Serum testosterone levels in non-dosed females after secondary exposure to 1.62% testosterone gel: effects of clothing barrier on testosterone absorption

Long vs Short Acting Testosterone Treatments: A Look at the Risks

Prescriptions for testosterone therapy (TT) to treat testosterone deficiency have increased in recent years. The purpose of this review was to evaluate the risks of several treatment modalities to better counsel patients. Both short-acting and long-acting TT has been shown to restore normal serum testosterone levels and improve symptoms of testosterone deficiency. Short-acting pharmacology mimics normal physiology more closely than long-acting TT but requires multiple doses per day. Long-acting TT has a higher rate of patient adherence but is more likely to create supraphysiologic serum testosterone and pathologic sequelae.

Oral administration of VDAC1-derived small molecule peptides increases circulating testosterone levels in male rats

Cholesterol is the precursor of all steroid hormones, and the entry of cholesterol into the mitochondria is the rate-limiting step of steroidogenesis. Voltage-dependent anion channel (VDAC1) is an outer mitochondrial protein part of a multiprotein complex that imports cholesterol. We previously reported that intratesticular administration of a 25 amino acid peptide blocking the interaction between 14-3-3ϵ with VDAC1 increased circulating levels of testosterone. This fusion peptide was composed of a HIV-1 transactivator of transcription (TAT) protein transduction domain cell-penetrating peptide, a glycine linker, and amino acids 159-172 of VDAC1 (TV159-172). Here, we describe the development of a family of small molecules that increase circulating testosterone levels after an oral administration. We first characterized an animal model where TV159-172 was delivered subcutaneously. This subcutaneous model allowed us to study the interactions between TV159-172 and the hypothalamus-pituitary-gonadal axis (HPG) and identify the biologically active core of TV159-172. The core consisted of the tetrapeptide RVTQ, which we used as a platform to design synthetic peptide derivatives that can be administered orally. We developed a second animal model to test various derivatives of RVTQ and found 11 active compounds. Dose-response experiments identified 4 synthetic peptides that robustly increased androgen levels in a specific manner. We selected RdVTQ as the leading VDAC1-core derivative and profiled the response across the lifespan of Brown-Norway rats. In summary, we present the development of a new class of therapeutics that act within the HPG axis to increase testosterone levels specifically. This new class of small molecules self-regulates, preventing abuse.

Testosterone Replacement Therapy in Hypogonadal Men

All approved testosterone replacement methods, when used according to recommendations, can restore normal serum testosterone concentrations, and relieve symptoms in most hypogonadal men. Selection of the method depends on the patient's preference with advice from the physician. Dose adjustment is possible with most delivery methods but may not be necessary in all hypogonadal men. The use of hepatotoxic androgens must be avoided. Testosterone treatment induces reversible suppression of spermatogenesis; if fertility is desired in the near future, human chronic gonadotropin, selective estrogen receptor modulator, estrogen antagonist, or an aromatase inhibitor that stimulates endogenous testosterone production may be used.

Preventing secondary exposure to women from men applying a novel nestorone/testosterone contraceptive gel

BACKGROUND

Testosterone (T)/Nestorone (NES) combination gel is a potential transdermal male contraceptive that suppresses gonadotropins and spermatogenesis. Transfer of transdermal T from men to women can be prevented by washing or covering application sites with clothing.

OBJECTIVES

We hypothesized that showering or wearing a shirt over gel application sites would prevent secondary exposure of T and NES to a woman after close skin contact.

MATERIALS AND METHODS

Twelve healthy male and 12 healthy female participants were recruited. Men applied T/NES 62 mg/8 mg gel to their shoulders and upper arms. Two hours after application, female partners rubbed the application site for 15 min. Exposure in the female partner was assessed under three conditions: a shirt covered the application site; the man showered prior to skin contact; or without intervention to reduce transfer. Serum T and NES concentrations were measured by LC-MS/MS in serial blood samples for 24 h after gel exposure.

MAIN OUTCOMES

Change in female serum T and NES levels as measured by average concentration over 24 h (C_avg ).

RESULTS

Median female serum T C_avg was 23.9 ng/dL (interquartile range, 19.3, 33.9) with the shirt barrier and 26.7 ng/dL (20.7, 33.9) after showering, which was higher than baseline 20.9 ng/dL (16.7, 25.0), both p < 0.03) but lower than without intervention (58.2 ng/dL [30.9, 89.1], both p < 0.01). Female serum NES C_avg and maximum concentration were below the lower limit of quantification with the shirt barrier and after showering, but increased without intervention in six of 12 women (maximum concentration <60 pg/mL). Men had lower average serum NES levels after showering (47 pg/ml [20, 94] compared to no intervention (153.3 pg/mL [51, 241], p < 0.02).

CONCLUSION

Secondary transfer of T and NES occurs after intensive skin contact with the gel application site. Secondary transfer is decreased by a shirt barrier or showering before contact.

Testosterone Is a Contraceptive and Should Not Be Used in Men Who Desire Fertility

Testosterone has a variety of functions and is commonly used in older men to treat symptoms of hypogonadism, such as decreased libido, decreased mood and erectile dysfunction. Despite its positive effects on sexual function, it has a negative effect on fertility. Exogenous testosterone therapy can negatively affect the hypothalamic-pituitary gonadal axis and inhibit the production of follicle stimulating hormone and luteinizing hormone. The purpose of this review is to discuss the contraceptive properties of testosterone therapy and to discuss strategies to increase testosterone in men with the desire to preserve fertility.

Testosterone replacement therapy for physician assistants and nurse practitioners

Physician assistants (PA) and nurse practitioners have been moving toward specialty practices, like urology. With increased training and education, they manage more complex conditions independently. Whether they are the primary provider or the follow up to a specialist, physician extenders can play a vital role in managing patients undergoing testosterone therapy. Physician extenders should be able to understand the indications, risks and associated adverse effects of administering testosterone in order to proficiently take care of patients with low testosterone. The goal of this review is to recognize the role and the limits to which physician extenders should manage hypogonadism, and when physician collaboration or referral is necessary.

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

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

Ten Most Important Things to Know About Caring for Transgender Patients

Transgender people have a gender that is not in agreement with their birth sex. Previous barriers, including lack of provider knowledge, have created significant healthcare disparities for this population. Recent societal changes are increasing the numbers of transgender people seen by primary care practitioners. Ten key principles are provided to help primary care practitioners create more welcoming environments and provide quality care to transgender patients. Overall, all members of the healthcare team (primary and specialty) need to become aware of the transition process and maintain communication regarding risks, benefits, and goals. Transwomen (aka male to female) can be treated with estrogens, antiandrogens, or a combination. Benefits include change in fat distribution, skin softening, and breast development. Significant risks for thrombosis from estrogens have been linked to genetic mutations, smoking, prolonged inactivity, and hormone formulation. Oral administration may provide increased risk over peripheral administration. Transmen (aka female to male) can be treated with peripheral testosterone preparations. Benefits include deepening of voice and development of facial and body hair with variable changes in muscle mass. Risks from testosterone appear to be less common than from estrogen. Laboratory monitoring can guide treatment decisions and provide early detection of some complications. Monitoring of "existing" anatomy (either hormonally or surgically created or removed) is an important component of healthcare for transgender patients. Primary care providers also should be aware of resources in their community and online, which can help patients optimize their transition.

Amount of Testosterone on Laundered Clothing After Use of Testosterone Topical 2% Solution by Healthy Male Volunteers

INTRODUCTION

Testosterone 2% solution (Axiron) applied to armpit(s) is used for replacement therapy in men with a deficiency of endogenous testosterone.

AIM

To determine the amount of testosterone on subjects' T-shirts 12 hours after applying testosterone solution, the residual testosterone on subjects' T-shirts after laundering, and the testosterone transferred to unworn textile items during laundering with worn T-shirts.

METHODS

Healthy males ≥18 years old applied 2 × 1.5 mL of testosterone 2% solution to both axillae (total testosterone dose: 120 mg) and dressed in cotton long-sleeved T-shirts after a ≥3-minute waiting period. T-shirts were worn 12 hours before being removed and cut into halves, after which a 10 × 10 cm sample of each armpit area was excised for testosterone quantification before or after laundering with samples of unworn textiles.

MAIN OUTCOME MEASURES

Testosterone on worn T-shirts before and after laundering, and on unworn textiles laundered with the worn T-shirts.

RESULTS

Twelve subjects enrolled and completed, with only minor adverse events. Mean testosterone in unwashed worn T-shirts was 7603 μg, with high between-subject variability (3359 μg to 13,069 μg), representing 13% of the dose to 1 armpit. Mean testosterone in worn, laundered T-shirts was 260 μg (7.55 μg to 1343 μg), representing 3% of the dose to 1 armpit. Mean transferred testosterone to other textiles during laundering ranged from 69 μg on texturized Dacron 56T Double to 10,402 μg on 87/13 nylon/Lycra knit, representing 0.0382% to 5.78% of the dose to 1 armpit.

CONCLUSION

Thirteen percent of the testosterone applied to axillae was transferred to T-shirts during wear. Ninety-seven percent of the transferred testosterone was removed from the T-shirts during washing, some of which was then absorbed to various degrees by other textiles. Clinical implications of these findings and biological activity of the remaining/transferred testosterone are unknown.

Alternatives to testosterone replacement: testosterone restoration

The European Male Aging Study has demonstrated that the hypogonadism of male aging is predominantly secondary. Theoretically with appropriate stimulation from the pituitary, the aging testis should be able to produce eugonadal levels of testosterone. The strategies for the treatment of late onset hypogonadism (LOH) have focused on replacement with exogenous testosterone versus restoration of endogenous production. The purpose of this article is to review existing peer-reviewed literature supporting the concept of restoration of endogenous testosterone in the treatment of LOH.

The practical management of testosterone deficiency in men

Despite increased global interest in testosterone deficiency in men and its treatment with testosterone therapy, practical aspects of care remain confusing to many practitioners. Testosterone deficiency can result from testicular dysfunction (primary hypogonadism) or hypothalamic-pituitary dysfunction (secondary hypogonadism), and be congenital or acquired. Sexual and nonsexual symptoms of testosterone deficiency can negatively affect quality of life and cause considerable general health concerns. Investigation of testosterone deficiency should be undertaken in men with symptoms of reduced libido, erectile dysfunction, depression, fatigue, poor concentration, and poor memory. Total and free testosterone are the most frequently used tests and evaluating serum concentrations of luteinizing hormone aids determination of primary versus secondary testosterone deficiency. Multiple formulations of testosterone therapy are available, but symptomatic benefits might not manifest for several weeks to many months; long-acting formulations are convenient and improve compliance. Concerns regarding cardiovascular and prostate cancer risks are not supported by current evidence, monitoring during therapy is mandatory. On balance, testosterone therapy can be considered a safe and effective treatment for testosterone deficiency.

Effect of application site, clothing barrier, and application site washing on testosterone transfer with a 1.62% testosterone gel

OBJECTIVES

To evaluate the effect of application site location, clothing barrier, and application site washing on testosterone transfer from males dosed with 1.62% testosterone gel to female partners.

RESEARCH DESIGN AND METHODS

Open-label, randomized, parallel group, crossover study performed in 24 healthy male/female couples. 2.5 or 5.0 g of gel was applied to upper arms and shoulders or abdomens of male subjects. Skin contact occurred 2 hours after gel application between male and female subjects to compare the effect of wearing or not wearing a t-shirt, washing or not washing before contact, and the effect of differing application sites. Treatments were separated by a 1-week washout period. On each dosing day, 15 minutes of supervised skin contact occurred between the dosed male and female partner. Contact was either abdomen to abdomen (male to female), or upper arms/shoulders (male) to upper arms/shoulders, wrists and hands (female), depending on the male application site. Serum samples were collected from females at baseline and after contact to assess secondary testosterone exposure.

MAIN OUTCOME MEASURES

C(max) (maximum serum concentration), AUC(0-24) (area under serum concentration-time curve from 0-24 hours), and C(av) (time-averaged concentration over 24-hour post-contact period) were assessed. Subjects were monitored for adverse events.

RESULTS

Testosterone exposure (C(av) and C(max)) in females increased by up to 27% (2.5 g) or up to 280% (5.0 g) from baseline after direct skin contact at 2 hours after gel application, although C(av) remained within the female eugonadal range. Transfer from the abdomen was prevented when a t-shirt was worn (2.5-g dose). When the application site was washed before contact, mean C(av) was comparable to baseline, and C(max) was slightly higher (14%). Transfer was higher after direct skin-to-skin contact when the application and contact sites were upper arms/shoulders versus the abdomen. Testosterone concentrations returned to baseline within 48 hours after last skin contact.

CONCLUSIONS

There is a risk of testosterone transfer from males using 1.62% testosterone gel to others who come into direct skin contact with the application site. This can be prevented by covering the application site with a t-shirt (2.5-g dose), or washing the application site before contact.

STUDY LIMITATIONS

Women for these studies were not selected by menopausal status. The study was conducted under circumstances that were intended to simulate exaggerated conditions of contact and may not represent average contact under normal conditions. CLINICAL TRIAL REGISTRATION NCT NUMBERS: Study was not registered (first subject enrolled 28 November 2007).