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Jaiswal V, Sawhney A, Nebuwa C, Borra V, Deb N, Halder A, Rajak K, Jha M, Wajid Z, Thachil R, Bandyopadhyay D, Mattumpuram J, Lavie CJ. Association between testosterone replacement therapy and cardiovascular outcomes: A meta-analysis of 30 randomized controlled trials. Prog Cardiovasc Dis 2024; 85:45-53. [PMID: 38589271 DOI: 10.1016/j.pcad.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/01/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The Cardiovascular safety of testosterone replacement therapy (TRT) among men with hypogonadism is not well established to date. Hence, we sought to evaluate the cardiovascular disease (CVD) outcomes among patients receiving testosterone therapy by using all recently published randomized controlled trials. METHODS We performed a systematic literature search on PubMed, EMBASE, and Clinicaltrial.gov for relevant randomized controlled trials (RCTs) from inception until September 30th, 2023. RESULTS A total of 30 randomized trials with 11,502 patients were included in the final analysis. The mean age was ranging from 61.61 to 61.82 years. Pooled analysis of primary and secondary outcomes showed that the incidence of any CVD events (OR, 1.12 (95%CI: 0.77-1.62), P = 0.55), stroke (OR, 1.01 (95%CI: 0.68-1.51), P = 0.94), myocardial infarction (OR, 1.05 (95%CI: 0.76-1.45), P = 0.77), all-cause mortality (OR, 0.94 (95%CI: 0.76-1.17), P = 0.57), and CVD mortality (OR, 0.87 (95%CI: 0.65-1.15), P = 0.31) was comparable between TRT and placebo groups. CONCLUSION Our analysis indicates that for patients with hypogonadism, testosterone replacement therapy does not increase the CVD risk and all-cause mortality.
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Affiliation(s)
- Vikash Jaiswal
- Department of Cardiovascular Research, Larkin Community Hospital, South Miami, FL, USA.
| | - Aanchal Sawhney
- Department of Internal Medicine, Crozer Chester Medical Center, Upland, PA, USA
| | - Chikodili Nebuwa
- Department of Internal Medicine, Nuvance Health, Poughkeepsie, NY, USA
| | - Vamsikalyan Borra
- Department of Internal Medicine, University of Texas Rio Grande Valley, Weslaco, TX, USA
| | - Novonil Deb
- North Bengal Medical College and Hospital, India
| | - Anupam Halder
- Department of Internal Medicine, UPMC, Harrisburg, PA, USA
| | - Kripa Rajak
- Department of Internal Medicine, UPMC, Harrisburg, PA, USA
| | - Mayank Jha
- Department of Medicine, Government Medical College, Surat, India
| | - Zarghoona Wajid
- Department of Internal Medicine, Wayne State University School of Medicine, USA
| | - Rosy Thachil
- Division of Cardiology, Elmhurst Hospital Center, Mount Sinai School of Medicine, New York, USA
| | | | - Jishanth Mattumpuram
- Division of Cardiology, University of Louisville School of Medicine, KY 40202, United States
| | - Carl J Lavie
- Department of Cardiovascular Disease, John Ochsner Heart and Vascular Institute, New Orleans, LA, USA.
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Corona G, Rastrelli G, Sparano C, Carinci V, Casella G, Vignozzi L, Sforza A, Maggi M. Cardiovascular safety of testosterone replacement therapy in men: an updated systematic review and meta-analysis. Expert Opin Drug Saf 2024; 23:565-579. [PMID: 38553429 DOI: 10.1080/14740338.2024.2337741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/28/2023] [Indexed: 05/07/2024]
Abstract
INTRODUCTION The cardiovascular (CV) safety of testosterone (T) replacement therapy (TRT) is still conflicting. Recent data suggested a TRT-related increased risk of atrial fibrillation (AF). The aim of this study was to systematic review and meta-analyze CV risk related to TRT as derived from placebo controlled randomized trials (RCTs). AREAS COVERED An extensive Medline, Embase, and Cochrane search was performed. All placebo-controlled RCTs reporting data on TRT-related CV safety were considered. To better analyze the role of T on AF, population-based studies investigating the relationship between endogenous circulating T levels and AF incidence were also included and analyzed. EXPERT OPINION Out of 3.615, 106 studies were considered, including 8.126 subjects treated with TRT and 7.310 patients allocated to placebo. No difference between TRT and placebo was observed when major adverse CV events were considered. Whereas the incidence of non-fatal arrhythmias and AF was increased in the only trial considering CV safety as the primary endpoint, this was not confirmed when all other studies were considered (MH-OR 1.61[0.84;3.08] and 1.44[0.46;4.46]). Similarly, no relationship between endogenous T levels and AF incidence was observed after the adjustment for confounders Available data confirm that TRT is safe and it is not related to an increased CV risk.
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Affiliation(s)
- Giovanni Corona
- Endocrinology Unit, Azienda AUSL, Maggiore Hospital, Bologna, Italy
| | - Giulia Rastrelli
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Mario Serio" Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Clotilde Sparano
- Endocrinology Unit, Mario Serio" Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Valeria Carinci
- Cardiology Unit, Azienda AUSL, Maggiore Hospital, Bologna, Italy
| | - Gianni Casella
- Cardiology Unit, Azienda AUSL, Maggiore Hospital, Bologna, Italy
| | - Linda Vignozzi
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Mario Serio" Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | | | - Mario Maggi
- Endocrinology Unit, Mario Serio" Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
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Lee H, Hwang EC, Oh CK, Lee S, Yu HS, Lim JS, Kim HW, Walsh T, Kim MH, Jung JH, Dahm P. Testosterone replacement in men with sexual dysfunction. Cochrane Database Syst Rev 2024; 1:CD013071. [PMID: 38224135 PMCID: PMC10788910 DOI: 10.1002/14651858.cd013071.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
BACKGROUND Clinical practice guidelines recommend testosterone replacement therapy (TRT) for men with sexual dysfunction and testosterone deficiency. However, TRT is commonly promoted in men without testosterone deficiency and existing trials often do not clearly report participants' testosterone levels or testosterone-related symptoms. This review assesses the potential benefits and harms of TRT in men presenting with complaints of sexual dysfunction. OBJECTIVES To assess the effects of testosterone replacement therapy compared to placebo or other medical treatments in men with sexual dysfunction. SEARCH METHODS We performed a comprehensive search of CENTRAL (the Cochrane Library), MEDLINE, EMBASE, and the trials registries ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform, with no restrictions on language of publication or publication status, up to 29 August 2023. SELECTION CRITERIA We included randomized controlled trials (RCTs) in men (40 years or over) with sexual dysfunction. We excluded men with primary or secondary hypogonadism. We compared testosterone or testosterone with phosphodiesterase-5 inhibitors (PDEI5I) to placebo or PDE5I alone. DATA COLLECTION AND ANALYSIS Two review authors independently screened the literature, assessed the risk of bias, extracted data, and rated the certainty of evidence (CoE) according to GRADE using a minimally contextualized approach. We performed statistical analyses using a random-effects model and interpreted them according to standard Cochrane methodology. Predefined primary outcomes were self-reported erectile dysfunction assessed by a validated instrument, sexual quality of life assessed by a validated instrument, and cardiovascular mortality. Secondary outcomes were treatment withdrawal due to adverse events, prostate-related events, and lower urinary tract symptoms (LUTS). We distinguished between short-term (up to 12 months) and long-term (> 12 months) outcomes. MAIN RESULTS We identified 43 studies with 11,419 randomized participants across three comparisons: testosterone versus placebo, testosterone versus PDE5I, and testosterone with PDE5I versus PDE5I alone. This abstract focuses on the most relevant comparison of testosterone versus placebo. Testosterone versus placebo (up to 12 months) Based on a predefined sensitivity analysis of studies at low risk of bias, and an analysis combing data from the similar International Index of Erectile Function (IIEF-EF) and IIEF-5 instruments, TRT likely results in little to no difference in erectile function assessed with the IIEF-EF (mean difference (MD) 2.37, 95% confidence interval (CI) 1.67 to 3.08; I² = 0%; 6 RCTs, 2016 participants; moderate CoE) on a scale from 6 to 30 with larger values reflecting better erectile function. We assumed a minimal clinically important difference (MCID) of greater than or equal to 4. TRT likely results in little to no change in sexual quality of life assessed with the Aging Males' Symptoms scale (MD -2.31, 95% CI -3.63 to -1.00; I² = 0%; 5 RCTs, 1030 participants; moderate CoE) on a scale from 17 to 85 with larger values reflecting worse sexual quality of life. We assumed a MCID of greater than or equal to 10. TRT also likely results in little to no difference in cardiovascular mortality (risk ratio (RR) 0.83, 95% CI 0.21 to 3.26; I² = 0%; 10 RCTs, 3525 participants; moderate CoE). Based on two cardiovascular deaths in the placebo group and an assumed MCID of 3%, this would correspond to no additional deaths per 1000 men (95% CI 1 fewer to 4 more). TRT also likely results in little to no difference in treatment withdrawal due to adverse events, prostate-related events, or LUTS. Testosterone versus placebo (later than 12 months) We are very uncertain about the longer-term effects of TRT on erectile dysfunction assessed with the IIEF-EF (MD 4.20, 95% CI -2.03 to 10.43; 1 study, 42 participants; very low CoE). We did not find studies reporting on sexual quality of life or cardiovascular mortality. We are very uncertain about the effect of testosterone on treatment withdrawal due to adverse events. We found no studies reporting on prostate-related events or LUTS. AUTHORS' CONCLUSIONS In the short term, TRT probably has little to no effect on erectile function, sexual quality of life, or cardiovascular mortality compared to a placebo. It likely results in little to no difference in treatment withdrawals due to adverse events, prostate-related events, or LUTS. In the long term, we are very uncertain about the effects of TRT on erectile function when compared to placebo; we did not find data on its effects on sexual quality of life or cardiovascular mortality. The certainty of evidence ranged from moderate (signaling that we are confident that the reported effect size is likely to be close to the true effect) to very low (indicating that the true effect is likely to be substantially different). The findings of this review should help to inform future guidelines and clinical decision-making at the point of care.
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Affiliation(s)
- Hunju Lee
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Eu Chang Hwang
- Department of Urology, Chonnam National University Medical School, Chonnam National University Hwasun Hospital, Hwasun, Korea, South
- Center of Evidence-Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea, South
| | - Cheol Kyu Oh
- Department of Urology, Heaundae Paik Hospital, Inje University, Busan, Korea, South
| | - Solam Lee
- Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Ho Song Yu
- Department of Urology, Chonnam National University, Gwangju, Korea, South
| | - Jung Soo Lim
- Division of Endocrinology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Hong Wook Kim
- Department of Urology, Konyang University College of Medicine, Daejeon, Korea, South
| | - Thomas Walsh
- Immunocompromised Host Section, Pediatric Oncology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Myung Ha Kim
- Yonsei Wonju Medical Library, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Jae Hung Jung
- Center of Evidence-Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea, South
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
- Department of Precision Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Philipp Dahm
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
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David K, Narinx N, Antonio L, Evenepoel P, Claessens F, Decallonne B, Vanderschueren D. Bone health in ageing men. Rev Endocr Metab Disord 2022; 23:1173-1208. [PMID: 35841491 DOI: 10.1007/s11154-022-09738-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 01/11/2023]
Abstract
Osteoporosis does not only affect postmenopausal women, but also ageing men. The burden of disease is projected to increase with higher life expectancy both in females and males. Importantly, osteoporotic men remain more often undiagnosed and untreated compared to women. Sex steroid deficiency is associated with bone loss and increased fracture risk, and circulating sex steroid levels have been shown to be associated both with bone mineral density and fracture risk in elderly men. However, in contrast to postmenopausal osteoporosis, the contribution of relatively small decrease of circulating sex steroid concentrations in the ageing male to the development of osteoporosis and related fractures, is probably only minor. In this review we provide several clinical and preclinical arguments in favor of a 'bone threshold' for occurrence of hypogonadal osteoporosis, corresponding to a grade of sex steroid deficiency that in general will not occur in many elderly men. Testosterone replacement therapy has been shown to increase bone mineral density in men, however data in osteoporotic ageing males are scarce, and evidence on fracture risk reduction is lacking. We conclude that testosterone replacement therapy should not be used as a sole bone-specific treatment in osteoporotic elderly men.
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Affiliation(s)
- Karel David
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000 , Leuven, Belgium
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Nick Narinx
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000 , Leuven, Belgium
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Leen Antonio
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000 , Leuven, Belgium
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Evenepoel
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Frank Claessens
- Laboratory of Molecular Endocrinology, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Brigitte Decallonne
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000 , Leuven, Belgium
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Vanderschueren
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000 , Leuven, Belgium.
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium.
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5
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Adverse cardiovascular events and mortality in men during testosterone treatment: an individual patient and aggregate data meta-analysis. THE LANCET. HEALTHY LONGEVITY 2022; 3:e381-e393. [PMID: 35711614 PMCID: PMC9184259 DOI: 10.1016/s2666-7568(22)00096-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background Testosterone is the standard treatment for male hypogonadism, but there is uncertainty about its cardiovascular safety due to inconsistent findings. We aimed to provide the most extensive individual participant dataset (IPD) of testosterone trials available, to analyse subtypes of all cardiovascular events observed during treatment, and to investigate the effect of incorporating data from trials that did not provide IPD. Methods We did a systematic review and meta-analysis of randomised controlled trials including IPD. We searched MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE Epub Ahead of Print, Embase, Science Citation Index, the Cochrane Controlled Trials Register, Cochrane Database of Systematic Reviews, and Database of Abstracts of Review of Effects for literature from 1992 onwards (date of search, Aug 27, 2018). The following inclusion criteria were applied: (1) men aged 18 years and older with a screening testosterone concentration of 12 nmol/L (350 ng/dL) or less; (2) the intervention of interest was treatment with any testosterone formulation, dose frequency, and route of administration, for a minimum duration of 3 months; (3) a comparator of placebo treatment; and (4) studies assessing the pre-specified primary or secondary outcomes of interest. Details of study design, interventions, participants, and outcome measures were extracted from published articles and anonymised IPD was requested from investigators of all identified trials. Primary outcomes were mortality, cardiovascular, and cerebrovascular events at any time during follow-up. The risk of bias was assessed using the Cochrane Risk of Bias tool. We did a one-stage meta-analysis using IPD, and a two-stage meta-analysis integrating IPD with data from studies not providing IPD. The study is registered with PROSPERO, CRD42018111005. Findings 9871 citations were identified through database searches and after exclusion of duplicates and of irrelevant citations, 225 study reports were retrieved for full-text screening. 116 studies were subsequently excluded for not meeting the inclusion criteria in terms of study design and characteristics of intervention, and 35 primary studies (5601 participants, mean age 65 years, [SD 11]) reported in 109 peer-reviewed publications were deemed suitable for inclusion. Of these, 17 studies (49%) provided IPD (3431 participants, mean duration 9·5 months) from nine different countries while 18 did not provide IPD data. Risk of bias was judged to be low in most IPD studies (71%). Fewer deaths occurred with testosterone treatment (six [0·4%] of 1621) than placebo (12 [0·8%] of 1537) without significant differences between groups (odds ratio [OR] 0·46 [95% CI 0·17-1·24]; p=0·13). Cardiovascular risk was similar during testosterone treatment (120 [7·5%] of 1601 events) and placebo treatment (110 [7·2%] of 1519 events; OR 1·07 [95% CI 0·81-1·42]; p=0·62). Frequently occurring cardiovascular events included arrhythmia (52 of 166 vs 47 of 176), coronary heart disease (33 of 166 vs 33 of 176), heart failure (22 of 166 vs 28 of 176), and myocardial infarction (10 of 166 vs 16 of 176). Overall, patient age (interaction 0·97 [99% CI 0·92-1·03]; p=0·17), baseline testosterone (interaction 0·97 [0·82-1·15]; p=0·69), smoking status (interaction 1·68 [0·41-6·88]; p=0.35), or diabetes status (interaction 2·08 [0·89-4·82; p=0·025) were not associated with cardiovascular risk. Interpretation We found no evidence that testosterone increased short-term to medium-term cardiovascular risks in men with hypogonadism, but there is a paucity of data evaluating its long-term safety. Long-term data are needed to fully evaluate the safety of testosterone. Funding National Institute for Health Research Health Technology Assessment Programme.
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Corona G, Vena W, Pizzocaro A, Giagulli VA, Francomano D, Rastrelli G, Mazziotti G, Aversa A, Isidori AM, Pivonello R, Vignozzi L, Mannucci E, Maggi M, Ferlin A. Testosterone supplementation and bone parameters: a systematic review and meta-analysis study. J Endocrinol Invest 2022; 45:911-926. [PMID: 35041193 DOI: 10.1007/s40618-021-01702-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/01/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The role of testosterone (T) replacement therapy (TRT) in subjects with late onset hypogonadism is still the object of an intense debate. METHODS All observational studies and placebo-controlled or -uncontrolled randomized trials (RCTs) comparing the effect of TRT on different bone parameters were considered. RESULTS Out of 349 articles, 36 were considered, including 3103 individuals with a mean trial duration of 66.6 weeks. TRT improves areal bone mineral density (aBMD) at the spine and femoral neck levels in observational studies, whereas placebo-controlled RTCs showed a positive effect of TRT only at lumber spine and when trials included only hypogonadal patients at baseline (total testosterone < 12 nM). The effects on aBMD were more evident in subjects with lower T levels at baseline and increased as a function of trial duration and a higher prevalence of diabetic subjects. Either T or estradiol increase at endpoint contributed to aBMD improvement. TRT was associated with a significant reduction of bone resorption markers in observational but not in controlled studies. CONCLUSION TRT is able to inhibit bone resorption and increase bone mass, particularly at the lumbar spine level and when the duration is long enough to allow the anabolic effect of T and estrogens on bone metabolism to take place.
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Affiliation(s)
- G Corona
- Endocrinology Unit, Medical Department, Azienda Usl, Maggiore-Bellaria Hospital, Bologna, Italy
| | - W Vena
- Unit of Endocrinology, Diabetology and Medical Andrology, IRCSS, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - A Pizzocaro
- Unit of Endocrinology, Diabetology and Medical Andrology, IRCSS, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - V A Giagulli
- Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - D Francomano
- Unit of Internal Medicine and Endocrinology, Madonna Delle Grazie Hospital, Velletri, Rome, Italy
| | - G Rastrelli
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Mario Serio Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - G Mazziotti
- Unit of Endocrinology, Diabetology and Medical Andrology, IRCSS, Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - A Aversa
- Department of Experimental and Clinical Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome-Policlinico Umberto I Hospital, Rome, Italy
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e della Sessualità Maschile e Femminile, Università Federico II di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - L Vignozzi
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Mario Serio Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - E Mannucci
- Department of Diabetology, Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - M Maggi
- Endocrinology Unit, Mario Serio Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy.
| | - A Ferlin
- Department of Medicine, Unit of Andrology and Reproductive Medicine, University of Padova, Padova, Italy
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Shi H, Cheer K, Simanainen U, Lesmana B, Ma D, Hew JJ, Parungao RJ, Li Z, Cooper MS, Handelsman DJ, Maitz PK, Wang Y. The contradictory role of androgens in cutaneous and major burn wound healing. BURNS & TRAUMA 2021; 9:tkaa046. [PMID: 33928173 PMCID: PMC8058007 DOI: 10.1093/burnst/tkaa046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/31/2020] [Indexed: 01/25/2023]
Abstract
Wound healing is a complex process involving four overlapping phases: haemostasis, inflammation, cell recruitment and matrix remodeling. In mouse models, surgical, pharmacological and genetic approaches targeting androgen actions in skin have shown that androgens increase interleukin-6 and tumor necrosis factor-α production and reduce wound re-epithelization and matrix deposition, retarding cutaneous wound healing. Similarly, clinical studies have shown that cutaneous wound healing is slower in men compared to women. However, in major burn injury, which triggers not only local wound-healing processes but also systemic hypermetabolism, the role of androgens is poorly understood. Recent studies have claimed that a synthetic androgen, oxandrolone, increases protein synthesis, improves lean body mass and shortens length of hospital stay. However, the possible mechanisms by which oxandrolone regulates major burn injury have not been reported. In this review, we summarize the current findings on the roles of androgens in cutaneous and major burn wound healing, as well as androgens as a potential therapeutic treatment option for patients with major burn injuries.
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Affiliation(s)
- Huaikai Shi
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Kenny Cheer
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Ulla Simanainen
- Andrology, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Brian Lesmana
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Duncan Ma
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Jonathan J Hew
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Roxanne J Parungao
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Zhe Li
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia.,Burns and Reconstructive Surgery Unit, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Mark S Cooper
- Adrenal Steroid Laboratory, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - David J Handelsman
- Andrology, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Peter K Maitz
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia.,Burns and Reconstructive Surgery Unit, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Yiwei Wang
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
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8
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Rochira V. Late-onset Hypogonadism: Bone health. Andrology 2020; 8:1539-1550. [PMID: 32469467 DOI: 10.1111/andr.12827] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/16/2020] [Accepted: 05/19/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Bone health is underdiagnosed and undermanaged in men. Bone loss occurs in men with hypogonadism and in aging men. Thus, patients with a diagnosis of late-onset hypogonadism (LOH) are at risk of osteoporosis and osteoporotic fractures. OBJECTIVES To provide an update on research data and clinical implications regarding bone health in men with LOH by reviewing literature articles on this issue. MATERIALS AND METHODS A thorough search of listed publications in PubMed on bone health in older men with hypogonadism was performed, and other articles derived from these publications were further identified. RESULTS Late-onset Hypogonadism may be associated with reduced bone mineral density (BMD). In a pathophysiological perspective, the detrimental effects of testosterone (T) deficiency on BMD are partly ascribed to relative estrogen deficiency and both serum T and serum estradiol (E2) need to be above 200 ng/dL and 20 pg/mL to prevent bone loss. The effects of exogenous T on BMD are controversial, but most of the studies confirm that testosterone replacement therapy (TRT) increases BMD and prevents further bone loss in men with hypogonadism. No data are available on TRT and the prevention of fractures. DISCUSSION AND CONCLUSION In men with documented LOH, a specific clinical workup should be addressed to the diagnosis of osteoporosis in order to program subsequent follow-up and consider specific bone active therapy. TRT should be started according to guidelines of male hypogonadism while keeping in mind that it may also have positive effects also on bone health in men with LOH.
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Affiliation(s)
- Vincenzo Rochira
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Department of Medical Specialties, Azienda Ospedaliero-Universitaria di Modena, Ospedale Civile di Baggiovara, Modena, Italy
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Zhang Z, Kang D, Li H. The effects of testosterone on bone health in males with testosterone deficiency: a systematic review and meta-analysis. BMC Endocr Disord 2020; 20:33. [PMID: 32145741 PMCID: PMC7060639 DOI: 10.1186/s12902-020-0509-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 02/14/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Testosterone deficiency (TD) may induce a series of clinical symptoms. Studies have shown that testosterone supplementation may prevent these unfavourable symptoms and improve patients' quality of life. Given the conflicting findings across studies, this systematic review aims to evaluate the effects and risks associated with testosterone supplementation in middle-aged or aging males with TD. METHODS Electronic databases (MEDLINE, EMBASE, PubMed, and Cochrane. Library were searched to December 2019. The risk of bias of individual included studies and the quality of the aggregate evidence were assessed using the GRADE approach. Our primary outcome was bone mineral density (BMD). Meta-analyses were performed. This systematic review was reported according to the PRISMA statement. RESULTS A total of 52 randomized controlled trials (RCTs) were included. When compared with placebo, testosterone supplementation did not increase total BMD (short-term: 1081 participants, MD - 0.01 g/cm2, 95% CI - 0.02 g/cm2 to 0.01 g/cm2; long-term: 156 participants, MD 0.04 g/cm2, 95% CI - 0.07 g/cm2 to 0.14 g/cm2), lumbar spine, hip, or femur neck BMD. Furthermore, testosterone supplementation did not decrease the risk of falling or fracture. Lastly, it was found that testosterone supplementation did not increase the risk of cardiovascular events (1374 participants, RR 1.28, 95% CI 0.62 to 2.64), all-cause mortality (729 participants, RR 0.55, 95% CI 0.29 to 1.04), or prostatic events. However, testosterone supplementation may improve sexual function and quality of life (1328 participants, MD -1.32, 95% CI - 2.11 to - 0.52). CONCLUSIONS The effect of testosterone supplementation on BMD and the risk of falls or fracture remains inconclusive. However, supplementation may benefit patients in the areas of sexual function and quality of life without increasing the risk of cardiovascular events, all-cause mortality, or prostatic events. RCTs with a longer follow-up period are still required. TRIAL REGISTRATION We registered our protocol in PROSPERO (CRD42018109738).
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Affiliation(s)
- Zhichao Zhang
- Andrology Center, Department of Urology, Peking University First Hospital; Institute of Urology, Peking University, No 8 Xishenku Street, Beijing, 100034, China
| | - Deying Kang
- Department of Evidence based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, No. 37 Guoxuexiang, Chengdu, 610041, China
| | - Hongjun Li
- Urological Department of Peking Union Medical College Hospital (PUMCH), Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuaifu, Eastern District, Beijing, 100730, China.
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Corona G, Rastrelli G, Di Pasquale G, Sforza A, Mannucci E, Maggi M. Testosterone and Cardiovascular Risk: Meta-Analysis of Interventional Studies. J Sex Med 2019; 15:820-838. [PMID: 29803351 DOI: 10.1016/j.jsxm.2018.04.641] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/09/2018] [Accepted: 04/11/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND The relationship between testosterone (T) and cardiovascular (CV) risk in men is conflicting. AIM To verify whether T therapy (TTh) represents a possible risk factor for CV morbidity and mortality. METHODS We conducted a random effect meta-analysis considering all available data from pharmaco-epidemiological studies as well as randomized placebo-controlled trials (RCTs). OUTCOMES CV mortality and morbidity were investigated. RESULTS After screening, 15 pharmaco-epidemiological and 93 RCT studies were considered. The analysis of pharmaco-epidemiological studies documented that TTh reduces overall mortality and CV morbidity. Conversely, in RCTs, TTh had no clear effect, either beneficial or detrimental, on the incidence of CV events. However, a protective role of TTh on CV morbidity was observed when studies enrolling obese (body mass index >30 kg/m2) patients were scrutinized (Mantel-Haenszel odds ratio 0.51 [95% CI 0.27-0.96]; P = .04), although this association disappeared when only high-quality RCTs were considered (Mantel-Haenszel odds ratio 0.64 [95% CI 0.22-1.88]; P = .42). Finally, an increased risk of CV diseases was observed in RCTs when T preparations were prescribed at dosages above those normally recommended, or when frail men were considered. CLINICAL IMPLICATIONS Pharmaco-epidemiological studies showed that TTh might reduce CV risk, but this effect was not confirmed when RCTs were considered. STRENGTHS & LIMITATIONS Meta-analysis of pharmaco-epidemiological studies indicates that TTh reduces overall mortality and CV morbidity. In addition, even in RCTs, a protective role of TTh on CV morbidity was envisaged when studies enrolling obese (body mass index >30 kg/m2) patients were considered. Pharmaco-epidemiological studies should be considered with caution due to the lack of completeness of follow-up and of the management of missing data. In addition, properly powered placebo-controlled RCTs with a primary CV end point, in men with late-onset hypo-gonadism, are not yet available. Finally, the duration of all studies evaluated in the present meta-analysis is relatively short, reaching a maximum of 3 years. CONCLUSIONS Data from RCTs suggest that treatment with T is not effective in reducing CV risk, however, when TTh is correctly applied, it is not associated with an increase in CV risk and it may have a beneficial effect in some sub-populations. Corona G, Rastrelli G, Di Pasquale G, et al. Testosterone and Cardiovascular Risk: Meta-Analysis of Interventional Studies. J Sex Med 2018;15:820-838.
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Affiliation(s)
- Giovanni Corona
- Endocrinology Unit, Medical Department, Azienda USL, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Giulia Rastrelli
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Florence, Italy
| | - Giuseppe Di Pasquale
- Cardiology Unit, Medical Department, Azienda USL, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Alessandra Sforza
- Endocrinology Unit, Medical Department, Azienda USL, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Edoardo Mannucci
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Florence, Italy; Diabetes Agency, Careggi Hospital, Florence, Italy
| | - Mario Maggi
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Florence, Italy.
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Dimitropoulos K, Verze P, Van den Broeck T, Salonia A, Yuan CY, Hatzimouratidis K, Dohle G. What are the benefits and harms of testosterone therapy for male sexual dysfunction?-a systematic review. Int J Impot Res 2019; 31:380-391. [PMID: 30918363 DOI: 10.1038/s41443-019-0131-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/08/2019] [Accepted: 02/13/2019] [Indexed: 12/11/2022]
Abstract
The role of Testosterone Therapy (TTh) in the management of male sexual dysfunction remains unclear. Objective of the authors was to systematically review the relevant literature assessing the benefits and harms of TTh in men with sexual dysfunction. EMBASE, MEDLINE, Cochrane Systematic Reviews-Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane HTA, DARE, HEED), Google Scholar, WHO international Clinical Trials Registry Platform Search Portal, CINAHL databases and clinicaltrial.gov were searched systematically in March 2015 and an updated search was performed in March 2016. Randomized and non-randomized comparative studies assessing the benefits and harms of TTh in hypogonadal, borderline eugonadal and eugonadal men suffering from sexual dysfunction were included. Risk of bias and confounding assessments were performed. A narrative synthesis was undertaken. Of the 6410 abstracts identified, 36 studies were judged to be eligible for inclusion, including 25 randomized clinical trials (RCTs) and 11 non-randomized comparative studies (NRCSs), recruiting a total of 4944 patients. RCTs were judged to have low or unclear risk of bias, while NRCSs had high risk of bias and thus, overall quality of evidence was judged to be at least unclear. Based on the evidence mainly provided by the RCTs included in this systematic review, TTh could be considered for men with low or low-normal testosterone levels and problems with their sexual desire, erectile function and satisfaction derived from intercourse and overall sexual life. The exact testosterone formulation, dosage and duration of treatment remain to be clarified, while the safety profile of TTh also remains unclear. TTh could be used with caution in hypogonadal and most probably borderline eugonadal men to manage disorders of sexual desire, erectile function and sexual satisfaction. The overall low-to-moderate evidence quality highlights the need for robust and adequately designed clinical trials.
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Affiliation(s)
| | - Paolo Verze
- Department of Urology, University of Naples Federico II, Naples, Italy
| | | | - Andrea Salonia
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | | | - Gert Dohle
- Urology Department, Erasmus University Medical Center, Rotterdam, Netherlands
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12
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Obesity’s role in secondary male hypogonadism: a review of pathophysiology and management issues. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s42399-019-00056-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Skinner JW, Otzel DM, Bowser A, Nargi D, Agarwal S, Peterson MD, Zou B, Borst SE, Yarrow JF. Muscular responses to testosterone replacement vary by administration route: a systematic review and meta-analysis. J Cachexia Sarcopenia Muscle 2018; 9. [PMID: 29542875 PMCID: PMC5989848 DOI: 10.1002/jcsm.12291] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Inconsistent fat-free mass (FFM) and muscle strength responses have been reported in randomized clinical trials (RCTs) administering testosterone replacement therapy (TRT) to middle-aged and older men. Our objective was to conduct a meta-analysis to determine whether TRT improves FFM and muscle strength in middle-aged and older men and whether the muscular responses vary by TRT administration route. METHODS Systematic literature searches of MEDLINE/PubMed and the Cochrane Library were conducted from inception through 31 March 2017 to identify double-blind RCTs that compared intramuscular or transdermal TRT vs. placebo and that reported assessments of FFM or upper-extremity or lower-extremity strength. Studies were identified, and data were extracted and validated by three investigators, with disagreement resolved by consensus. Using a random effects model, individual effect sizes (ESs) were determined from 31 RCTs reporting FFM (sample size: n = 1213 TRT, n = 1168 placebo) and 17 reporting upper-extremity or lower-extremity strength (n = 2572 TRT, n = 2523 placebo). Heterogeneity was examined, and sensitivity analyses were performed. RESULTS When administration routes were collectively assessed, TRT was associated with increases in FFM [ES = 1.20 ± 0.15 (95% CI: 0.91, 1.49)], total body strength [ES = 0.90 ± 0.12 (0.67, 1.14)], lower-extremity strength [ES = 0.77 ± 0.16 (0.45, 1.08)], and upper-extremity strength [ES = 1.13 ± 0.18 (0.78, 1.47)] (P < 0.001 for all). When administration routes were evaluated separately, the ES magnitudes were larger and the per cent changes were 3-5 times greater for intramuscular TRT than for transdermal formulations vs. respective placebos, for all outcomes evaluated. Specifically, intramuscular TRT was associated with a 5.7% increase in FFM [ES = 1.49 ± 0.18 (1.13, 1.84)] and 10-13% increases in total body strength [ES = 1.39 ± 0.12 (1.15, 1.63)], lower-extremity strength [ES = 1.39 ± 0.17 (1.07, 1.72)], and upper-extremity strength [ES = 1.37 ± 0.17 (1.03, 1.70)] (P < 0.001 for all). In comparison, transdermal TRT was associated with only a 1.7% increase in FFM [ES = 0.98 ± 0.21 (0.58, 1.39)] and only 2-5% increases in total body [ES = 0.55 ± 0.17 (0.22, 0.88)] and upper-extremity strength [ES = 0.97 ± 0.24 (0.50, 1.45)] (P < 0.001). Interestingly, transdermal TRT produced no change in lower-extremity strength vs. placebo [ES = 0.26 ± 0.23 (-0.19, 0.70), P = 0.26]. Subanalyses of RCTs limiting enrolment to men ≥60 years of age produced similar results. CONCLUSIONS Intramuscular TRT is more effective than transdermal formulations at increasing LBM and improving muscle strength in middle-aged and older men, particularly in the lower extremities.
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Affiliation(s)
- Jared W Skinner
- Geriatrics Research, Education, and Clinical Center, North Florida/South Georgia Veterans Health System, Gainesville, FL, 32608, USA
| | - Dana M Otzel
- Brain Rehabilitation Research Center (BRRC) Center of Excellence, North Florida/South Georgia Veterans Health System, Gainesville, FL, 32608, USA
| | - Andrew Bowser
- Research Service, Malcom Randall VA Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, FL, 32608, USA
| | - Daniel Nargi
- Research Service, Malcom Randall VA Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, FL, 32608, USA
| | - Sanjay Agarwal
- Research Service, Malcom Randall VA Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, FL, 32608, USA
| | - Mark D Peterson
- School of Medicine, Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Baiming Zou
- Departments of Biostatistics, University of Florida, Gainesville, FL, 32611, USA
| | - Stephen E Borst
- Geriatrics Research, Education, and Clinical Center, North Florida/South Georgia Veterans Health System, Gainesville, FL, 32608, USA.,Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, 32611, USA
| | - Joshua F Yarrow
- Research Service, Malcom Randall VA Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, FL, 32608, USA.,Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, 32611, USA
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Onasanya O, Iyer G, Lucas E, Lin D, Singh S, Alexander GC. Association between exogenous testosterone and cardiovascular events: an overview of systematic reviews. Lancet Diabetes Endocrinol 2016; 4:943-956. [PMID: 27669646 DOI: 10.1016/s2213-8587(16)30215-7] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 08/01/2016] [Accepted: 08/01/2016] [Indexed: 01/02/2023]
Abstract
Given the conflicting evidence regarding the association between exogenous testosterone and cardiovascular events, we systematically assessed published systematic reviews for evidence of the association between exogenous testosterone and cardiovascular events. We searched PubMed, MEDLINE, Embase, Cochrane Collaboration Clinical Trials, ClinicalTrials.gov, and the US Food and Drug Administration website for systematic reviews of randomised controlled trials published up to July 19, 2016. Two independent reviewers screened 954 full texts from 29 335 abstracts to identify systematic reviews of randomised controlled trials in which the cardiovascular effects of exogenous testosterone on men aged 18 years or older were examined. We extracted data for study characteristics, analytic methods, and key findings, and applied the AMSTAR (A Measurement Tool to Assess Systematic Reviews) checklist to assess methodological quality of each review. Our primary outcome measure was the direction and magnitude of association between exogenous testosterone and cardiovascular events. We identified seven reviews and meta-analyses, which had substantial clinical heterogeneity, differing statistical methods, and variable methodological quality and quality of data abstraction. AMSTAR scores ranged from 3 to 9 out of 11. Six systematic reviews that each included a meta-analysis showed no significant association between exogenous testosterone and cardiovascular events, with summary estimates ranging from 1·07 to 1·82 and imprecise confidence intervals. Two of these six meta-analyses showed increased risk in subgroup analyses of oral testosterone and men aged 65 years or older during their first treatment year. One meta-analysis showed a significant association between exogenous testosterone and cardiovascular events, in men aged 18 years or older generally, with a summary estimate of 1·54 (95% CI 1·09-2·18). Our optimal information size analysis showed that any randomised controlled trial aiming to detect a true difference in cardiovascular risk between treatment groups receiving exogenous testosterone and their controls (with a two-sided p value of 0·05 and a power of 80%) would require at least 17 664 participants in each trial group. Therefore, given the challenge of adequately powering clinical trials for rare outcomes, rigorous observational studies are needed to clarify the association between testosterone-replacement therapy and major adverse cardiovascular outcomes.
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Affiliation(s)
- Oluwadamilola Onasanya
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Geetha Iyer
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Eleanor Lucas
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dora Lin
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sonal Singh
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore, MD, USA.
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15
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Huo S, Scialli AR, McGarvey S, Hill E, Tügertimur B, Hogenmiller A, Hirsch AI, Fugh-Berman A. Treatment of Men for “Low Testosterone”: A Systematic Review. PLoS One 2016; 11:e0162480. [PMID: 27655114 PMCID: PMC5031462 DOI: 10.1371/journal.pone.0162480] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 08/23/2016] [Indexed: 01/23/2023] Open
Abstract
Testosterone products are recommended by some prescribers in response to a diagnosis or presumption of “low testosterone” (low-T) for cardiovascular health, sexual function, muscle weakness or wasting, mood and behavior, and cognition. We performed a systematic review of 156 eligible randomized controlled trials in which testosterone was compared to placebo for one or more of these conditions. We included studies in bibliographic databases between January 1, 1950 and April 9, 2016, and excluded studies involving bodybuilding, contraceptive effectiveness, or treatment of any condition in women or children. Studies with multiple relevant endpoints were included in all relevant tables. Testosterone supplementation did not show consistent benefit for cardiovascular risk, sexual function, mood and behavior, or cognition. Studies that examined clinical cardiovascular endpoints have not favored testosterone therapy over placebo. Testosterone is ineffective in treating erectile dysfunction and controlled trials did not show a consistent effect on libido. Testosterone supplementation consistently increased muscle strength but did not have beneficial effects on physical function. Most studies on mood-related endpoints found no beneficial effect of testosterone treatment on personality, psychological well-being, or mood. The prescription of testosterone supplementation for low-T for cardiovascular health, sexual function, physical function, mood, or cognitive function is without support from randomized clinical trials.
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Affiliation(s)
- Samantha Huo
- Tulane University, School of Medicine, New Orleans, LA, United States of America
| | - Anthony R. Scialli
- Department of Pharmacology and Physiology, Georgetown University Medical Center, Washington, DC, United States of America
- Scialli Consulting LLC, Washington, DC, United States of America
| | - Sean McGarvey
- Department of Pharmacology and Physiology, Georgetown University Medical Center, Washington, DC, United States of America
| | - Elizabeth Hill
- Department of Pharmacology and Physiology, Georgetown University Medical Center, Washington, DC, United States of America
| | - Buğra Tügertimur
- University of South Florida, Tampa, FL, United States of America
| | - Alycia Hogenmiller
- Department of Pharmacology and Physiology, Georgetown University Medical Center, Washington, DC, United States of America
| | | | - Adriane Fugh-Berman
- Department of Pharmacology and Physiology, Georgetown University Medical Center, Washington, DC, United States of America
- * E-mail:
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Gaffney CD, Pagano MJ, Kuker AP, Stember DS, Stahl PJ. Osteoporosis and Low Bone Mineral Density in Men with Testosterone Deficiency Syndrome. Sex Med Rev 2015; 3:298-315. [PMID: 27784602 DOI: 10.1002/smrj.63] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Testosterone deficiency syndrome (TDS) is a risk factor for low bone mineral density (BMD) and osteoporosis. Knowledge of the relationship between TDS and bone health, as well as the practical aspects of how to diagnose and treat low BMD, is therefore of practical importance to sexual medicine practitioners. AIM The aim of this study was to review the physiologic basis and clinical evidence of the relationship between TDS and bone health; and to provide a practical, evidence-based algorithm for the diagnosis and management of low BMD in men with TDS. METHODS Method used was a review of relevant publications in PubMed. MAIN OUTCOME MEASURES Pathophysiology of low BMD in TDS, morbidity, and mortality of osteoporosis in men, association between TDS and osteoporosis, indications for dual X-ray absorptiometry (DXA) scanning in TDS, evidence for testosterone replacement therapy (TRT) in men with osteoporosis, treatment for osteoporosis in the setting of TDS. RESULTS Sex hormones play a pleomorphic role in maintenance of BMD. TDS is associated with increased risk of osteoporosis and osteopenia, both of which contribute to morbidity and mortality in men. DXA scanning is indicated in men older than 50 years with TDS, and in younger men with longstanding TDS. Men with TDS and osteoporosis should be treated with anti-osteoporotic agents and TRT should be highly considered. Men with osteopenia should be stratified by fracture risk. Those at high risk should be treated with anti-osteoporotic agents with strong consideration of TRT; while those at low risk should be strongly considered for TRT, which has a beneficial effect on BMD. CONCLUSION Low BMD is a prevalent and treatable cause of morbidity and mortality in men with TDS. Utilization of a practical, evidence-based approach to diagnosis and treatment of low BMD in men with TDS enables sexual medicine practitioners to make a meaningful impact on patient quality of life and longevity. Gaffney CD, Pagano MJ, Kuker AP, Stember DS, and Stahl PJ. Osteoporosis and low bone mineral density in men with testosterone deficiency syndrome.
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Affiliation(s)
| | - Matthew J Pagano
- Department of UrologyColumbia University Medical CenterNew YorkNYUSA
| | - Adriana P Kuker
- Division of EndocrinologyDepartment of MedicineColumbia University Medical CenterNew YorkNYUSA
| | - Doron S Stember
- Department of UrologyIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Peter J Stahl
- Department of UrologyColumbia University Medical CenterNew YorkNYUSA.
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Hisasue SI. Contemporary perspective and management of testosterone deficiency: Modifiable factors and variable management. Int J Urol 2015; 22:1084-95. [DOI: 10.1111/iju.12880] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 06/16/2015] [Indexed: 01/10/2023]
Affiliation(s)
- Shin-ichi Hisasue
- Department of Urology; Graduate School of Medicine; Juntendo University; Tokyo Japan
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Borst SE, Yarrow JF. Injection of testosterone may be safer and more effective than transdermal administration for combating loss of muscle and bone in older men. Am J Physiol Endocrinol Metab 2015; 308:E1035-42. [PMID: 25898953 PMCID: PMC6189635 DOI: 10.1152/ajpendo.00111.2015] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 04/16/2015] [Indexed: 01/18/2023]
Abstract
The value of testosterone replacement therapy (TRT) for older men is currently a topic of intense debate. While US testosterone prescriptions have tripled in the past decade (9), debate continues over the risks and benefits of TRT. TRT is currently prescribed for older men with either low serum testosterone (T) or low T plus accompanying symptoms of hypogonadism. The normal range for serum testosterone is 300 to 1,000 ng/dl. Serum T ≤ 300 ng/dl is considered to be low, and T ≤ 250 is considered to be frank hypogonadism. Most experts support TRT for older men with frank hypogonadism and symptoms. Treatment for men who simply have low T remains somewhat controversial. TRT is most frequently administered by intramuscular (im) injection of long-acting T esters or transdermally via patch or gel preparations and infrequently via oral administration. TRT produces a number of established benefits in hypogonadal men, including increased muscle mass and strength, decreased fat mass, increased bone mineral density, and improved sexual function, and in some cases those benefits are dose dependent. For example, doses of TRT administered by im injection are typically higher than those administered transdermally, which results in greater musculoskeletal benefits. TRT also produces known risks including development of polycythemia (Hct > 50) in 6% of those treated, decrease in HDL, breast tenderness and enlargement, prostate enlargement, increases in serum PSA, and prostate-related events and may cause suppression of the hypothalamic-pituitary-gonadal axis. Importantly, TRT does not increase the risk of prostate cancer. Putative risks include edema and worsening of sleep apnea. Several recent reports have also indicated that TRT may produce cardiovascular (CV) risks, while others report no risk or even benefit. To address the potential CV risks of TRT, we have recently reported via meta-analysis that oral TRT increases CV risk and suggested that the CV risk profile for im TRT may be better than that for oral or transdermal TRT.
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Affiliation(s)
- Stephen E Borst
- Geriartic Research, Education and Clinical Center, Veterans Affairs Medical Center, Gainesville, Florida; Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Joshua F Yarrow
- Research Service, Veterans Affairs Medical Center, Gainesville, Florida; and Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
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Kang DY, Li HJ. The effect of testosterone replacement therapy on prostate-specific antigen (PSA) levels in men being treated for hypogonadism: a systematic review and meta-analysis. Medicine (Baltimore) 2015; 94:e410. [PMID: 25621688 PMCID: PMC4602637 DOI: 10.1097/md.0000000000000410] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Testosterone replacement therapy is used for the treatment of age-related male hypogonadism, and prostate-specific antigen (PSA) is a primary screening tool for prostate cancer. The systematic review and meta-analysis aimed to determine the effect of testosterone replacement therapy on PSA levels.Medline, Cochrane Library, EMBASE, and Google Scholar databases were searched until February 28, 2014, and inclusion criteria were as follows: randomized controlled trial; intervention group received testosterone/androgen replacement therapy; control group did not receive treatment; and no history of prostate cancer. The primary outcome was change of PSA level between before and after treatment. Secondary outcomes were elevated PSA level after treatment, and the number of patients who developed prostate cancer.After initially identifying 511 articles, 15 studies with a total of 739 patients that received testosterone replacement and 385 controls were included. The duration of treatment ranged from 3 to 12 months. Patients treated with testosterone tended to have higher PSA levels, and thus a greater change than those that received control treatments (difference in means of PSA levels = 0.154, 95% confidence interval [CI] 0.069 to 0.238, P < 0.001). The difference in means of PSA levels were significant higher for patients that received testosterone intramuscularly (IM) than controls (difference in means of PSA levels = 0.271, 95% CI 0.117-0.425, P = 0.001). Elevated PSA levels after treatment were similar between patients that received treatment and controls (odds ratio [OR] = 1.02, 95% CI 0.48-2.20, P = 0.953). Only 3 studies provided data with respect to the development of prostate cancer, and rates were similar between those that received treatment and controls.Testosterone replacement therapy does not increase PSA levels in men being treated for hypogonadism, except when it is given IM and even the increase with IM administration is minimal.
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Affiliation(s)
- De-Ying Kang
- From the Department of Evidence based Medicine and Clinical Epidemiology (D-YK), West China Hospital, Sichuan University, Chengdu; and Urological Department of Peking Union Medical College Hospital (PUMCH) (H-JL), Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Isidori AM, Balercia G, Calogero AE, Corona G, Ferlin A, Francavilla S, Santi D, Maggi M. Outcomes of androgen replacement therapy in adult male hypogonadism: recommendations from the Italian society of endocrinology. J Endocrinol Invest 2015; 38:103-12. [PMID: 25384570 PMCID: PMC4282686 DOI: 10.1007/s40618-014-0155-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 08/06/2014] [Indexed: 01/21/2023]
Abstract
OBJECTIVE We developed clinical practice guidelines to assess the individual risk-benefit profile of androgen replacement therapy in adult male hypogonadism (HG), defined by the presence of specific signs and symptoms and serum testosterone (T) below 12 nmol/L. PARTICIPANTS The task force consisted of eight clinicians experienced in treating HG, selected by the Italian Society of Endocrinology (SIE). The authors received no corporate funding or remuneration. CONSENSUS PROCESS Consensus was guided by a systematic review of controlled trials conducted on men with a mean T < 12 nmol/L and by interactive discussions. The guidelines were reviewed and sequentially approved by the SIE Guidelines Commission and Executive Committee. CONCLUSIONS We recommend T supplementation (TS) for adult men with severely reduced T levels (T < 8 nmol/L) to improve body composition and sexual function. We suggest that TS be offered to subjects with T < 12 nmol/L to improve glycaemic control, lipid profile, sexual function, bone mineral density, muscle mass and depressive symptoms, once major contraindications have been ruled out. We suggest that lifestyle changes and other available interventions (e.g. for erectile dysfunction) be suggested prior to TS. We suggest that TS should be combined with currently available treatments for individuals at high risk for complications, such as those with osteoporosis and/or metabolic disorders. We recommend against using TS to improve cardiac outcome and limited mobility. We recommend against using TS in men with prostate cancer, unstable cardiovascular conditions or elevated haematocrit. The task force places a high value on the timely treatment of younger and middle-aged subjects to prevent the long-term consequences of hypoandrogenism.
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Affiliation(s)
- A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - G Balercia
- Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | - A E Calogero
- Department of Medical and Pediatric Sciences, University of Catania, Catania, Italy
| | - G Corona
- Medical Department Endocrinology Unit, Maggiore-Bellaria Hospital, Bologna, Italy
| | - A Ferlin
- Department of Medicine, University of Padua, Padua, Italy
| | - S Francavilla
- Department of Life, Health and Environment Sciences, Andrology, and Epidemiology, University of L'Aquila, L'Aquila, Italy
| | - D Santi
- Department of Biosciences, Metabolism and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - M Maggi
- Sexual Medicine and Andrology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Firenze, Italy.
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Maggio M, De Vita F, Fisichella A, Lauretani F, Ticinesi A, Ceresini G, Cappola A, Ferrucci L, Ceda GP. The Role of the Multiple Hormonal Dysregulation in the Onset of "Anemia of Aging": Focus on Testosterone, IGF-1, and Thyroid Hormones. Int J Endocrinol 2015; 2015:292574. [PMID: 26779261 PMCID: PMC4686706 DOI: 10.1155/2015/292574] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 10/23/2015] [Accepted: 10/27/2015] [Indexed: 12/13/2022] Open
Abstract
Anemia is a multifactorial condition whose prevalence increases in both sexes after the fifth decade of life. It is a highly represented phenomenon in older adults and in one-third of cases is "unexplained." Ageing process is also characterized by a "multiple hormonal dysregulation" with disruption in gonadal, adrenal, and somatotropic axes. Experimental studies suggest that anabolic hormones such as testosterone, IGF-1, and thyroid hormones are able to increase erythroid mass, erythropoietin synthesis, and iron bioavailability, underlining a potential role of multiple hormonal changes in the anemia of aging. Epidemiological data more consistently support an association between lower testosterone and anemia in adult-older individuals. Low IGF-1 has been especially associated with anemia in the pediatric population and in a wide range of disorders. There is also evidence of an association between thyroid hormones and abnormalities in hematological parameters under overt thyroid and euthyroid conditions, with limited data on subclinical statuses. Although RCTs have shown beneficial effects, stronger for testosterone and the GH-IGF-1 axis and less evident for thyroid hormones, in improving different hematological parameters, there is no clear evidence for the usefulness of hormonal treatment in improving anemia in older subjects. Thus, more clinical and research efforts are needed to investigate the hormonal contribution to anemia in the older individuals.
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Affiliation(s)
- Marcello Maggio
- Department of Clinical and Experimental Medicine, Section of Geriatrics, University of Parma, 43126 Parma, Italy
- Geriatric Rehabilitation Department, University Hospital of Parma, 43126 Parma, Italy
- *Marcello Maggio:
| | - Francesca De Vita
- Department of Clinical and Experimental Medicine, Section of Geriatrics, University of Parma, 43126 Parma, Italy
| | - Alberto Fisichella
- Department of Clinical and Experimental Medicine, Section of Geriatrics, University of Parma, 43126 Parma, Italy
| | - Fulvio Lauretani
- Geriatric Rehabilitation Department, University Hospital of Parma, 43126 Parma, Italy
| | - Andrea Ticinesi
- Department of Clinical and Experimental Medicine, Section of Geriatrics, University of Parma, 43126 Parma, Italy
| | - Graziano Ceresini
- Department of Clinical and Experimental Medicine, Section of Geriatrics, University of Parma, 43126 Parma, Italy
- Geriatric Rehabilitation Department, University Hospital of Parma, 43126 Parma, Italy
| | - Anne Cappola
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Luigi Ferrucci
- National Institute on Aging, National Institutes of Health (NIH), Baltimore, MD 21201, USA
| | - Gian Paolo Ceda
- Department of Clinical and Experimental Medicine, Section of Geriatrics, University of Parma, 43126 Parma, Italy
- Geriatric Rehabilitation Department, University Hospital of Parma, 43126 Parma, Italy
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Borst SE, Shuster JJ, Zou B, Ye F, Jia H, Wokhlu A, Yarrow JF. Cardiovascular risks and elevation of serum DHT vary by route of testosterone administration: a systematic review and meta-analysis. BMC Med 2014; 12:211. [PMID: 25428524 PMCID: PMC4245724 DOI: 10.1186/s12916-014-0211-5] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 10/14/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Potential cardiovascular (CV) risks of testosterone replacement therapy (TRT) are currently a topic of intense interest. However, no studies have addressed CV risk as a function of the route of administration of TRT. METHODS Two meta-analyses were conducted, one of CV adverse events (AEs) in 35 randomized controlled trials (RCTs) of TRT lasting 12 weeks or more, and one of 32 studies reporting the effect of TRT on serum testosterone and dihydrotestosterone (DHT). RESULTS CV risks of TRT: Of 2,313 studies identified, 35 were eligible and included 3,703 mostly older men who experienced 218 CV-related AEs. No significant risk for CV AEs was present when all TRT administration routes were grouped (relative risk (RR) = 1.28, 95% confidence interval (CI): 0.76 to 2.13, P = 0.34). When analyzed separately, oral TRT produced significant CV risk (RR = 2.20, 95% CI: 1.45 to 3.55, P = 0.015), while neither intramuscular (RR = 0.66, 95% CI: 0.28 to 1.56, P = 0.32) nor transdermal (gel or patch) TRT (RR = 1.27, 95% CI: 0.62 to 2.62, P = 0.48) significantly altered CV risk. Serum testosterone/DHT following TRT: Of 419 studies identified, 32 were eligible which included 1,152 men receiving TRT. No significant difference in the elevation of serum testosterone was present between intramuscular or transdermal TRT. However, transdermal TRT elevated serum DHT (5.46-fold, 95% CI: 4.51 to 6.60) to a greater magnitude than intramuscular TRT (2.20-fold, 95% CI: 1.74 to 2.77). CONCLUSIONS Oral TRT produces significant CV risk. While no significant effects on CV risk were observed with either injected or transdermal TRT, the point estimates suggest that further research is needed to establish whether administration by these routes is protective or detrimental, respectively. Differences in the degree to which serum DHT is elevated may underlie the varying CV risk by TRT administration route, as elevated serum dihydrotestosterone has been shown to be associated with CV risk in observational studies.
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Affiliation(s)
- Stephen E Borst
- Geriatric Research, Education and Clinical Center, Malcom Randall VA Medical Center, 1601 SW Archer RD, Gainesville 32605-1197, FL, USA.
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Martits AM, Costa EMF, Nardi AC, Nardozza Jr. A, Facio Jr. FN, Faria G, Bernardo WM. Late-onset hypogonadism or ADAM: treatment. Rev Assoc Med Bras (1992) 2014. [DOI: 10.1590/1806-9282.60.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Corona G, Maseroli E, Rastrelli G, Isidori AM, Sforza A, Mannucci E, Maggi M. Cardiovascular risk associated with testosterone-boosting medications: a systematic review and meta-analysis. Expert Opin Drug Saf 2014; 13:1327-51. [PMID: 25139126 DOI: 10.1517/14740338.2014.950653] [Citation(s) in RCA: 211] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Recent reports have significantly halted the enthusiasm regarding androgen-boosting; suggesting that testosterone supplementation (TS) increases cardiovascular (CV) events. AREAS COVERED In order to overcome some of the limitations of the current evidence, the authors performed an updated systematic review and meta-analysis of all placebo-controlled randomized clinical trials (RCTs) on the effect of TS on CV-related problems. Out of 2747 retrieved articles, 75 were analyzed, including 3016 and 2448 patients in TS and placebo groups, respectively, and a mean duration of 34 weeks. Our analyses, performed on the largest number of studies collected so far, indicate that TS is not related to any increase in CV risk, even when composite or single adverse events were considered. In RCTs performed in subjects with metabolic derangements a protective effect of TS on CV risk was observed. EXPERT OPINION The present systematic review and meta-analysis does not support a causal role between TS and adverse CV events. Our results are in agreement with a large body of literature from the last 20 years supporting TS of hypogonadal men as a valuable strategy in improving a patient's metabolic profile, reducing body fat and increasing lean muscle mass, which would ultimately reduce the risk of heart disease.
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Affiliation(s)
- Giovanni Corona
- Azienda-Usl Bologna, Maggiore-Bellaria Hospital, Medical Department, Endocrinology Unit , Bologna , Italy
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Martits AM, Costa EMF, Nardi AC, Nardozza Jr A, Faria G, Facio Jr FN, Bernardo WM. Late-onset hypogonadism or ADAM: diagnosis. Rev Assoc Med Bras (1992) 2014; 60:286-94. [DOI: 10.1590/1806-9282.60.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Indexed: 11/22/2022] Open
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Abstract
INTRODUCTION Men who have symptoms associated with persistently low serum total testosterone level should be assessed for testosterone replacement therapy. AREAS COVERED Acute and chronic illnesses are associated with low serum testosterone and these should be recognized and treated. Once the diagnosis of male hypogonadism is made, the benefits of testosterone treatment usually outweigh the risks. Without contraindications, the patient should be offered testosterone replacement therapy. The options of testosterone delivery systems (injections, transdermal patches/gels, buccal tablets, capsules and implants) have increased in the last decade. Testosterone improves symptoms and signs of hypogonadism such as sexual function and energy, increases bone density and lean mass and decreases visceral adiposity. In men who desire fertility and who have secondary hypogonadism, testosterone can be withdrawn and the patients can be placed on gonadotropins. New modified designer androgens and selective androgen receptor modulators have been in preclinical and clinical trials for some time. None of these have been assessed for the treatment of male hypogonadism. EXPERT OPINION Despite the lack of prospective long-term data from randomized, controlled clinical trials of testosterone treatment on prostate health and cardiovascular disease risk, the available evidence suggests that testosterone therapy should be offered to symptomatic hypogonadal men.
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Affiliation(s)
- Prasanth Surampudi
- Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Division of Endocrinology, Department of Medicine , Torrance, CA, 90509 , USA
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Xu L, Freeman G, Cowling BJ, Schooling CM. Testosterone therapy and cardiovascular events among men: a systematic review and meta-analysis of placebo-controlled randomized trials. BMC Med 2013; 11:108. [PMID: 23597181 PMCID: PMC3648456 DOI: 10.1186/1741-7015-11-108] [Citation(s) in RCA: 377] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 03/15/2013] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Testosterone therapy is increasingly promoted. No randomized placebo-controlled trial has been implemented to assess the effect of testosterone therapy on cardiovascular events, although very high levels of androgens are thought to promote cardiovascular disease. METHODS A systematic review and meta-analysis was conducted of placebo-controlled randomized trials of testosterone therapy among men lasting 12+ weeks reporting cardiovascular-related events. We searched PubMed through the end of 2012 using "("testosterone" or "androgen") and trial and ("random*")" with the selection limited to studies of men in English, supplemented by a bibliographic search of the World Health Organization trial registry. Two reviewers independently searched, selected and assessed study quality with differences resolved by consensus. Two statisticians independently abstracted and analyzed data, using random or fixed effects models, as appropriate, with inverse variance weighting. RESULTS Of 1,882 studies identified 27 trials were eligible including 2,994, mainly older, men who experienced 180 cardiovascular-related events. Testosterone therapy increased the risk of a cardiovascular-related event (odds ratio (OR) 1.54, 95% confidence interval (CI) 1.09 to 2.18). The effect of testosterone therapy varied with source of funding (P-value for interaction 0.03), but not with baseline testosterone level (P-value for interaction 0.70). In trials not funded by the pharmaceutical industry the risk of a cardiovascular-related event on testosterone therapy was greater (OR 2.06, 95% CI 1.34 to 3.17) than in pharmaceutical industry funded trials (OR 0.89, 95% CI 0.50 to 1.60). CONCLUSIONS The effects of testosterone on cardiovascular-related events varied with source of funding. Nevertheless, overall and particularly in trials not funded by the pharmaceutical industry, exogenous testosterone increased the risk of cardiovascular-related events, with corresponding implications for the use of testosterone therapy.
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Affiliation(s)
- Lin Xu
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong, China
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Hoppé E, Bouvard B, Royer M, Chappard D, Audran M, Legrand E. Is androgen therapy indicated in men with osteoporosis? Joint Bone Spine 2013; 80:459-65. [PMID: 23587643 DOI: 10.1016/j.jbspin.2013.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2013] [Indexed: 01/25/2023]
Abstract
Male osteoporosis is not rare, and its management is a public health issue. The clinical evaluation must include investigations for one or more etiological factors such as hypogonadism, which is found in 5% to 15% of men with osteoporosis. Gradual development of moderate hypogonadism is the most common situation, and the prevalence of hypogonadism increases with advancing age. The wealth of scientific data establishing a major role for sex hormones in growth, bone turnover, and the osteoporotic fracture risk is in striking contrast to the paucity of therapeutic trials. Androgen therapy did not consistently produce bone mass gains, and no data on potential anti-fracture effects are available. Androgen therapy was not associated with significant increases in mortality, prostate disorders, or cardiovascular events, but few data were obtained in patients older than 75 years. In practice, in a male patient with osteoporosis, a diagnosis of marked and persistent hypogonadism requires investigations for treatable causes. In patients younger than 75 years of age, androgen replacement therapy should be started, in collaboration with an endocrinologist. A history of fractures indicates a need for additional osteoporosis pharmacotherapy. The risk/benefit ratio of androgen therapy is unclear in men older than 75 years, in whom a reasonable option consists in combining fall-prevention measures, vitamin D supplementation, and a medication proven to decrease the risk of proximal femoral fractures.
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Affiliation(s)
- Emmanuel Hoppé
- Service de rhumatologie, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex 9, France; Groupe Etude sur le Remodelage Osseux et les bioMatériaux (GEROM), UPRES EA 4658, IRIS-IBS, Institut de Biologie en Santé, CHU d'Angers, Angers, France.
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As P, Nn T, Ka O, Jc H. Benefits and Consequences of Testosterone Replacement Therapy: A Review. EUROPEAN ENDOCRINOLOGY 2013; 9:59-64. [PMID: 30349612 PMCID: PMC6193518 DOI: 10.17925/ee.2013.09.01.59] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Accepted: 01/21/2013] [Indexed: 11/24/2022]
Abstract
Late onset hypogonadism (LOH) is an issue of increasing concern. Studies have shown the importance of testosterone in the maintenance of homeostasis, especially with respect to bone health, sexual function, diabetes, cardiovascular risk, mental health and cognition. Much of the dysfunction in hypogonadism can be reversed or improved with testosterone replacement therapy (TRT). Physicians worry about the possible consequences of TRT, especially regarding the prostate. By reviewing the literature, we have found there are significant benefits to TRT, and fears of adverse effects on the prostate are largely unfounded, though there is a great need for larger studies with longer periods of follow-up, especially to evaluate adverse events.
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Affiliation(s)
| | | | | | - Hedges Jc
- Assistant Professor, Department of Urology, Oregon Health & Science University, Portland, OR, USA
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Deb P, Gupta SK, Godbole MM. Effects of short-term testosterone replacement on areal bone mineral density and bone turnover in young hypogonadal males. Indian J Endocrinol Metab 2012; 16:947-951. [PMID: 23226640 PMCID: PMC3510965 DOI: 10.4103/2230-8210.102997] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
CONTEXT Effect of parenteral testosterone esters administration on bone-mineral density (BMD) and bone turnover in young age onset male hypogonadism is not studied in Indian subjects. AIMS To prospectively study the effect of short-term (6 months) replacement therapy with parenteral testosterone enanthate-propionate combination on BMD and bone turnover markers in hypogonadal adult patients. SETTINGS AND DESIGN Prospective, tertiary care academic center. MATERIALS AND METHODS Thirteen young, otherwise healthy hypogonadal males (age 25.5 ± 4.9 yrs, serum testosterone 2.56 ± 4.29 nmol/l) were subjected to BMD measurements (DXA) and estimation of urinary Crosslaps™ and serum osteocalcin at baseline. Twelve healthy age and BMI-matched males served as controls for BMD measurements. The hypogonadal patients were administered parenteral testosterone esters (as mixed enanthate and propionate) 250 mg i.m. every 2-3 weeks, and prospectively followed for 6 months. BMD and bone markers were studied at the end of 6 months. STATISTICAL ANALYSIS USED Mann-Whitney nonparametric test, paired t-test and Pearson's test of two-tail significance. RESULTS At baseline, BMD was significantly lower in hypogonadal males as compared to that in controls. With testosterone replacement, there was significant improvement in BMD, both at trabecular and cortical sites, There was a decline in bone turnover with treatment (Ur Crosslaps™:creatinine ratio: pretreatment 72.8 ± 40.4, post-treatment 35.5 ± 23.8 μg/mmol, P = 0.098; serum osteocalcin: pre-treatment 41.0 ± 16.8, post-treatment 31.7 ± 2.1 ng/ml, P = 0.393). CONCLUSIONS Short-term parenteral testosterone replacement significantly improves BMD at the hip, lumbar spine and forearm in hypogonadal young males.
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Affiliation(s)
- Prasun Deb
- Department of Medical Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sushil Kumar Gupta
- Department of Medical Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Madan M. Godbole
- Department of Medical Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Maggio M, Snyder PJ, Ceda GP, Milaneschi Y, Luci M, Cattabiani C, Masoni S, Vignali A, Volpi R, Lauretani F, Peachey H, Valenti G, Cappola AR, Longo D, Ferrucci L. Is the haematopoietic effect of testosterone mediated by erythropoietin? The results of a clinical trial in older men. Andrology 2012; 1:24-8. [PMID: 23258626 DOI: 10.1111/j.2047-2927.2012.00009.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2011] [Revised: 06/21/2012] [Accepted: 07/04/2012] [Indexed: 10/27/2022]
Abstract
The stimulatory effects of testosterone on erythropoiesis are very well known, but the mechanisms underlying the erythropoietic action of testosterone are still poorly understood, although erythropoietin has long been considered a potential mediator. A total of 108 healthy men >65 years old with serum testosterone concentration <475 ng/dL were recruited by direct mailings to alumni of the University of Pennsylvania and Temple University, and randomized to receive a 60-cm(2) testosterone or placebo patch for 36 months. Ninety-six subjects completed the trial. We used information and stored serum specimens from this trial to test the hypothesis that increasing testosterone increases haemoglobin by stimulating erythropoietin production. We used information of 67 men, 43 in the testosterone group and 24 in the placebo group who had banked specimens available for assays of testosterone, haemoglobin and erythropoietin at baseline and after 36 months. The original randomized clinical study was primarily designed to verify the effects of testosterone on bone mineral density. The primary outcome of this report was to investigate whether or not transdermal testosterone increases haemoglobin by increasing erythropoietin levels. The mean age ± SD of the 67 subjects at baseline was 71.8 ± 4.9 years. Testosterone replacement therapy for 36 months, as compared with placebo, induced a significant increase in haemoglobin (0.86 ± 0.31 g/dL, p = 0.01), but no change in erythropoietin levels (-0.24 ± 2.16 mIU/mL, p = 0.91). Included time-varying measure of erythropoietin did not significantly account for the effect of testosterone on haemoglobin (Treatment-by-time: β = 0.93, SE = 0.33, p = 0.01). No serious adverse effect was observed. Transdermal testosterone treatment of older men for 36 months significantly increased haemoglobin, but not erythropoietin levels. The haematopoietic effect of testosterone does not appear to be mediated by stimulation of erythropoietin production.
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Affiliation(s)
- M Maggio
- Department of Internal Medicine and Biomedical Sciences, Section of Geriatrics, University of Parma, via Gramsci 14, Parma, Italy.
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Surampudi PN, Wang C, Swerdloff R. Hypogonadism in the aging male diagnosis, potential benefits, and risks of testosterone replacement therapy. Int J Endocrinol 2012; 2012:625434. [PMID: 22505891 PMCID: PMC3312212 DOI: 10.1155/2012/625434] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Revised: 12/04/2011] [Accepted: 12/07/2011] [Indexed: 01/26/2023] Open
Abstract
Hypogonadism in older men is a syndrome characterized by low serum testosterone levels and clinical symptoms often seen in hypogonadal men of younger age. These symptoms include decreased libido, erectile dysfunction, decreased vitality, decreased muscle mass, increased adiposity, depressed mood, osteopenia, and osteoporosis. Hypogonadism is a common disorder in aging men with a significant percentage of men over 60 years of age having serum testosterone levels below the lower limits of young male adults. There are a variety of testosterone formulations available for treatment of hypogonadism. Data from many small studies indicate that testosterone therapy offers several potential benefits to older hypogonadal men. A large multicenter NIH supported double blind, placebo controlled study is ongoing, and this study should greatly enhance the information available on efficacy and side effects of treatment. While safety data is available across many age groups, there are still unresolved concerns associated with testosterone therapy. We have reviewed the diagnostic methods as well as benefits and risks of testosterone replacement therapy for hypogonadism in aging men.
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Affiliation(s)
- Prasanth N. Surampudi
- Division of Endocrinology, Department of Medicine, Harbor UCLA Medical Center and Los Angeles Biomedical Institute, Torrance, CA 90509, USA
| | - Christina Wang
- Division of Endocrinology, Department of Medicine, Harbor UCLA Medical Center and Los Angeles Biomedical Institute, Torrance, CA 90509, USA
| | - Ronald Swerdloff
- Division of Endocrinology, Department of Medicine, Harbor UCLA Medical Center and Los Angeles Biomedical Institute, Torrance, CA 90509, USA
- *Ronald Swerdloff:
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Abstract
The prevalence of osteoporosis is estimated to be 18% in men, but 30% of all fractures occur in men. With age, men experience a gradual decline in testosterone production and bone density. The rate of trabecular bone loss in the lumbar spine in men over age 50 can be double the rate of loss in men under age 50. Endogenous testosterone, estradiol, and their metabolites play a role in maintaining bone health, but their specific effects on bone turnover have been difficult to elucidate. Recently, large cohort studies have provided more detailed information confirming estrogen’s associations and further characterizing the effect of endogenous testosterone and its metabolites on bone mineral density and fractures. Very few clinical trials have assessed the impact of testosterone replacement therapy (TRT) on bone density and fractures in men. The few studies that have been conducted are generally small and not robust enough to show the true treatment effect of TRT and adequately determine its safety. In the absence of data on patient outcomes, it is important for pharmacists to understand the impact of drug therapy on biomarkers and surrogate markers of disease for optimal pharmacotherapy selection and monitoring.
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Affiliation(s)
- Andrew C. Martin
- Pharmacy Practice, Union University School of Pharmacy, Jackson, TN, USA
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Abstract
CONTEXT Symptoms and signs consistent with androgen deficiency and low testosterone levels are recognized frequently in clinical practice. Recent population-based epidemiological studies indicate that low testosterone levels in men are associated with increased morbidity and mortality. The clinician must be able to counsel patients to help them determine whether testosterone replacement therapy is appropriate for them. EVIDENCE ACQUISITION The authors have conducted a literature search in PubMed, and we have reviewed references in the multiple systematic reviews and meta-analyses that have been published on this topic. EVIDENCE SYNTHESIS We have attempted to provide the reader with an appreciation of the evidence that can be used to support the diagnosis of androgen deficiency, the efficacy of treatment, the potential risks of treatment, the therapeutic options, and the recommendations for monitoring treatment. CONCLUSIONS We think that published clinical experience justifies testosterone replacement therapy in males who have not initiated puberty by age 14 and in males with low testosterone levels due to classical diseases of the hypothalamic-pituitary-gonadal axis. The benefit:risk ratio is less certain in older men and in those with chronic diseases associated with low testosterone levels. The decision to treat in this setting is much more controversial because there are few large clinical trials that have demonstrated efficacy and no large clinical trials that have determined potential risks of increasing the incidence of clinical prostate cancers or cardiovascular events. We provide a critical review of the evidence that supports treatment and potential risks and ways to reduce the risks if the physician and patient elect testosterone replacement.
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Affiliation(s)
- Glenn R Cunningham
- Baylor College of Medicine and St. Luke's Episcopal Hospital, Houston, Texas 77030, USA.
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Giltay EJ, Tishova YA, Mskhalaya GJ, Gooren LJ, Saad F, Kalinchenko SY. Effects of Testosterone Supplementation on Depressive Symptoms and Sexual Dysfunction in Hypogonadal Men with the Metabolic Syndrome. J Sex Med 2010; 7:2572-82. [DOI: 10.1111/j.1743-6109.2010.01859.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Langham S, Maggi M, Schulman C, Quinton R, Uhl‐Hochgraeber K. Health‐Related Quality of Life Instruments in Studies of Adult Men with Testosterone Deficiency Syndrome: A Critical Assessment. J Sex Med 2008; 5:2842-52. [DOI: 10.1111/j.1743-6109.2008.01015.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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