83-89. [PMID: 33993064 DOI: 10.1016/j.coph.2021.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/05/2021] [Accepted: 04/11/2021] [Indexed: 11/26/2022]
Abstract
Men with obesity and/or type 2 diabetes (T2D) have a high prevalence of testosterone deficiency (TD). Similarly, men with TD have an increased risk of developing obesity and/or T2D, and further body fat accumulation and deterioration of glycemic control create a vicious cycle. The landmark testosterone for diabetes mellitus trial, the largest randomized controlled trial of testosterone therapy (TTh) to date, confirms the beneficial effects of TTh on fat loss and gain in muscle mass, and that TTh for 2 years significantly reduces the risk of incident T2D, and may also reverse T2D. The testosterone for diabetes mellitus trial suggests that TTh reduces the risk of T2D and results in greater improvement in sexual function and wellbeing, beyond lifestyle intervention alone.
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Affiliation(s)
- Monica Caliber
- American Medical Writers Association (AMWA), Rockville, MD, USA; International Society for Medical Publication Professionals (ISMPP), Fort Lauderdale, FL, USA
| | - Farid Saad
- Consultant Medical Affairs, Bayer AG, Hamburg, Germany.
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14
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Qu M, Feng C, Wang X, Gu Y, Shang X, Zhou Y, Xiong C, Li H. Association of Serum Testosterone and Luteinizing Hormone With Blood Pressure and Risk of Cardiovascular Disease in Middle-Aged and Elderly Men. J Am Heart Assoc 2021; 10:e019559. [PMID: 33739129 PMCID: PMC8174322 DOI: 10.1161/jaha.120.019559] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background The age‐related decline in testosterone levels is thought to be of great importance for male aging and cardiovascular diseases. However, data are controversial on whether abnormal sex hormones are linked to the presence of cardiovascular diseases and it is also uncertain how blood pressure modifies the association between testosterone levels and major cardiovascular diseases. Methods and Results This is a multicenter, population‐based, cross‐sectional study of 6296 men conducted between 2013 and 2016. Basic information and clinical symptoms were obtained by questionnaires. Blood pressure and plasma levels of total testosterone, sex hormone–binding globulin, luteinizing hormone, and free testosterone were determined in men in a multistage random, cluster sampling in 6 provinces of China. There were 5786 Chinese men (mean [SD] age 55.0 [10.1] years) included after exclusion criteria were applied; 37.2% (2150) of them were diagnosed with hypertension. Total testosterone, free testosterone, and sex hormone–binding globulin were inversely associated with the prevalence of hypertension. Age >65 years or body mass index ≥24 negatively impacted the inverse correlation between testosterone levels and hypertension, whereas smoking and family history of hypertension strengthened the correlation. In participants with grade 2 hypertension, total testosterone was positively associated with the presence of stroke, and luteinizing hormone was also positively correlated with cardiovascular and cerebrovascular diseases. Conclusions Lower total testosterone could be a promising risk marker for prevalent hypertension. Both low and high levels of testosterone are associated with greater cardiovascular risk. Primary hypogonadism may be a risk marker for major cardiovascular diseases in men with severe hypertension.
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Affiliation(s)
- Mengyuan Qu
- Institute of Reproductive Health/Center of Reproductive Medicine Tongji Medical CollegeHuazhong University of Science and Technology Wuhan China
| | - Chenzhao Feng
- School of Basic Medicine Tongji Medical CollegeHuazhong University of Science and Technology Wuhan China
| | - Xiaotong Wang
- Institute of Reproductive Health/Center of Reproductive Medicine Tongji Medical CollegeHuazhong University of Science and Technology Wuhan China
| | - Yiqun Gu
- National Research Institute for Family Planning Beijing China
| | - Xuejun Shang
- Jinling Hospital School of Medicine Nanjing University Nanjing China
| | - Yuanzhong Zhou
- School of Public health Zunyi Medical University Zunyi China
| | | | - Honggang Li
- Institute of Reproductive Health/Center of Reproductive Medicine Tongji Medical CollegeHuazhong University of Science and Technology Wuhan China.,Wuhan Tongji Reproductive Medicine Hospital Wuhan China
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15
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Rosa IN, de Sousa Munhoz Soares AA, Rodrigues MP, Naves LA. Classic cardiovascular risk factors improve in very elderly hypopituitary patients treated on standard hormone replacement in long term follow- up. Clin Diabetes Endocrinol 2021; 7:6. [PMID: 33731193 PMCID: PMC7972213 DOI: 10.1186/s40842-021-00119-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 02/22/2021] [Indexed: 12/03/2022] Open
Abstract
Background Hypopituitarism in the elderly population is an underdiagnosed condition and may increase comorbidities related to glucose metabolism, dyslipidemia, and cardiovascular risk factors. Optimization of hormone replacement that considers alterations in clearance rates of hormones, interaction with other medications, and evaluation of the risk-benefit ratio of treatment is a big challenge for clinical practice. Objectives This study aimed to evaluate classic cardiovascular risk factors in hypopituitary septuagenarians and octagenarians by diagnosis and after long-term hormone replacement. Methods This is a retrospective observational study, with patients recruited and selected from a registry in a tertiary medical center. We included patients aged 70–99 years with hypopituitarism, evaluated hormonal and biochemical parameters, and cardiovascular risk scores were calculated by diagnosis and compared after long-term follow-up. All patients gave informed consent. Patient data were compared to a sex and age-matched control group, with long-term geriatric follow-up, without endocrine diseases. Results Thirty-five patients were included, 16 patients aged 70–75 years (72.61), 12 patients 76–80 years (72.28), 7 patients 81–99 years (89.28). Pituitary macroadenomas were the main cause of hypopituitarism, mean maximal diameter 3.4 cm (2.9–4.3), and invasive craniopharyngiomas. At the moment of diagnosis, most patients were overweight, and abdominal adiposity was observed in 76.9% of women and 36.4% of men, primarily in octagenarians and nonagenarians. Comorbidities were frequent; 85.7% presented hypertension, 37.1% diabetes, 53.1% low HDL, 51.5% hypertriglyceridemia. Most patients presented more than two combined pituitary deficiencies; hypogonadism in 88.6%, central hypothyroidism in 82.9%, GH deficiency in 65.7%, and adrenal insufficiency in 25.7%. Analysis of cardiovascular risk prediction in the total cohort showed that 57.1% of patients presented a reduction in the General Cardiovascular Disease (CVD) Risk Prediction Score and 45.7% in atherosclerotic CVD risk estimated by ACC/AHA 2013 Pooled Cohort Equation, despite being submitted to conventional hormone replacement, during the mean follow-up of 14.5 years. This reduction was not observed in the control group. Discussion and conclusion In this study, aged hypopituitary patients presented a reduction in estimated general CVD risk during long-term follow-up, despite replacement with corticosteroids, levothyroxine, or gonadal steroids. Early diagnosis and treatment of hypopituitarism in the elderly remain challenging. Larger studies should be performed to assess the risk-benefit ratio of hormone replacement on the metabolic profile in septuagenarian and octogenarian patients.
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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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