Systematic Review of the Impact of Testosterone Replacement Therapy on Depression in Patients with Late-onset Testosterone Deficiency

CONTEXT

Clinical guidelines recommend testosterone replacement therapy (TRT) for adult men with late-onset testosterone deficiency (TD), with the goal of improving symptoms and elevating testosterone levels into the normal reference range.

OBJECTIVE

To investigate and critically analyze the current evidence regarding the impact of TRT on depression and depressive symptoms in adult men with late-onset TD compared with placebo.

EVIDENCE ACQUISITION

A systematic search of EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials databases, and clinicaltrials.gov was performed on April 1, 2018 using any combination of the terms Testosterone (EXP) OR Testosterone replacement therapy (EXP) AND Depression (EXP) OR Depressive symptoms (EXP). Studies were considered eligible if they included adult men with late-onset TD (total testosterone <350ng/ml and age >30yr.) treated with TRT, used placebo groups comparison arm, were randomized clinical trials (RCTs), included at least 10 individuals per treatment arm, and assessed the impact of TRT on depression compared with that of placebo.

EVIDENCE SYNTHESIS

Fifteen studies encompassing 1586 individuals were included. Six RCTs investigated the impact of TRT on patients with late-onset TD compared with placebo in patients with clinically significant levels of depression, and nine RCTs investigated the impact of TRT on patients with late-onset TD compared with placebo in patients with no clinically significant depression.

CONCLUSIONS

TRT reduces depressive symptoms, according to data coming from small-sized, placebo-controlled RCTs of patients with pretreatment clinical mild depression. This impact was not noticed in men with major depressive disorders. In patients without pretreatment depression, TRT leads to a reduction of scores for depressive symptoms; however, clinical value of this is difficult to measure.

PATIENT SUMMARY

We investigated the effect of testosterone replacement therapy (TRT) on depressive symptoms in patients with late-onset testosterone deficiency. TRT improves depressive symptoms in most trials, except in patients with major depressive disorder.

Benefits and Health Implications of Testosterone Therapy in Men With Testosterone Deficiency

INTRODUCTION

Testosterone (T) deficiency (TD; hypogonadism) has deleterious effects on men's health; negatively affects glycometabolic and cardiometabolic functions, body composition, and bone mineral density; contributes to anemia and sexual dysfunction; and lowers quality of life. T therapy (TTh) has been used for the past 8 decades to treat TD, with positive effects on signs and symptoms of TD.

AIM

To summarize the health benefits of TTh in men with TD.

METHODS

A comprehensive literature search was carried out using PubMed, articles relevant to TTh were accessed and evaluated, and a comprehensive summary was synthesized.

MAIN OUTCOME MEASURES

Improvements in signs and symptoms of TD reported in observational studies, registries, clinical trials, and meta-analyses were reviewed and summarized.

RESULTS

A large body of evidence provides significant valuable information pertaining to the therapeutic value of TTh in men with TD. TTh in men with TD provides real health benefits for bone mineral density, anemia, sexual function, glycometabolic and cardiometabolic function, and improvements in body composition, anthropometric parameters, and quality of life.

CONCLUSION

TTh in the physiologic range for men with TD is a safe and effective therapeutic modality and imparts great benefits on men's health and quality of life. Traish AM. Benefits and Health Implications of Testosterone Therapy in Men With Testosterone Deficiency. Sex Med Rev 2018;6:86-105.

Argirein alleviates stress-induced and diabetic hypogonadism in rats via normalizing testis endothelin receptor A and connexin 43

AIM

Argirein (rhein-arginine) is a derivative of rhein isolated from Chinese rhubarb (Rheum Officinale Baill.) that exhibits antioxidant and anti-inflammatory activities. In the present study we investigated the effects of argirein on stress-induced (hypergonadotrophic) and diabetic (hypogonadotrophic) hypogonadism in male rats.

METHODS

Stress-induced and diabetic hypogonadism was induced in male rats via injection of isoproterenol (ISO) or streptozotocin (STZ). ISO-injected rats were treated with argirein (30 mg·kg(-1)·d(-1), po) or testosterone replacement (0.5 mg·kg(-1)·d(-1), sc) for 5 days, and STZ-injected rats were treated with argirein (40-120 mg·kg(-1)·d(-1), po) or aminoguanidine (100 mg·kg(-1)·d(-1), po) for 4 weeks. After the rats were euthanized, blood samples and testes were collected. Serum hormone levels were measured, and the expression of endothelin receptor A (ETA), connexin 43 (Cx43) and other proteins in testes was detected. For in vitro experiments, testis homogenate was prepared from normal male rats, and incubated with ISO (1 μmol/L) or high glucose (27 mmol/L).

RESULTS

ISO injection induced hyper-gonadotrophic hypogonadism characterized by low testosterone and high FSH and LH levels in the serum, whereas STZ injection induced hypogonadotrophic hypogonadism as evidenced by low testosterone and low FSH and LH levels in the serum. In the testes of ISO- and STZ-injected rats, the expression of ETA, MMP-9, NADPH oxidase and pPKCε was significantly increased, and the expression of Cx43 was decreased. Administration of argirein attenuated both the abnormal serum hormone levels and the testis changes in ISO- and STZ-injected rats, and aminoguanidine produced similar actions in STZ-injected rats; testosterone replacement reversed the abnormal serum hormone levels, but did not affect the testis changes in ISO-injected rats. Argirein (0.3-3 μmol/L) exerted similar effects in testis homogenate incubated with ISO or high glucose in vitro.

CONCLUSION

Two types of hypogonadism of male rats exhibit increased expression of ETA and depressed expression of Cx43 in testes, despite different patterns of serum FSH and LH. Argirein alleviates the two types of male hypogonadism via normalizing ETA and Cx43 in testes.

Outcomes of testosterone therapy in men with testosterone deficiency (TD): part II

Testosterone (T) deficiency (TD) is a common clinical condition, which contributes to co-morbidities including loss of muscle mass, increased fat mass, increased inflammation, insulin resistance, risk of vascular disease, sexual dysfunction, fatigue, depressed mood and reduced quality of life. T therapy attenuates inflammation, increases insulin sensitivity, muscle mass and reduces fat mass and adiposity. T therapy improves lipid profiles and endothelial function and reduces systolic and diastolic blood pressure. In addition, T therapy may reduce risk of vascular disease and mortality. T therapy improves bone mineral density and increases energy and vitality and improves mood and sexual function and overall quality of life. T therapy appears to be safe if treatment and monitoring are appropriately executed. The evidence available to date does not support alleged concerns regarding risk of cardiovascular disease and prostate cancer. Indeed, T therapy remains controversial. The data in the contemporary literature suggest that T therapy reduces cardiovascular risk and fears promoted by some recent studies should be re-evaluated. The cardiovascular risk and mortality with T therapy must await large prospective controlled clinical trials, which depend on many complex factors. Such studies may be prohibitive in the current environment due to logistical challenges, such as recruiting large number of men to be treated for long-durations with appropriate follow-up, requiring astronomical cost.

Adverse health effects of testosterone deficiency (TD) in men

Testosterone and its metabolite, 5α-dihydrotestosterone are critical metabolic and vascular hormones, which regulate a host of biochemical pathways including carbohydrate, lipid and protein metabolism and modulate vascular function. Testosterone deficiency (TD) is a well-recognized medical condition with important health implications. TD is associated with a number of co-morbidities including increased body weight, adiposity and increased waist circumference, insulin resistance (IR) and type 2 diabetes mellitus (T2DM), hypertension, inflammation, atherosclerosis and cardiovascular disease, erectile dysfunction (ED) and increased incidence of mortality. In this review, we summarize the data in the literature on the prevalence of TD and its association with the various co-morbidities and suggest that T therapy is necessary to improve health outcomes in men with TD.