Serum testosterone levels in male hypogonadism: Why and when to check-A review

Beneficial effects of exercise, testosterone, vitamin D, calcium and protein in older men-A randomized clinical trial

BACKGROUND

Due to increasing older populations worldwide, injuries, disabilities and deaths caused by falls among the elderly represent a growing human and societal problem. We aimed to improve health among men of at least 70 years of age with low-normal to low testosterone and mobility problems by using testosterone undecanoate (TU) injections, progressive strength training, and oral supplements of vitamin D, calcium and protein.

METHODS

This was a single-centre, randomized, placebo-controlled, double-blind trial with 148 older men with a median age of 77 (73-81) years, testosterone levels at median 8 (5-9) nmol/L (full range from 1.1 to 12.9 nmol/L) and mobility problems, recruited at University Hospital of Copenhagen, Herlev Hospital, Denmark. Participants were randomized into four arms for 20 weeks: (1) TU therapy (n = 37); (2) progressive resistance training with supplements of calcium, vitamin D and protein (n = 36); (3) both interventions combined (n = 36); or (4) no intervention (n = 39). The main outcome measure was the 30-s chair stand test, due to test performance correlating with the risk of serious fall injuries and lower extremity muscle strength. Outcome measurements were performed at baseline and after 20 weeks.

RESULTS

After the intervention, the combination group receiving progressive resistance training, TU and supplements achieved a median score of 13 (11-15) compared to the control group at 10 (0-14) in the 30-s chair stand test (P = 0.003). This median improvement of 3.0 was clinically important. Compared to the control group, participants in the combination group also increased quality of life (P < 0.05) and reduced both tiredness (P < 0.05) and leg fat (P < 0.05) and had higher variability in the RR interval (P < 0.01). The group receiving TU reduced gynoid and leg fat compared to the control group (both P < 0.05). Blood tests improved for several variables, especially in the combination group. There was no statistically significant increase in adverse effects from either the supplements or training.

CONCLUSIONS

In men ≥70 years old with low-normal to low testosterone and mobility problems, supplements of testosterone, calcium, vitamin D and protein combined with progressive resistance training improved 30-s chair stand test performance, muscle strength and quality of life. Both tiredness and leg fat were reduced, and RR interval variability was increased. Significant adverse effects were not observed.

Relationship of Testosterone, LH, Estradiol, IGF-1, and SHBG with Physical Performance of Master Athletes

Purpose: The aim of this study was to investigate and compare the levels of luteinizing hormone (LH), testosterone (T), estradiol (ES), sex hormone-binding globulin (SHBG), and insulin-like growth factor 1 (IGF-1) in master sprint (MS) and master endurance (ME) athletes. Additionally, the possible associations between these hormones, body composition, and lipid profile with athletic performance (% of performance in relation to the current world record) were analyzed. Materials and Methods: The participants were all men: (i) 34 MS (51.0 ± 6.8 years); and (ii) 32 ME (51.7 ± 9.4 years). Student's t-tests for independent samples were performed to compare all variables between groups. Results: MS had a significantly higher (p = .008) average IGF-1 (154.78 ± 29.85 ng/mL) when compared to ME (129.92 ± 25.48 ng/mL). Performance was significantly correlated with IGF-1 (r = 0.424). The MS group had a moderately lower body fat than ME athletes (MS 12.54 ± 4.07 vs. ME 14.60 ± 4.12; p = .078; d = 0.503). Conclusions: Thus, strength/power training exercise/sport seems to be more beneficial for obtaining a higher IGF-1 compared to aerobic/distance exercise/sport. In addition, LH, T, ES, and SHBG were similar between the two groups of athletes and were comparable to the reference values of younger adults.

Testosterone Therapy for Late-Onset Hypogonadism: A Clinical, Biological, and Analytical Approach Using Compounded Testosterone 0.5-20% Topical Gels

Testosterone is integral to men's sexual and overall health, but there is a gradual decline in the ageing male. The topical administration of testosterone is a valuable option as a supplement (replacement) therapy to alleviate hypogonadal symptoms. The clinical efficacy of a compounded testosterone 5% topical gel was assessed retrospectively in a male patient in his seventies by evaluating the laboratory testing of the serum total testosterone and the results of a validated androgen deficiency questionnaire. After treatment, the patient's hypogonadal symptoms improved and the serum total testosterone level achieved was considered clinically optimal. The skin permeation of the testosterone topical gel (biological testing) was evaluated in vitro using the Franz finite dose model and human cadaver skin, and it is shown that testosterone can penetrate into and through ex vivo human skin. Testosterone therapy is often prescribed for extended periods, and consequently, it is crucial to determine the beyond-use date of the compounded formulations. The analytical testing involved a valid, stability-indicating assay method for compounded testosterone 0.5% and 20% topical gels. This multidisciplinary study shows evidence supporting topically applied testosterone's clinical efficacy and the compounded formulations' extended stability. Personalized, topical testosterone therapy is a promising alternative in current therapeutics for hypogonadal patients.

Alpha-pinene neutralizes cisplatin-induced reproductive toxicity in male rats through activation of Nrf2 pathway

PURPOSE

Testicular toxicity is one of the most important side effects of cisplatin (CP) therapy. Alpha-pinene (AP) is a naturally occurring monoterpene with antioxidant character in plants. Here, we aimed to evaluate the therapeutic activity of AP against CP-induced testicular toxicity by including the nuclear factor erythroid 2-associated factor 2 (Nrf2) pathway in rats.

METHODS

Thirty male rats were divided into 5 groups: control, CP, CP + AP (5 and 10 mg/kg) and only AP (10 mg/kg). CP was administered intraperitoneally at a dose of 5 mg/kg on the first day, followed by three consecutive injections of AP. Serum reproductive hormone levels were evaluated using ELISA kits. Oxidative stress (OS), inflammation, endoplasmic reticulum stress (ERS) and apoptosis markers in testicular tissue were also determined colorimetrically. In addition, how CP affects Nrf2 pathway and the effect of AP on this situation were also addressed.

RESULTS

Treatment with CP significantly increased OS, inflammation, ERS and apoptosis in testicular tissue. Administrations of AP resulted in an amelioration of these altered parameters. The mechanism of therapeutic effect of AP appeared to involve induction of Nrf2. Furthermore, these results were also confirmed by histological data.

CONCLUSION

Results suggest that AP can exhibit therapeutic effects against CP-induced testicular toxicity. It can be concluded that AP may be a potential molecule to abolish reproductive toxicity after chemotherapy.

Sexual Dysfunction in Diabetic Patients: Τhe Role of Advanced Glycation End Products

Sexual dysfunction is a common but underestimated disorder of diabetic patients of both genders, entailing specific and complex pathogenesis and severely affecting reproductive health and quality of life. Hyperglycemia, dyslipidemia, hypertension, obesity, aging, and psychological factors underlie its pathogenesis. A large body of evidence indicates that advanced glycation end products and oxidative stress have a distinct impact on the pathogenesis of diabetes and its complications, including hypogonadism, which is closely related to sexual dysfunction. Advanced glycation end products seem to affect sexual function either directly by accumulation in various regions of the reproductive system and/or correlation or indirectly through oxidative stress induction via several mechanisms. They are also involved in the pathogenesis of diabetic complications, which are related to sexual dysfunction. Herein, we review the issue of sexual dysfunction in diabetic males and females, with special emphasis on the impact of advanced glycation end products in the pathogenesis of sexual dysfunction, the relationship of advanced glycation end products with low testosterone levels in diabetic subjects, which account for the proportion of disorder and the available therapeutic interventions.

Adult Male Hypogonadism: A Laboratory Medicine Perspective on Its Diagnosis and Management

Testosterone (T), the principal androgen secreted by the testes, plays an essential role in male health. Male hypogonadism is diagnosed based on a combination of associated clinical signs and symptoms and laboratory confirmation of low circulating T levels. In this review, we have highlighted factors, both biological and analytical, that introduce variation into the measurement of serum T concentrations in men; these need to be considered when requesting T levels and interpreting results. There is an ongoing need for analytical standardisation of T assays and harmonisation of pre- and post-analytical laboratory practices, particularly in relation to the laboratory reference intervals provided to clinicians. Further, there is a need to share with service users the most up-to-date and evidence-based action thresholds for serum T as recommended in the literature. Estimation of free testosterone may be helpful. Causes of secondary hypogonadism should be considered. A comprehensive approach is required in the management of male hypogonadism, including lifestyle modification as well as medication where appropriate. The goal of treatment is the resolution of symptoms as well as the optimisation of metabolic, cardiovascular, and bone health. The advice of an endocrinologist should be sought when there is doubt about the cause and appropriate management of the hypogonadism.

VDR promotes testosterone synthesis in mouse Leydig cells via regulation of cholesterol side chain cleavage cytochrome P450 (Cyp11a1) expression

BACKGROUND

The vitamin D receptor (VDR) mediates the pleiotropic biological actions that include osteoporosis, immune responses and androgen synthesis.VDR is widely expressed in testis cells such as Leydig cells, Sertoli cells, and sperm. The levels of steroids are critical for sexual development. In the early stage of steroidogenesis, cholesterol is converted to pregnenolone (precursor of most steroid hormones) by cholesterol side-chain lyase (CYP11A1), which eventually synthesizes the male hormone testosterone.

OBJECTIVE

This study aims to reveal how VDR regulates CYP11A1 expression and affects testosterone synthesis in murine Leydig cells.

METHODS

The levels of VDR, CYP11A1 were determined by quantitative real-time polymerase chain reaction (RT-qPCR) or western blot. Targeted relationship between VDR and Cyp11a1 was evaluated by dual-luciferase reporter assay. The levels of testosterone concentrations in cell culture media serum by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Phylogenetic and motif analysis showed that the Cyp11a1 family had sequence loss, which may have special biological functions during evolution. The results of promoter prediction showed that vitamin D response element (VDRE) existed in the upstream promoter region of murine Cyp11a1. Dual-luciferase assay confirmed that VDR could bind candidate VDREs in upstream region of Cyp11a1, and enhance gene expression. Tissue distribution and localizatio analysis showed that Cyp11a1 was mainly expressed in testis, and dominantly existed in murine Leydig cells. Furthermore, over-expression VDR and CYP11A1 significantly increased testosterone synthesis in mice Leydig cells.

CONCLUSIONS

Active vitamin D3 (VD3) and Vdr interference treatment showed that VD3/VDR had a positive regulatory effect on Cyp11a1 expression and testosterone secretion. VDR promotes testosterone synthesis in male mice by up-regulating Cyp11a1 expression, which played an important role for male reproduction.

Expert Opinion on the Diagnosis and Management of Male Hypogonadism in India

Male hypogonadism (MH) is a clinical and biochemical syndrome caused by inadequate synthesis of testosterone. Untreated MH can result in long-term effects, including metabolic, musculoskeletal, mood-related, and reproductive dysfunction. Among Indian men above 40 years of age, the prevalence of MH is 20%-29%. Among men with type 2 diabetes mellitus, 20.7% are found to have hypogonadism. However, due to suboptimal patient-physician communication, MH remains heavily underdiagnosed. For patients with confirmed hypogonadism (either primary or secondary testicular failure), testosterone replacement therapy (TRT) is recommended. Although various formulations exist, optimal TRT remains a considerable challenge as patients often need individually tailored therapeutic strategies. Other challenges include the absence of standardized guidelines on MH for the Indian population, inadequate physician education on MH diagnosis and referral to endocrinologists, and a lack of patient awareness of the long-term effects of MH in relation to comorbidities. Five nationwide advisory board meetings were convened to garner expert opinions on diagnosis, investigations, and available treatment options for MH, as well as the need for a person-centered approach. Experts' opinions have been formulated into a consensus document with the aim of improving the screening, diagnosis, and therapy of men living with hypogonadism.

Nonpharmacological Interventions for the Management of Testosterone and Sperm Parameters: A Scoping Review

PURPOSE

Testosterone replacement and associated pharmacologic agents are effective strategies to treat male hypogonadism; however, nutraceutical agents and lifestyle modification approaches have gained medical interest. The purpose of this scoping review is to highlight the evidence (or lack thereof) of nutraceuticals and lifestyle modification approaches in the management of testosterone levels and sperm parameters.

METHODS

A scoping review of nonpharmacologic interventions (supplements, herbal medicines, diets, sleep, and exercise) with the potential to improve male health was undertaken to elucidate changes in testosterone levels and sperm parameters in men with hypogonadism or infertility compared with healthy patients.

FINDINGS

A multitude of nutraceuticals and functional nutrients are purported to stimulate testosterone production; however, only a select few have had promising results, such as zinc, vitamin D (in case of hypovitaminosis D), l-arginine, mucuna, and ashwagandha, based on well-controlled randomized clinical trials of men with low testosterone levels and related problems. Except for l-arginine, these natural agents, as well as tribulus and ω3 fatty acids, can improve some degree of sperm parameters in infertile men. Before implementing these nutraceutical agents, adequate sleep, exercise, and weight loss in patients with obesity are imperative. The effects of nonpharmacologic interventions on testosterone levels are modest and hence do not directly translate into clinical benefits. Correspondingly, androgen receptor content, but not endogenous androgens, has been regarded as the principal factor in muscle hypertrophy.

IMPLICATIONS

A limited number of supplements and herbal medicines can be considered as adjunctive approaches in the management of testosterone levels and sperm parameters, primarily in men with low testosterone levels and infertility, whereas most nonpharmacologic supplements appear to lack evidence. Although proper physical exercise, sleep, and diet are indisputable approaches because of the general benefits to health, the use of nutraceuticals, if considered, must be personalized by physicians and/or registered dietitians.

Association between hypertriglyceridemic waist phenotype and hypogonadism in Taiwanese adult men

Background

Aging-related hypogonadism in men is related to the deterioration of overall health. Those with this disease rarely receive treatment. The hypertriglyceridemic waist (HTGW) phenotype is a tool for predicting abnormalities of cardiovascular metabolism. However, the relationship between the HTGW phenotype and hypogonadism remains undetermined. This study aimed to determine the association between HTGW phenotype and hypogonadism in different age groups.

Methods

Data of this cross-sectional study were obtained from MJ Health Screening Center in Taiwan from 2007 to 2016. The HTGW phenotype was divided into four categories based on whether the waist circumference (WC) and triglyceride levels were normal. WC of <90 cm and triglyceride level of <150 mg/dL were defined as normal. Hypogonadism was defined as a testosterone level of <300 ng/dL.

Results

Overall, 6442 male participants were divided into three age groups: <50, 50–64, and ≥65 years (n = 4135, 1958, and 349; age groups 1, 2, and 3, respectively). The overall prevalence of hypogonadism was 10.6%. In group 1, participants with HTGW (odds ratio, 1.98; 95% confidence interval (CI), 1.354–2.896) had a higher risk of hypogonadism than those with normal WC and normal triglyceride levels after adjustment for body mass index and fasting blood glucose level. In group 2, participants with HTGW (odds ratio, 1.873; 95% CI, 1.099–3.193) had an increased risk of hypogonadism after adjustment for body mass index, fasting blood glucose level, Cholesterol levels, high-density lipoprotein (HDL) levels, low-density lipoprptein (LDL) levels and smoking status. However, no relationship was observed between HTGW phenotype and hypogonadism in group 3.

Conclusion

HTGW phenotype was highly associated with hypogonadism in Taiwanese adult men. More attention should be paid to men aged <50 years with HTGW.

Delayed ejaculation in men with depressive disorders

Delayed ejaculation belongs to the group of sexual disorders in men. The causes of delayed ejaculation or anejaculation are not exactly known. It is assumed that it can be caused by psychogenic or organic influences or their combinations. One of the causes of delayed ejaculation may be elevated prolactin levels, which may be increased by psychosocial stress, pituitary disorders or also treatment with selective serotonin reuptake inhibitors in the treatment of depression. We tested a selected group of 50 men who were diagnosed with a depressive disorder and whose antidepressant treatment lasted for at least 24 weeks. These patients reported long-term delayed ejaculation or, in some cases, anejaculation as comorbidity. The results showed significant Spearman's correlation between elevated prolactin levels and intravaginal ejaculation latency values (R = 0.45), as well as between Beck's Depression-II inventory and intravaginal ejaculation latency and latency values (R = 0.48).

Relationship Between Serum Testosterone Levels and Kidney Stones Prevalence in Men

BACKGROUND

The role of serum testosterone levels in male renal stone formation remains controversial. This study aimed to evaluate the relationship between serum testosterone levels and kidney stone prevalence in males.

METHODS

We conducted a cross-sectional study based on the data from the National Health and Nutrition Examination Survey 2011-2016, which included 6,633 male participants, to investigate the association between testosterone levels and the prevalence of kidney stones.

RESULTS

In this study, using the highest quartile of serum testosterone as a reference, a logistic regression model adjusted for confounders in all participants showed that the first quartile (OR: 1.375, p = 0.016), the second quartile (OR: 1.348, p = 0.021), and the third quartile (OR: 1.472, p = 0.003) of testosterone significantly increased kidney stone risks. In the 41-60 age group, the ORs of kidney stone risk in the first, second, and third of serum testosterone were 1.904 (P = 0.005), 1.599 (P = 0.040), and 1.734 (P = 0.015), respectively. This trend can also be found in the 61-80-year group, except in the first quartile of serum testosterone (OR: 1.169, P = 0.436). Adjusted smoothed curves suggest a non-linear relationship between the 8 quantiles of serum testosterone and the risk of kidney stones in all participants and the 61-80 age group and a significant negative relationship in the 41-60 age group (OR: 0.921, P = 0.0193). But no correlation was seen in the 20-40 group.

CONCLUSIONS

Serum testosterone levels were significantly inversely associated with the prevalence of kidney stones in men over 40 years of age, but no correlation was seen in the 20-40 group. The role of testosterone in stone formation should be redefined, and its effect should be further verified.

Is Li-ESWT effective in diabetic patients with severe erectile dysfunction?

Noninvasive low-intensity extracorporeal shockwave treatment (Li-ESWT) has been widely used to treat erection disorders. There is no clear information regarding either the selection of patients for the treatment or the treatment protocol. In this study, we aimed to investigate the efficacy of extracorporeal shockwave therapy in diabetic patients with severe erectile dysfunction (International Index of Erectile Function-5 [IIEF-5] scores of 5 to 7). Sixty-three diabetes mellitus patients with erectile dysfunction having IIEF-5 scores of 5 to 7 and not showing a recovery of potency despite phosphodiesterase type 5 inhibitor therapy for the past 6 months were included in the study. The patients were evaluated based on their IIEF-5 scores and Erection Hardness Scale scores. The IIEF-5 score (mean ± standard deviation [s.d.]) increased from 5.29 ± 1.67 to 5.56 ± 1.85, with a difference of 0.27 ± 0.18 (P > 0.05). The Erection Hardness Scale scores (mean ± s.d.), on the other hand, increased from 1.46 ± 0.50 to 1.48 ± 0.50, with a difference of 0.02 ± 0 (P > 0.05). In conclusion, the response to phosphodiesterase type 5 inhibitors did not change after extracorporeal shockwave treatment in diabetes mellitus patients with severe erectile dysfunction (IIEF-5 scores of 5 to 7).

Cardiovascular Disease, Hypogonadism and Erectile Dysfunction: Early Detection, Prevention and the Positive Effects of Long-Term Testosterone Treatment: Prospective Observational, Real-Life Data

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.

Is a fasting testosterone level really necessary for the determination of androgen status in men?

BACKGROUND

As circulating testosterone may be suppressed in the post-prandial state, it has been recommended that measurements are carried out with the patient fasted.

OBJECTIVES

In this regard, we assessed the effect of fasting/non-fasting status on total testosterone (T) levels in men.

MATERIALS AND METHODS

Data was collected in a single UK Hospital in men with two serum T requests taken within a 6-month period of each other and sampled at a time of day ≤ 2 h apart. Three groups were established, with T levels compared via signed-rank test in men with both a fasting and non-fasting sample (Group 1; n = 69), and in men with paired non-fasting (Group 2; n = 126) and paired fasting (Group 3; n = 18) samples. The differences in T levels between the paired samples was compared between the three groups using the rank-sum test and also via multiple regression analysis with the groups factorised.

RESULTS

Median (Interquartile Range, IQR) age did not vary significantly between Groups 1, 2 and 3 at 49 (38-56), 51.5 (42-60) and 51.5 (40-59) years, respectively. No significant difference (p = 0.89) was found between the T levels in Group 1 with non-fasting (median (IQR) T = 11.1 (9.3-13.6) nmol/L) versus fasting samples T = 10.8 (8.9-14.1) nmol/L). Paired T levels did not significantly differ in each of the other two groups (2 and 3). There was no significant association between the differences in paired T levels between the three groups, even when the model was adjusted for age and time, with Group 1 (as reference) versus Group 2 (p = 0.79) and versus Group 3 (p = 0.63).

DISCUSSION

We found no significant differences between fasting and non-fasting T levels. A definitive confirmatory study is required to determine whether fasting status is necessary to diagnose hypogonadism.

CONCLUSION

Non-requirement of fasting status when checking testosterone levels would remove a major hurdle in the diagnosis of hypogonadism.

Signs of diastolic dysfunction are graded by serum testosterone levels in aging C57BL/6 male mice

We investigated whether maladaptive, age-associated changes in heart structure and function were linked to circulating testosterone levels. Male C57BL/6 mice had a gonadectomy (GDX) or sham surgery at 4 weeks and effects of GDX on the heart were examined with echocardiography. Serum testosterone was measured with ELISA. Left ventricular (LV) mass increased with age but was smaller in GDX mice than sham at 18 months (144.0 ± 8.7 vs 118.2 ± 11.9 mg; p = 0.009). The isovolumic relaxation time (IVRT) declined with age but was prolonged in GDX mice at 18 months (10.5 ± 0.8 vs 12.5 ± 0.5 msec, p = 0.008). Ejection fraction did not change with age or GDX, but E/A ratios were lower in GDX mice than controls at 18 months (1.6 ± 0.2 vs 1.3 ± 0.1, p = 0.021). When links between serum testosterone and cardiac parameters were examined longitudinally in 18-24-month-old mice, LV mass declined with decreasing testosterone (β = 37.70, p = 0.016), however IVRT increased as testosterone decreased (β=-2.69, p = 0.036). Since longer IVRT and lower E/A ratios are signs of diastolic dysfunction, low circulating testosterone may promote or exacerbate diastolic dysfunction in older males. These findings suggest that lower testosterone directly modifies heart structure and function to promote maladaptive remodeling and diastolic dysfunction in the aging heart.

The Burden of Hormonal Disorders: A Worldwide Overview With a Particular Look in Italy

Endocrine diseases have a considerable impact on public health from an epidemiological point of view and because they may cause long-term disability, alteration of the quality-of-life of the affected patients, and are the fifth leading cause of death. In this extensive review of the literature, we have evaluated the prevalence of the different disorders of endocrine interest in the world and Italy, highlighting their epidemiological, clinical, and economic impact.

EHD3 positively regulated by NR5A1 participates in testosterone synthesis via endocytosis

AIMS

Increasing evidence has shown that hormone secretion is regulated by endocytosis. Eps15 homology domain-containing protein 3 (EHD3) is an endocytic-trafficking regulatory protein, but whether EHD3 is associated with testosterone secretion is not clear. This work aims to explore the role of EHD3 in testosterone synthesis.

MAIN METHODS

Testosterone concentration was determined by ELISA. The effects of EHD3 on endocytosis were assessed by exosomes tracing assay and Immunofluorescence. Targeting relationship between EHD3 and NR5A1 was verified by chromatin immunoprecipitation (ChIP) and dual luciferase reporter gene assay in Leydig cells. For in vivo assessments, conditional NR5A1 knockout mouse model was established with CRISPR/Cas9 gene targeting technology.

KEY FINDINGS

EHD3 overexpression significantly increased the concentration of testosterone. EHD3 knockdown markedly decreased testosterone synthesis by reducing endocytosis. The activity of the EHD3 promoter was positively regulated by NR5A1, which occupied the conserved sequence "AGGTCA" in the EHD3 promoter. Furthermore, mice with a Leydig cell-specific conditional NR5A1 knockout displayed the blunted levels of EHD3 and clathrin (a key factor for endocytosis), and serum testosterone concentration compared with NR5A1^f/f mice.

SIGNIFICANCE

This study suggests a potential molecular mechanism of testosterone synthesis to fully understand male reproductive health.

Hypogonadism and its treatment among prostate cancer survivors

Adult-onset hypogonadism (AOH) is associated with sexual dysfunction, poor bone mineralization, decreased muscle mass, metabolic syndrome disorder, and cognitive suppression. Historically, testosterone has been contraindicated in men with a history of prostate cancer. However, there has been a modern resurgence in re-evaluating this belief. Not only can testosterone be safely utilized to alleviate AOH symptoms in prostate cancer survivors, it has been also touted as a treatment option for aggressive prostatic cancer. While much work remains in understanding the relationship between testosterone and prostate cancer, those who survive this disease should not be automatically turned away from an opportunity to be treated and restored.

A 6-month, double-blind, placebo-controlled, randomized trial to evaluate the effect of Eurycoma longifolia (Tongkat Ali) and concurrent training on erectile function and testosterone levels in androgen deficiency of aging males (ADAM)

BACKGROUND

Androgen deficiency of aging males (ADAM) largely manifests as sexual symptoms. Erectile dysfunction is one of the most common symptoms of ADAM.

AIM

To ascertain the effect of concurrent training and supplementation with Eurycoma longifolia on erectile function and testosterone levels in men with ADAM, and the association of erectile function with levels of total testosterone.

METHODS

6-month, randomized, double-blind, placebo-controlled four-arm clinical. 45 men (47.38 ± 5.03 years) were randomized into 4 groups (G1: control + placebo; G2: control + Eurycoma longifolia; G3: concurrent training + placebo; G4: concurrent training + Eurycoma longifolia). 22 received a 200 mg supplement of Eurycoma longifolia and 23 underwent the intervention with concurrent training, 3 times a week for 60 min at progressive intensity.

OUTCOMES

International Index of Erectile Function (IIEF-5), Aging Male Scale (AMS) and total testosterone.

RESULTS

Erectile function demonstrated improvements in both interventions; however, the most significant results were obtained by men allocated to concurrent training + Eurycoma longifolia.

CLINICAL IMPLICATIONS

A 200 mg supplement of Eurycoma longifolia and the practice of concurrent training for 6 months significantly improved the erectile function of men with ADAM.

STRENGTHS & LIMITATIONS

The study's design stands out as a strength, in addition to the six-month intervention. The main limitation is the study not having groups that used only Eurycoma longifolia and only concurrent training.

CONCLUSION

The combination of Eurycoma longifolia and concurrent training improved erectile function and increased total testosterone levels in men with ADAM.

Association between testosterone with type 2 diabetes in adult males, a meta-analysis and trial sequential analysis

OBJECTIVE

We performed this meta-analysis to assess serum testosterone changes in adult males with Type 2 diabetes (T2DM).

METHODS

PubMed, Embase, Web of Science, and Cochrane Library were searched to identify qualified studies. Pooled weighted mean differences (WMDs) with 95% confidence intervals (CIs) were utilized to test the changes of total testosterone (TT), free testosterone (FT) and sex hormone-binding globulin (SHBG) in patients with T2DM. Besides, trial sequential analysis was used to verify the pooled results.

RESULTS

A total of 56 studies were enrolled in our meta-analysis. Meta-analyses of the cross-sectional studies showed that patients with T2DM has significant decreases in TT (WMD: -2.98, 95%CI: -3.48 to -2.47), FT (WMD: -32.82, 95%CI: -39.70 to -25.95) and SHBG (WMD: -2.47, 95%CI: -3.93 to -1.02). In terms of the prospective studies, our results showed decreases in TT (WMD: -2.35, 95%CI: -3.24 to -1.46), FT (WMD: -25.96, 95%CI: -83.98 to 32.05), and SHBG (WMD: -10.06, 95%CI: -13.29 to -6.84) in patients with T2DM. By trial sequential analyses, the findings in current meta-analysis were based on reliable evidence.

CONCLUSION

Our results indicate that patients with T2DM have lower serum TT, FT, and SHBG levels.

An audit of the measurement and reporting of male testosterone levels in UK clinical biochemistry laboratories

INTRODUCTION

A number of guidance documents have been published in recent years for the diagnosis and management of hypogonadism (HG). Laboratory practice has a major role in supporting guidelines with accurate and precise serum total testosterone (TT) methods and standardised pre- and post-analytical protocols. Our study investigated whether laboratory practice currently supports the management guidelines for HG.

METHODS

An internet-based questionnaire survey of senior laboratory biochemists (UK/Republic of Ireland) was conducted (April-May 2018). Questions reflected sampling, laboratory practice, reference ranges and reporting of results. The results were analysed in conjunction with data obtained from the UK National External Quality Assurance Service (UK NEQAS) on testosterone assay performance.

RESULTS

Analyses of 96 laboratory surveys returned the following: 74 laboratories stated that the optimal sampling time was communicated to users; 81 laboratories used immunoassays; 76 laboratories included reference ranges for adult men (31 had dual/multiple age-related intervals). Wide variability in lower/upper limits was evident in the common immunoassays; the majority of reference ranges were from manufacturers (50.0%) or historical (18.8%). Action limits based on TT levels were used by 64 laboratories, but 63 did not report a borderline range as suggested by the guidelines. Protocols for cascading tests based on TT were evident in 58 laboratories, with 50 laboratories offering estimated free testosterone; interpretative comments were provided by 67 laboratories, but no references were made to the management guidelines. Data from UK NEQAS demonstrated considerable variation in testosterone assay performance.

CONCLUSIONS

Our survey has highlighted inconsistencies that could lead to HG (and other conditions requiring measurement of TT) not being managed appropriately. The results from this survey and from UK NEQAS reinforce the requirement for action to be considered regarding the standardisation of testosterone assays and harmonisation of laboratory practice.

Tert-butylhydroquinone preserve testicular steroidogenesis and spermatogenesis in cisplatin-intoxicated rats by targeting oxidative stress, inflammation and apoptosis

Cisplatin (Cis) is an effective chemotherapeutic intervention against many cancer types. However, the oxidative stress-related toxicities associated with cancer cell resistance-induced dose scaling has limited its long-term use. In the present study, we explored the benefits of the antioxidant, tert-butylhydroquinone (tBHQ; 50 mg/kg b.w./day, for 14 days) against Cis single dose injection (7 mg/kg b.w., i.p on Day 8), on testicular toxicity of male Wistar rats. Cis triggered testicular and epididymal oxidative stress, testicular inflammation (upregulated NF-κB, TNF-α and IL-1β mRNA levels, and downregulated IL-10 mRNA level), increased testicular apoptosis (increased Bax/Bcl2 and caspase-3 mRNA levels) and decreased testicular germ cells proliferation. Further, Cis decreased testicular steroidogenesis (decreased expression of StAR, CYP11A1, 3β-HSD and 17β-HSD mRNA and proteins) and decreased follicle stimulating hormone, luteinizing hormone and testosterone levels. Cis also decreased sperm count, motility, viability, normal morphology and Johnsen score. However, intervention with tBHQ significantly decreased oxidative stress by upregulating Nrf2 gene, suppressed inflammation, apoptosis and increased testicular germ cells proliferation. tBHQ also increased steroidogenesis and improved sperm parameters. Taken together, tBHQ improves steroidogenesis and spermatogenesis in Cis-intoxicated rats by improving antioxidant status, dampening inflammation and apoptosis, thus improving the proliferative capacity of spermatogenic cells.

Diagnostic cut-offs, prevalence, and biochemical predictors of sarcopenia in healthy Indian adults: The Sarcopenia-Chandigarh Urban Bone Epidemiological Study (Sarco-CUBES)

PURPOSE

Comprehensive data on diagnosis and prevalence of sarcopenia in India are lacking. The present study was undertaken to determine cut-offs for low muscle strength (MS) and low muscle mass (MM), and find out the prevalence of sarcopenia in Indians.

METHODS

Apparently healthy individuals aged ≥ 20 years with no prior history of any co-morbidities were recruited from community by door-to-door survey. Participants eligible for study underwent blood sampling. Individuals identified as having biochemical abnormalities that could potentially affect MS and MM were excluded. Enrolled participants underwent DEXA. Muscle mass, MS, and physical performance were expressed as appendicular skeletal muscle index (ASMI), dominant handgrip strength (HGS), and usual gait speed (GS), respectively. Cut-offs for low MS and MM were defined as HGS and ASMI 2SD < mean of young reference population (20-39 years). A GS ≤ 0.8 m/s defined poor physical performance. Using them, the prevalence of sarcopenia was estimated as per EWGSOP2 recommendations.

RESULTS

After exclusion, 804 participants were enrolled (mean age = 44.4 years). Peak HGS, ASMI, and GS were achieved in the 3rd/4th decades. Muscle strength/mass was lower than Caucasians. A HGS < 27.5 kg (males)/18.0 kg (females) and an ASMI < 6.11 kg/m² (males)/4.61 kg/m² (females) defined low MS and MM, respectively. Accordingly, prevalence of 'probable sarcopenia', 'sarcopenia', and 'severe sarcopenia' was 14.6%, 3.2%, and 2.3%, respectively. Corresponding values were higher when European cut-offs were used. Only serum testosterone positively predicted HGS/ASMI/GS in males.

CONCLUSIONS

Indians have low MS/MM, and hence, indigenous and not Western cut-offs should be used to define sarcopenia in Indians.

Secular trends in testosterone- findings from a large state-mandate care provider

BACKGROUND

Several studies from the US and Europe have shown a population-level decline in serum testosterone in men from 1970's to early 2000's. However, to the best of our knowledge, no study examining population-level decline in testosterone has been published in more recent years. The study objective was therefore to examine secular trends in testosterone levels among Israeli men in the first and second decades of the twenty-first century, METHODS: All incident total testosterone performed between1/2006 and 3/2019 among 102,334 male members of a large health organization.

RESULTS

A significant (p < 0.001) and prominent trend of age-independent decline in the testosterone levels was recorded during the study period for most age groups.

CONCLUSIONS

There was a highly significant age-independent decline in total testosterone in the first and second decades of the twenty-first century. The decline was unlikely to be explained by increasing rates of obesity.

A review of the evolving landscape between the consumer Internet and men's health

Internet adoption continues to increase as broadband access and mobile connectivity penetrate developing global markets. Alongside increasing adoption, the Internet continues to evolve and usher in new modes of user interaction. Social media and search engines have facilitated the emergence of the participatory web, in which users are able to contribute content, form online communities, and disseminate information. This participatory web is reshaping the patient-physician relationship as patients are able to search for medical information, directly engage with healthcare practitioners through social media, and make therapeutic decisions via online marketplaces. The ability for patients to self-diagnose and self-treat is highly relevant to andrology, given that men have a baseline reluctance to visit healthcare providers. Furthermore, men’s health issues such as erectile dysfunction and male infertility are stigmatized, with men turning to the Internet for guidance. The focus of this review is to survey the academic literature that evaluates the quality of online content for four common men’s health conditions: hypogonadism, male infertility, erectile dysfunction, and Peyronie’s disease.

Beyond tribulus (Tribulus terrestris L.): The effects of phytotherapics on testosterone, sperm and prostate parameters

ETHNO-PHARMACOLOGICAL RELEVANCE

Phytotherapeutic approaches have been widely proposed to improve male health. Despite the well-touted effects of tribulus (Tribulus terrestris L) on men's health, an optimal phytotherapy remains an elusive challenge.

AIM OF THE REVIEW

We sought to critically analyze the evidence in the phytotherapic literature beyond the effects of tribulus on testosterone (T) concentration and sperm analysis to also include indications for prostate health.

MATERIALS AND METHODS

A focused literature search was conducted to include studies published in Cochrane, Pubmed, and Web of Science databases between the years 2002 and 2018.

RESULTS

The use of tribulus and maca (Lepidium meyenii Walp, Brassicaceae) were not scientifically supported to improve serum T levels in men. Moderate evidence supports the use of long Jack (Eurycoma longifolia Jack, Simaroubaceae), mucuna (Mucuna pruriens (L.) DC., Fabaceae), ashwagandha (Withania somnifera (L.) Dunal, Solanaceae), fenugreek (Trigonella foenum-graceum L., Fabaceae), and black seeds (Nigella sativa L., Ranunculaceae) to increase total T and improve seminal parameters. Data suggests an increase in total T with the use of 5000 mg/d of powdered mucuna seed and ashwagandha root (151 and 143 ng/dL, respectively) over a 12-week period in patients with oligozoospermia. The use of mucuna was supported for patients with oligozoospermia to improve sperm parameters, with an increase of 83.3 million/mL observed after use of 5000 mg/d of powdered mucuna seed over a 12-week period. Evidence supporting the use of saw palmetto (Serenoa repens, (W.Bartram) Small, Arecaceae) to improve prostate health remains equivocal; whereas, evidence supporting the use of Pygeum africanum Hook.f., Rosaceae, Urtica dioica L., Urticaceae, beta-sitosterols, pollen extract, onion, garlic, and tomato, appears favorable and promising.

CONCLUSION

Scientific evidence supports the use of mucuna and ashwagandha as phytotherapics for improving serum T concentrations and semen parameters. Despite inconclusive evidence for use of tribulus as a T booster, it may provide advantageous effects on sperm parameters in men with idiopathic infertility. Nutraceutical strategies and some phytotherapics may also be effective to promote prostate health. Popular foodstuffs (onion, garlic, and tomato), nutraceutical agents (pollen extract and beta-sitosterols), and herbal medicines (Pygeum africanum and Urtica dioica) are rational approaches.

Angiotensin blockade attenuates diabetic nephropathy in hypogonadal adult male rats

This study examined the effect of the aromatase inhibitor letrozole (0.5 mg/kg) alone or in combination with the angiotensin-receptor blocker valsartan (30 mg/kg) against streptozocin-induced diabetic nephropathy (DN) in hypogonadal (HG) rats for 12 weeks. First, we tested the HG effect on hormone levels, inflammatory cytokines, and oxidative stress in nondiabetic (ND) and diabetic (D) rats. HG was induced with the luteinizing hormone-releasing hormone antagonist cetrorelix (0.71 mg/kg). Diabetes enhanced hormonal hypogonadism and increased inflammation and oxidative stress. Next, experiments examined the effect of early letrozole and valsartan intervention on DN in HG rats. HG-ND and HG-D rats were treated with letrozole alone or in combination with valsartan. HG-D rats developed proteinuria and had increased blood urea nitrogen and creatinine, and histopathological evidence of renal injury, including glomerular hypertrophy and mesangial expansion. Valsartan alone or in combination with letrozole reduced proteinuria, improved renal functions, and reduced diabetes-induced renal angiotensin II. Both agents ameliorated nuclear factor kappa light chain enhancer of activated B cells, interleukin 1β, interleukin 6, and tumor necrosis factor alpha levels. The combination decreased superoxide dismutase, malondialdehyde, and glutathione peroxidase levels, and prevented glomerular hypertrophy. In HG-D rats, valsartan reduced renal collagen IV and transforming growth factor-beta 1, especially when the testosterone level was corrected by letrozole. Thus, normalizing testosterone and inhibiting renal angiotensin II have a renoprotective effect against DN in HG male rats.

Testosterone Therapy: An Assessment of the Clinical Consequences of Changes in Hematocrit and Blood Flow Characteristics

INTRODUCTION

Clinical guidelines indicate that hematocrit should be monitored during testosterone replacement therapy (TTh), with action taken if a level of 0.54 is exceeded.

AIM

To consider the extent of changes in hematocrit and putative effects on viscosity, blood flow, and mortality rates after TTh.

METHODS

We focused on literature describing benefits and possible pitfalls of TTh, including increased hematocrit. We used data from the BLAST RCT to determine change in hematocrit after 30 weeks of TTh and describe a clinical case showing the need for monitoring. We consider the validity of the current hematocrit cutoff value at which TTh may be modified. Ways in which hematocrit alters blood flow in the micro- and macro-vasculature are also considered.

MAIN OUTCOME MEASURES

The following measures were assessed: (i) change in hematocrit, (ii) corresponding actions taken in clinical practice, and (iii) possible blood flow changes following change in hematocrit.

RESULTS

Analysis of data from the BLAST RCT showed a significant increase in mean hematocrit of 0.01, the increase greater in men with lower baseline values. Although 0 of 61 men given TTh breached the suggested cutoff of 0.54 after 30 weeks, a clinical case demonstrates the need to monitor hematocrit. An association between hematocrit and morbidity and mortality appears likely but not proven and may be evident only in patient subgroups. The consequences of an increased hematocrit may be mediated by alterations in blood viscosity, oxygen delivery, and flow. Their relative impact may vary in different vascular beds.

CONCLUSIONS

TTh can effect an increased hematocrit via poorly understood mechanisms and may have harmful effects on blood flow that differ in patient subgroups. At present, there appears no scientific basis for using a hematocrit of 0.54 to modify TTh; other values may be more appropriate in particular patient groups. König CS, Balabani S, Hackett GI, et al. Testosterone Therapy: An Assessment of the Clinical Consequences of Changes in Hematocrit and Blood Flow Characteristics. Sex Med Rev 2019;7:650-660.

Investigating the basis of sexual dysfunction during late-onset hypogonadism

Late-onset hypogonadism (LOH) is the term used to describe the decline in serum testosterone levels associated with increasing age in men above 40 years. A number of symptoms are attributed to LOH, but the most common association is that of sexual dysfunction. LOH has recently come under greater scrutiny with the widespread use of testosterone therapy, and concerns regarding the efficacy and safety of testosterone replacement therapy have been raised. In particular, the cardiovascular safety and the beneficial effects of testosterone replacement therapy on general health have been questioned. This review will give an overview of the current evidence for the relationship of LOH and male sexual dysfunction.

Sugar-sweetened beverage intake and serum testosterone levels in adult males 20-39 years old in the United States

BACKGROUND

This population-based study was designed to investigate whether consumption of sugar-sweetened beverages (SSB) is associated with lower serum total testosterone concentration in men 20-39 years old.

METHODS

All data for this study were retrieved from the National Health and Nutrition Examination Survey (NHANES) 2011-2012. The primary outcome was serum testosterone concentration, and main independent variable was SSB intake. Other variables included age, race/ethnicity, poverty/income ratio, body mass index (BMI), serum cotinine, heavy drinking, and physical activity.

RESULTS

Among all subjects (N = 545), 486 (90.4%) had normal testosterone levels (defined as ≥231 ng/dL) and 59 (9.6%) had low testosterone levels (defined as < 231 ng/dL). Multivariate logistic regression revealed the odds of low testosterone was significantly greater with increasing SSB consumption (Q4 [≥442 kcal/day] vs. Q1 [≤137 kcal/day]), adjusted odds ratio [aOR] = 2.29, p = 0.041]. After adjusting for possible confounding variables, BMI was an independent risk factor for low testosterone level; subjects with BMI ≥ 25 kg/m² had a higher risk of having a low testosterone level than those with BMI < 25 kg/m² (aOR = 3.68, p = 0.044).

CONCLUSION

SSB consumption is significantly associated with low serum testosterone in men 20-39 years old in the United States.

A new 2% testosterone gel formulation: a comparison with currently available topical preparations

Testosterone gel formulations have become a popular testosterone replacement therapy in patients with hypogonadism since their advent in the year 2000. The gel formulations restore testosterone levels to mid-normal physiological levels (14-17.5 nmol/L) as early as within 24 h, and help alleviate the signs and symptoms of testosterone deficiency, thereby leading to an improved quality of life. Although testosterone gels have a favourable efficacy and safety profile as compared to injectable and patch formulations, risk of secondary exposure poses a challenge. Approved testosterone topical formulations include Tostrex^® (Tostran^® , Fortesta^® ), Androgel^® (Testogel^® ), Testim^® and Axiron^® (solution), which have a favourable efficacy profile and positively impacted patient-reported outcome(s). Besides, Testavan, which is a 2% testosterone gel, is under registration in Europe and already approved in Australia in May 2017. Testavan uses a novel hydroalcoholic and highly viscous topical formulation. This product comes with a metered dose dispenser and a cap applicator that allows a hands-free application for precise dispensing and application. The present article provides a comprehensive review of pharmacokinetic, tolerability and safety profile of the testosterone gels available in the market along with the new 2% testosterone gel, Testavan.

Serum testosterone levels in male hypogonadism: Why and when to check-A review

AIM

Although "late onset hypogonadism", a condition that includes low testosterone and symptoms, is common in men over the age of 40 years, diagnosis is not clear cut amongst non-specialists. It is the aim of this review to provide an up to date picture of how this state should be diagnosed and managed.

METHODS

We aim to describe how primary and secondary hypogonadism should be excluded before the diagnosis of late onset hypogonadism is reached. As laboratory testosterone measurements are essential the current pitfalls such as inappropriate sample collection and the use of population derived reference ranges are expanded. We review current evidence to determine associations between late onset hypogonadism and morbidity/mortality and benefits following testosterone replacement therapy.

RESULTS

A review of the current evidence shows that late onset hypogonadism is associated with a worse metabolic state and increased mortality. Longitudinal studies have suggested that significant reductions in both symptoms and mortality are seen, especially in patients with type 2 diabetes.

DISCUSSION

This review highlights the importance of diagnosing late onset hypogonadism due to its association with morbidity/mortality and benefits following testosterone replacement. Thus, after making recommendations to ensure correct diagnosis we speculate whether the time has come to move away from population derived testosterone levels towards evidence based action limits.