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Cruickshank M, Hudson J, Hernández R, Aceves-Martins M, Quinton R, Gillies K, Aucott LS, Kennedy C, Manson P, Oliver N, Wu F, Bhattacharya S, Dhillo WS, Jayasena CN, Brazzelli M. The effects and safety of testosterone replacement therapy for men with hypogonadism: the TestES evidence synthesis and economic evaluation. Health Technol Assess 2024; 28:1-210. [PMID: 39248210 PMCID: PMC11404359 DOI: 10.3310/jryt3981] [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] [Indexed: 09/10/2024] Open
Abstract
Background Low levels of testosterone cause male hypogonadism, which is associated with sexual dysfunction, tiredness and reduced muscle strength and quality of life. Testosterone replacement therapy is commonly used for ameliorating symptoms of male hypogonadism, but there is uncertainty about the magnitude of its effects and its cardiovascular and cerebrovascular safety. Aims of the research The primary aim was to evaluate the safety of testosterone replacement therapy. We also assessed the clinical and cost-effectiveness of testosterone replacement therapy for men with male hypogonadism, and the existing qualitative evidence on men's experience and acceptability of testosterone replacement therapy. Design Evidence synthesis and individual participant data meta-analysis of effectiveness and safety, qualitative evidence synthesis and model-based cost-utility analysis. Data sources Major electronic databases were searched from 1992 to February 2021 and were restricted to English-language publications. Methods We conducted a systematic review with meta-analysis of individual participant data according to current methodological standards. Evidence was considered from placebo-controlled randomised controlled trials assessing the effects of any formulation of testosterone replacement therapy in men with male hypogonadism. Primary outcomes were mortality and cardiovascular and cerebrovascular events. Data were extracted by one reviewer and cross-checked by a second reviewer. The risk of bias was assessed using the Cochrane Risk of Bias tool. We performed one-stage meta-analyses using the acquired individual participant data and two-stage meta-analyses to integrate the individual participant data with data extracted from eligible studies that did not provide individual participant data. A decision-analytic Markov model was developed to evaluate the cost per quality-adjusted life-years of the use of testosterone replacement therapy in cohorts of patients of different starting ages. Results We identified 35 trials (5601 randomised participants). Of these, 17 trials (3431 participants) provided individual participant data. There were too few deaths to assess mortality. There was no difference between the testosterone replacement therapy group (120/1601, 7.5%) and placebo group (110/1519, 7.2%) in the incidence of cardiovascular and/or cerebrovascular events (13 studies, odds ratio 1.07, 95% confidence interval 0.81 to 1.42; p = 0.62). Testosterone replacement therapy improved quality of life and sexual function in almost all patient subgroups. In the testosterone replacement therapy group, serum testosterone was higher while serum cholesterol, triglycerides, haemoglobin and haematocrit were all lower. We identified several themes from five qualitative studies showing how symptoms of low testosterone affect men's lives and their experience of treatment. The cost-effectiveness of testosterone replacement therapy was dependent on whether uncertain effects on all-cause mortality were included in the model, and on the approach used to estimate the health state utility increment associated with testosterone replacement therapy, which might have been driven by improvements in symptoms such as sexual dysfunction and low mood. Limitations A meaningful evaluation of mortality was hampered by the limited number of defined events. Definition and reporting of cardiovascular and cerebrovascular events and methods for testosterone measurement varied across trials. Conclusions Our findings do not support a relationship between testosterone replacement therapy and cardiovascular/cerebrovascular events in the short-to-medium term. Testosterone replacement therapy improves sexual function and quality of life without adverse effects on blood pressure, serum lipids or glycaemic markers. Future work Rigorous long-term evidence assessing the safety of testosterone replacement therapy and subgroups most benefiting from treatment is needed. Study registration The study is registered as PROSPERO CRD42018111005. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/68/01) and is published in full in Health Technology Assessment; Vol. 28, No. 43. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Richard Quinton
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Lorna S Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Charlotte Kennedy
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Paul Manson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Frederick Wu
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Siladitya Bhattacharya
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | | | | | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Barnett N, Ljubic M, Chung J, Capizzi A. Testosterone and neurobehavioral outcomes in special operations forces military with multiple mild traumatic brain injury. NeuroRehabilitation 2024:NRE230291. [PMID: 38995807 DOI: 10.3233/nre-230291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2024]
Abstract
BACKGROUND U.S. Special Operations Forces (SOF) are at increased risk of multiple mild traumatic brain injury (mmTBI). Testosterone was prescribed for several participants in a VA program designed to address sequelae of mmTBI for SOF. OBJECTIVE To determine testosterone prevalence in the Palo Alto VA Intensive Evaluation and Treatment Program (IETP) and observe for association between testosterone and neurobehavioral outcomes. METHODS A retrospective cohort study included patients in the Palo Alto VA IETP. Sociodemographic data, testosterone blood levels, and neurobehavioral outcomes were collected from medical records. RESULTS 55 IETP participants were included: six were testosterone users; the rest were classified as non-users. Testosterone use in this population is 11%, higher than reported national averages in the U.S. Of the 6 testosterone users, 2 (33%) had a formal diagnosis of hypogonadism prior to initiation of testosterone. Neurobehavioral outcome scores between testosterone users and non-users failed to show statistically significant differences, except for the PROMIS pain score, which was higher in the testosterone user population. CONCLUSION The current study did not find an association between mmTBI, testosterone use, or testosterone level and neurobehavioral outcomes. This study highlights a need to further examine the relationship between hypogonadism, mmTBI, SOF culture around testosterone, and the effects of testosterone use in this population.
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Affiliation(s)
- Nathan Barnett
- Polytrauma System of Care, VA Palo Alto Healthcare System, Palo Alto, CA, USA
- Department of Physical Medicine and Rehabilitation, Stanford School of Medicine, Redwood City, CA, USA
| | - Milica Ljubic
- Polytrauma System of Care, VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Joyce Chung
- Polytrauma System of Care, VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Allison Capizzi
- Polytrauma System of Care, VA Palo Alto Healthcare System, Palo Alto, CA, USA
- Department of Physical Medicine and Rehabilitation, Stanford School of Medicine, Redwood City, CA, USA
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Chung E, Hui J, Xin ZC, Kim SW, Moon DG, Yuan Y, Nagao K, Hakim L, Chang HC, Mak SK, Duarsa GWK, Dai Y, Yao B, Son H, Huang W, Lin H, Nguyen Q, Mai DBT, Park K, Lee J, Tantiwongse K, Sato Y, Jiann BP, Ho C, Park HJ. Management of Male Infertility with Coexisting Sexual Dysfunction: A Consensus Statement and Clinical Recommendations from the Asia-Pacific Society of Sexual Medicine (APSSM) and the Asian Society of Men's Health and Aging (ASMHA). World J Mens Health 2024; 42:471-486. [PMID: 37853539 PMCID: PMC11216964 DOI: 10.5534/wjmh.230180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 07/01/2023] [Accepted: 07/09/2023] [Indexed: 10/20/2023] Open
Abstract
Male infertility (MI) and male sexual dysfunction (MSD) can often coexist together due to various interplay factors such as psychosexual, sociocultural and relationship dynamics. The presence of each form of MSD can adversely impact male reproduction and treatment strategies will need to be individualized based on patients' factors, local expertise, and geographical socioeconomic status. The Asia Pacific Society of Sexual Medicine (APSSM) and the Asian Society of Men's Health and Aging (ASMHA) aim to provide a consensus statement and practical set of clinical recommendations based on current evidence to guide clinicians in the management of MI and MSD within the Asia-Pacific (AP) region. A comprehensive, narrative review of the literature was performed to identify the various forms of MSD and their association with MI. MEDLINE and EMBASE databases were searched for the following English language articles under the following terms: "low libido", "erectile dysfunction", "ejaculatory dysfunction", "premature ejaculation", "retrograde ejaculation", "delayed ejaculation", "anejaculation", and "orgasmic dysfunction" between January 2001 to June 2022 with emphasis on published guidelines endorsed by various organizations. This APSSM consensus committee panel evaluated and provided evidence-based recommendations on MI and clinically relevant MSD areas using a modified Delphi method by the panel and specific emphasis on locoregional socio-economic-cultural issues relevant to the AP region. While variations exist in treatment strategies for managing MI and MSD due to geographical expertise, locoregional resources, and sociocultural factors, the panel agreed that comprehensive fertility evaluation with a multidisciplinary management approach to each MSD domain is recommended. It is important to address individual MI issues with an emphasis on improving spermatogenesis and facilitating reproductive avenues while at the same time, managing various MSD conditions with evidence-based treatments. All therapeutic options should be discussed and implemented based on the patient's individual needs, beliefs and preferences while incorporating locoregional expertise and available resources.
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Affiliation(s)
- Eric Chung
- Department of Urology, Princess Alexandra Hospital, University of Queensland, Brisbane, QLD, Australia
- AndroUrology Centre, Brisbane, QLD, Australia.
| | - Jiang Hui
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Zhong Cheng Xin
- Male Reproductive and Sexual Medicine, Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Sae Woong Kim
- Department of Urology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Du Geon Moon
- Department of Urology, Korea University Guro Hospital, Seoul, Korea
| | - Yiming Yuan
- Andrology Centre, Peking University First Hospital, Peking University, Beijing, China
| | - Koichi Nagao
- Department of Urology, Toho University, Tokyo, Japan
| | - Lukman Hakim
- Department of Urology, Universitas Airlangga Teaching Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Hong-Chiang Chang
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
| | - Siu King Mak
- Department of Surgery, Union Hospital, Hong Kong, China
| | | | - Yutian Dai
- The Department of Andrology, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Bing Yao
- Department of Urology, Affiliated Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Hwancheol Son
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - William Huang
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Haocheng Lin
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Quang Nguyen
- Centre of Andrology and Sexual Medicine, Viet Duc University Hospital, Hanoi, Vietnam
| | - Dung Ba Tien Mai
- Department of Urology, Binh Dan Hospital, Ho Chi Minh City, Vietnam
| | - Kwangsung Park
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Joe Lee
- Department of Urology, National University Hospital, Singapore
| | | | - Yoshikazu Sato
- Department of Urology, Sanjukai Hospital, Sapporo, Japan
| | - Bang-Ping Jiann
- Department of Urology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Christopher Ho
- School of Medicine, Taylor's University, Subang, Selangor, Malaysia
| | - Hyun Jun Park
- Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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Arcand MA, Poulin D, Testa EJ, Lemme NJ. Testosterone: A Review for Orthopaedic Surgeons. JBJS Rev 2024; 12:01874474-202406000-00005. [PMID: 38889232 DOI: 10.2106/jbjs.rvw.24.00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
» Testosterone replacement treatment (TRT) and anabolic androgenic steroid (AAS) use is common and possibly increasing.» Diagnosing and treating hypogonadism in men is controversial.» Hypogonadism and the use of AASs seem to have a detrimental effect on the musculoskeletal system. The current literature on TRT and the musculoskeletal system shows an increased risk of tendon injury.» There may be a role for testosterone supplementation in the postoperative period.
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Affiliation(s)
- Michel A Arcand
- Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
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Kanakis GA, Pofi R, Goulis DG, Isidori AM, Armeni E, Erel CT, Fistonić I, Hillard T, Hirschberg AL, Meczekalski B, Mendoza N, Mueck AO, Simoncini T, Stute P, van Dijken D, Rees M, Lambrinoudaki I. EMAS position statement: Testosterone replacement therapy in older men. Maturitas 2023; 178:107854. [PMID: 37845136 DOI: 10.1016/j.maturitas.2023.107854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Late-onset hypogonadism is the clinical entity characterised by low testosterone concentrations associated with clinical symptoms in the absence of organic disease in ageing men. It has been associated with metabolic syndrome, reduced bone mineral density, and increased cardiovascular morbidity and mortality risk. Although testosterone replacement therapy (TRT) reverses most of these conditions in young hypogonadal men, the risk/benefit ratio of TRT in older men is debatable. AIM To update the 2015 EMAS statement on TRT in older men with new research on late-onset hypogonadism and TRT. MATERIALS AND METHODS Literature review and consensus of expert opinion. SUMMARY RECOMMENDATIONS TRT should be offered only to symptomatic older men with confirmed low testosterone concentrations after explaining the uncertainties regarding the long-term safety of this treatment. TRT may be offered to men with severe hypogonadism and erectile dysfunction to improve sexual desire, erectile, and orgasmic function. It should also be considered in hypogonadal men with severe insulin resistance or pre-diabetes mellitus. TRT may also be considered, in combination with proven treatment strategies, for osteoporosis, or for selected patients with persistent mild depressive symptoms and/or low self-perceived quality of life, combined with standard medical care for each condition. TRT is contraindicated in hypogonadal men actively seeking fertility treatment. Due to a lack of data, TRT should not be routinely used in older men to improve exercise capacity/physical function, improve cognitive function, or prevent cognitive decline. TRT must be avoided in older, frail men with known breast cancer or untreated prostate cancer and all men who have had myocardial infarction or stroke within the last four months, and those with severe or decompensated heart failure. The quality of evidence regarding patients with previous prostate cancer or cardiovascular disease is too low to draw definitive conclusions. Any limits on duration of use are arbitrary, and treatment should continue for as long as the man feels the benefits outweigh the risks for him, and decisions must be made on an individual basis. Withdrawal should be considered when hypogonadism is reversed after the resolution of underlying disorder. Short-acting transdermal preparations should be preferred for TRT initiation in older men, but injectable forms may be considered subsequently. Older men on TRT should be monitored at 3, 6, and 12 months after initiation and at least yearly thereafter, or earlier and more frequently if indicated. Evaluation should include assessment of the clinical response, and measurement of total testosterone, haematocrit, and prostate-specific antigen (PSA) concentrations. Bone density and/or quality should also be assessed. Obese and overweight patients should be encouraged to undergo lifestyle modifications, including exercise and weight loss, to increase endogenous testosterone.
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Affiliation(s)
- George A Kanakis
- Department of Endocrinology & IVF Unit, Athens Naval and Veteran Affairs Hospital, Athens, Greece.
| | - Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Greece
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Eleni Armeni
- Second Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Greece; Royal Free Hospital, London, UK
| | - C Tamer Erel
- İstanbul-Cerrahpaşa University, Cerrahpaşa School of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
| | - Ivan Fistonić
- Faculty for Health Studies, University of Rijeka, Rijeka, Croatia
| | - Timothy Hillard
- Department of Obstetrics & Gynaecology, University Hospitals Dorset, Poole, UK
| | - Angelica-Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Blazej Meczekalski
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, Poznan, Poland
| | - Nicolás Mendoza
- Department of Obstetrics and Gynecology, University of Granada, Spain
| | - Alfred O Mueck
- Department of Women's Health, University Hospital Tuebingen, Germany; Beijing OB/GYN Hospital, Capital Medical University, China
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56100 Pisa, Italy
| | - Petra Stute
- Department of Obstetrics and Gynecology, University Clinic Inselspital, Bern, Switzerland
| | - Dorenda van Dijken
- Department of Obstetrics and Gynecology, OLVG Hospital, Amsterdam, the Netherlands
| | - Margaret Rees
- Women's Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Irene Lambrinoudaki
- Second Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Greece
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Oberlin DJ. Sex differences and athletic performance. Where do trans individuals fit into sports and athletics based on current research? Front Sports Act Living 2023; 5:1224476. [PMID: 37964771 PMCID: PMC10641525 DOI: 10.3389/fspor.2023.1224476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/10/2023] [Indexed: 11/16/2023] Open
Abstract
There are well known sex differences in parameters of physical fitness/performance due to changes occurring during sexual development. Thus, many sport and athletic events have regulations separating male and female participants. However, the inclusion or exclusion of transgender individuals in athletics has recently received outsized attention despite relatively few cases of transgender athletes. When determining which athletic gender category trans individuals should be permitted to compete in, it is important to understand the level of physical fitness/performance these individuals possess relative to their cisgender counterparts. Unfortunately, there are few studies investigating this topic, and several complications that confound this research. The current review seeks to discuss sex and gender as concepts, review sex differences in fitness/performance and how they develop, and then, consider how current evidence suggests that trans individuals compare to cis individuals. Finally, this review seeks to offer considerations for whether trans individuals should be excluded from sports and athletics, and how future research should proceed to better understand this marginalized population.
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Affiliation(s)
- D. J. Oberlin
- Department of Exercise Sciences and Recreation, City University of New York, Lehman College, Bronx, NY, United States
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Tannock LR. Management of Dyslipidemia in Endocrine Diseases. Endocrinol Metab Clin North Am 2022; 51:589-602. [PMID: 35963630 PMCID: PMC9382690 DOI: 10.1016/j.ecl.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Most endocrine disorders are chronic in nature, and thus even a minor effect to increase risk for cardiovascular disease can lead to a significant impact over prolonged duration. Although robust therapies exist for many endocrine disorders (eg suppression of excess hormone amounts, or replacement of hormone deficiencies), the therapies do not perfectly restore normal physiology. Thus, individuals with endocrine disorders are at potential increased cardiovascular disease risk, and maximizing strategies to reduce that risk are needed. This article reviews various endocrine conditions that can impact lipid levels and/or cardiovascular disease risk.
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Affiliation(s)
- Lisa R Tannock
- Division of Endocrinology, Diabetes, and Metabolism, University of Kentucky, Department of Veterans Affairs, MN145, 780 Rose Street, Lexington, KY 40536, USA.
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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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Venkatesh VS, Grossmann M, Zajac JD, Davey RA. The role of the androgen receptor in the pathogenesis of obesity and its utility as a target for obesity treatments. Obes Rev 2022; 23:e13429. [PMID: 35083843 PMCID: PMC9286619 DOI: 10.1111/obr.13429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 01/09/2022] [Accepted: 01/09/2022] [Indexed: 11/27/2022]
Abstract
Obesity is associated with hypothalamic-pituitary-testicular axis dysregulation in males. Here, we summarize recent evidence derived from clinical trials and studies in preclinical animal models regarding the role of androgen receptor (AR) signaling in the pathophysiology of males with obesity. We also discuss therapeutic strategies targeting the AR for the treatment of obesity and their limitations and provide insight into the future research necessary to advance this field.
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Affiliation(s)
- Varun S Venkatesh
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria
| | - Mathis Grossmann
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria.,Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
| | - Jeffrey D Zajac
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria.,Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
| | - Rachel A Davey
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria
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Abstract
Endocrine diseases may be associated with dyslipidaemia and may increase atherosclerotic cardiovascular disease (ASCVD) risk. This chapter describes changes in lipids and lipoproteins in diseases of the pituitary, thyroid, adrenal glands, ovaries, and testes, the mechanisms for these changes, ASCVD risk in these endocrine disorders, and whether treatment of the endocrine disorder improves the lipid profile and reduces ASCVD risk. Acromegaly, GH deficiency, Cushing syndrome, chronic glucocorticoid replacement, hypothyroidism, PCOS and male hypogonadism can increase LDL-C and/or TG. Marked reductions in LDL-C are associated with hyperthyroidism, and extremely low HDL-C levels with testosterone and/or other anabolic steroid abuse. Acromegaly, GH deficiency, Cushing syndrome, and chronic glucocorticoid replacement are associated with increased ASCVD risk. Treatment of acromegaly, GH deficiency, hypothyroidism, Cushing syndrome, and testosterone deficiency reduce LDL-C, although statin therapy may still be needed. Effects on ASCVD are not known.
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Affiliation(s)
- Connie B Newman
- Division of Endocrinology, Diabetes and Metabolism, New York University Grossman School of Medicine, New York, NY 10016, USA.
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11
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Macdowall WG, Clifton S, Palmer MJ, Tanton C, Copas AJ, Lee DM, Mitchell KR, Mercer CH, Sonnenberg P, Johnson AM, Wellings K. Salivary Testosterone and Sexual Function and Behavior in Men and Women: Findings from the Third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3). JOURNAL OF SEX RESEARCH 2022; 59:135-149. [PMID: 34634954 PMCID: PMC7613951 DOI: 10.1080/00224499.2021.1968327] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Using data from the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3) we examined associations between salivary testosterone (Sal-T) and sexual function and behavior. Single morning saliva samples were self-collected from a subsample of participants aged 18-74 years and analyzed using mass spectrometry. 1,599 men and 2,123 women were included in the analysis (40.6% of those invited to provide a sample). We adjusted for confounders in a stepwise manner: in model 1 we adjusted for age only; model 2 for age, season and relationship status, and model 3 we added BMI and self-reported health. In the fully adjusted models, among men, Sal-T was positively associated with both partnered sex (vaginal sex and concurrent partners) and masturbation. Among women, Sal-T was positively associated with masturbation, the only association with partnered sex was with ever experience of same-sex sex. We found no clear association between Sal-T and sexual function. Our study contributes toward addressing the sparsity of data outside the laboratory on the differences between men and women in the relationship between T and sexual function and behavior. To our knowledge, this is the first population study, among men and women, using a mass spectrometry Sal-T assay to do so.
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Affiliation(s)
- W G Macdowall
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine
| | - S Clifton
- Institute for Global Health, University College London, Mortimer Market Centre
- NatCen Social Research
| | - M J Palmer
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine
| | - C Tanton
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine
| | - A J Copas
- Institute for Global Health, University College London, Mortimer Market Centre
| | - D M Lee
- Faculty of Health, Psychology and Social Care, Manchester Metropolitan University
| | - K R Mitchell
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow
| | - C H Mercer
- Institute for Global Health, University College London, Mortimer Market Centre
| | - P Sonnenberg
- Institute for Global Health, University College London, Mortimer Market Centre
| | - A M Johnson
- Institute for Global Health, University College London, Mortimer Market Centre
| | - K Wellings
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine
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12
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Neurochemical and Hormonal Contributors to Compulsive Sexual Behavior Disorder. CURRENT ADDICTION REPORTS 2022. [DOI: 10.1007/s40429-021-00403-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
Compulsive sexual behavior disorder has been recently included in the 11th revision of the International Classification of Diseases (ICD-11), and the possible contribution of neurochemical and hormonal factors have been reported. However, relatively little is known concerning the neurobiology underlying this disorder. The aim of this article is to review and discuss published findings in the area.
Recent Findings
Evidence suggests that the neuroendocrine systems are involved in the pathophysiology of compulsive sexual behavior. The hypothalamus-pituitary adrenal axis, the hypothalamus-pituitary–gonadal axis, and the oxytocinergic system have been implicated.
Summary
Further studies are needed to elucidate the exact involvement of neuroendocrine and hormonal systems in compulsive sexual behavior disorder. Prospective longitudinal studies are particularly needed, especially those considering co-occurring psychiatric disorders and obtaining hormonal assessments in experimental circumstances with appropriate control groups.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to examine the recent evidence regarding the effects of exogenous androgens on the brain. Understanding these effects is of high importance, as the consequences of androgens on the reproductive and endocrine system are well documented, while fewer studies have focused on the neural and cerebral consequences of androgen use. RECENT FINDINGS Supraphysiological doses of androgens have been shown to contribute to neurodegeneration, decreased brain-derived neurotrophic factor, increased inflammation and decreased neuronal density in animal studies, which may correspond to changes in mood, cognition and aggression. Findings from human studies suggest that similar behavioural and cognitive deficits may occur as a result of prolonged use of androgens. Additional evidence suggests that androgen use, particularly in high doses, may contribute to brain ageing and cerebrovascular problems. SUMMARY Findings from recent human and animal studies indicate that androgen use likely contributes to brain alterations, which may cause the frequently observed deficits in cognitive and emotional functioning. Although exogenous testosterone in appropriate doses for therapeutic purposes likely have some neurobiological benefits for certain populations, supraphysiological doses may cause multiple mental and physical health problems, indicating a need for additional large-scale studies in humans.
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Affiliation(s)
- Morgan Scarth
- Anabolic Androgenic Steroid Research Group, Section for Clinical Addiction Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
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14
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Carmichael OT, Pillai SR, Murray K, Shankapal P, Caldwell J, Vartanian O, Berryman CE, Karl JP, Harris M, Rood JC, Pasiakos SM, Lieberman HR. Effects of testosterone administration on fMRI responses to executive function, aggressive behavior, and emotion processing tasks during severe exercise- and diet-induced energy deficit. Neuroimage 2021; 243:118496. [PMID: 34425226 DOI: 10.1016/j.neuroimage.2021.118496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 08/10/2021] [Accepted: 08/19/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Clinical administration of testosterone is widely used due to a variety of claimed physical and cognitive benefits. Testosterone administration is associated with enhanced brain and cognitive function, as well as mood, in energy-balanced males, although such relationships are controversial. However, the effects of testosterone administration on the brains of energy-deficient males, whose testosterone concentrations are likely to be well below normal, have not been investigated. METHODS This study collected functional magnetic resonance imaging (fMRI) data from 50 non-obese young men before (PRE) and shortly after (POST) 28 days of severe exercise-and-diet-induced energy deficit during which testosterone (200 mg testosterone enanthate per week in sesame oil, TEST) or placebo (sesame seed oil only, PLA) were administered. Scans were also collected after a post-energy-deficit weight regain period (REC). Participants completed five fMRI tasks that assessed aspects of: 1) executive function (Attention Network Task or ANT; Multi-Source Interference Task or MSIT; AXE Continuous Processing Task or AXCPT); 2) aggressive behavior (Provoked Aggression Task or AGG); and 3) latent emotion processing (Emotional Face Processing or EMO). RESULTS Changes over time in task-related fMRI activation in a priori defined task-critical brain regions during performance of 2 out of 5 tasks were significantly different between TEST and PLA, with TEST showing greater levels of activation during ANT in the right anterior cingulate gyrus at POST and during MSIT in several brain regions at REC. Changes over time in objective task performance were not statistically significant; testosterone-treated volunteers had greater self-reported anger during AGG at POST. CONCLUSIONS Testosterone administration can alter some aspects of brain function during severe energy deficit and increase levels of anger.
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Affiliation(s)
| | | | - Kori Murray
- Pennington Biomedical Research Center, Baton Rouge, LA, USA
| | | | - John Caldwell
- Military Nutrition Division, US Army Research Institute of Environmental Medicine (USARIEM), Natick, MA, USA; Laulima Government Solutions, Orlando, FL, USA
| | - Oshin Vartanian
- Defence Research and Development Canada, Toronto Research Centre, Toronto, ON, Canada; Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Claire E Berryman
- Military Nutrition Division, US Army Research Institute of Environmental Medicine (USARIEM), Natick, MA, USA; Oak Ridge Institute for Science and Education, Belcamp, MD, USA; Department of Nutrition and Integrative Physiology, Florida State University, Tallahassee, FL, USA
| | - J P Karl
- Military Nutrition Division, US Army Research Institute of Environmental Medicine (USARIEM), Natick, MA, USA
| | - Melissa Harris
- Pennington Biomedical Research Center, Baton Rouge, LA, USA
| | | | - Stefan M Pasiakos
- Military Nutrition Division, US Army Research Institute of Environmental Medicine (USARIEM), Natick, MA, USA
| | - Harris R Lieberman
- Military Nutrition Division, US Army Research Institute of Environmental Medicine (USARIEM), Natick, MA, USA
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15
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Gregori G, Celli A, Barnouin Y, Paudyal A, Armamento-Villareal R, Napoli N, Qualls C, Villareal DT. Cognitive response to testosterone replacement added to intensive lifestyle intervention in older men with obesity and hypogonadism: prespecified secondary analyses of a randomized clinical trial. Am J Clin Nutr 2021; 114:1590-1599. [PMID: 34375393 PMCID: PMC8588849 DOI: 10.1093/ajcn/nqab253] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 07/09/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Both obesity and hypogonadism are common in older men which could additively exacerbate age-related declines in cognitive function. However, little is known about the effects of lifestyle intervention plus testosterone replacement therapy in this population. OBJECTIVES In this secondary analysis of the LITROS (Lifestyle Intervention and Testosterone Replacement in Obese Seniors) trial, we examined whether testosterone replacement therapy would improve cognitive function when added to intensive lifestyle intervention in older men with obesity and hypogonadism. METHODS Eighty-three older, obese hypogonadal men with frailty were randomly assigned to lifestyle therapy (weight management and exercise training) plus testosterone (LT + Test) or lifestyle therapy plus placebo (LT + Pbo) for 6 mo. For this report, the primary outcome was change in the global cognition composite z score. Secondary outcomes included changes in z score subcomponents: attention/information processing, memory, executive function, and language. Changes between groups were analyzed using mixed-model repeated-measures ANCOVAs following the intention-to-treat principle. RESULTS Global cognition z score increased more in the LT + Test than in the LT + Pbo group (mean change: 0.49 compared with 0.21; between-group difference: -0.28; 95% CI: -0.45, -0.11; Cohen's d = 0.74). Moreover, attention/information z score and memory z score increased more in the LT + Test than in the LT + Pbo group (mean change: 0.55 compared with 0.23; between-group difference: -0.32; 95% CI: -0.55, -0.09; Cohen's d = 0.49 and mean change: 0.90 compared with 0.37; between-group difference: -0.53; 95% CI: -0.93, -0.13; Cohen's d = 1.43, respectively). Multiple regression analyses showed that changes in peak oxygen consumption, strength, total testosterone, and luteinizing hormone were independent predictors of the improvement in global cognition (R2 = 0.38; P < 0.001). CONCLUSIONS These findings suggest that in the high-risk population of older men with obesity and hypogonadism, testosterone replacement may improve cognitive function with lifestyle behaviors controlled via lifestyle intervention therapy.This trial was registered at clinicaltrials.gov as NCT02367105.
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Affiliation(s)
- Giulia Gregori
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston, TX, USA,Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Alessandra Celli
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston, TX, USA,Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Yoann Barnouin
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston, TX, USA,Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Arjun Paudyal
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston, TX, USA,Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Reina Armamento-Villareal
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston, TX, USA,Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Nicola Napoli
- Division of Endocrinology and Metabolism, Washington University School of Medicine, St Louis, MO, USA
| | - Clifford Qualls
- Department of Mathematics and Statistics, University of New Mexico School of Medicine, Albuquerque, NM, USA
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16
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Salonia A, Bettocchi C, Boeri L, Capogrosso P, Carvalho J, Cilesiz NC, Cocci A, Corona G, Dimitropoulos K, Gül M, Hatzichristodoulou G, Jones TH, Kadioglu A, Martínez Salamanca JI, Milenkovic U, Modgil V, Russo GI, Serefoglu EC, Tharakan T, Verze P, Minhas S. European Association of Urology Guidelines on Sexual and Reproductive Health-2021 Update: Male Sexual Dysfunction. Eur Urol 2021; 80:333-357. [PMID: 34183196 DOI: 10.1016/j.eururo.2021.06.007] [Citation(s) in RCA: 336] [Impact Index Per Article: 112.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/09/2021] [Indexed: 02/07/2023]
Abstract
CONTEXT The present summary of the European Association of Urology (EAU) guidelines is based on the latest guidelines on male sexual health published in March 2021, with a last comprehensive update in January 2021. OBJECTIVE To present a summary of the 2021 version of the EAU guidelines on sexual and reproductive health. EVIDENCE ACQUISITION A literature review was performed up to January 2021. The guidelines were updated, and a strength rating for each recommendation was included based on either a systematic review of the evidence or a consensus opinion from the expert panel. EVIDENCE SYNTHESIS Late-onset hypogonadism is a clinical condition in the ageing male combining low levels of circulating testosterone and specific symptoms associated with impaired hormone production and/or action. A comprehensive diagnostic and therapeutic work-up, along with screening recommendations and contraindications, is provided. Erectile dysfunction (ED) is the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance. Along with a detailed basic and advanced diagnostic approach, a novel decision-making algorithm for treating ED in order to better tailor therapy to individual patients is provided. The EAU guidelines have adopted the definition of premature ejaculation (PE), which has been developed by the International Society for Sexual Medicine. After the subtype of PE has been defined, patient's expectations should be discussed thoroughly and pharmacotherapy must be considered as the first-line treatment for patients with lifelong PE, whereas treating the underlying cause must be the initial goal for patients with acquired PE. Haemospermia is defined as the appearance of blood in the ejaculate. Several reasons of haemospermia have been acknowledged; the primary goal over the management work-up is to exclude malignant conditions and treat any other underlying cause. CONCLUSIONS The 2021 guidelines on sexual and reproductive health summarise the most recent findings, and advise in terms of diagnosis and treatment of male hypogonadism and sexual dysfunction for their use in clinical practice. These guidelines reflect the multidisciplinary nature of their management. PATIENT SUMMARY Updated European Association of Urology guidelines on sexual and reproductive health are presented, addressing the diagnosis and treatment of the most prevalent conditions in men. Patients must be fully informed of all relevant diagnostic and therapeutic options and, together with their treating physicians, decide on optimal personalised management strategies.
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Affiliation(s)
- Andrea Salonia
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy.
| | | | - Luca Boeri
- Department of Urology, Foundation IRCCS Ca' Granda - Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Paolo Capogrosso
- Department of Urology and Andrology, Ospedale di Circolo and Macchi Foundation, Varese, Italy
| | - Joana Carvalho
- CPUP: Center for Psychology of Porto University, Faculty of Psychology and Educational Sciences, Porto University, Porto, Portugal
| | - Nusret Can Cilesiz
- Department of Urology, Taksim Training & Research Hospital, Istanbul, Turkey
| | - Andrea Cocci
- Department of Minimally Invasive and Robotic Urologic Surgery and Kidney Transplantation, University of Florence, Florence, Italy
| | - Giovanni Corona
- Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Kostantinos Dimitropoulos
- Academic Urology Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK; Department of Urology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Murat Gül
- School of Medicine, Department of Urology, Selcuk University, Konya, Turkey
| | | | - T Hugh Jones
- Centre for Diabetes and Endocrinology, Barnsley Hospital NHS Trust, Barnsley, UK
| | - Ates Kadioglu
- Department of Urology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Juan Ignatio Martínez Salamanca
- Department of Urology, Hospital Universitario Puerta de Hierro-Majadahonda, Lyx Institute of Urology, Universidad Francisco de Vitoria, Madrid, Spain
| | - Uros Milenkovic
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Vaibhav Modgil
- Manchester Andrology Centre, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Giorgio Ivan Russo
- Urology Section, Department of Surgery, University of Catania, Catania, Italy
| | - Ege Can Serefoglu
- Department of Urology, Biruni University School of Medicine, Istanbul, Turkey
| | - Tharu Tharakan
- Department of Urology, Imperial Healthcare NHS Trust, Charing Cross Hospital, London, UK; Section of Investigative Medicine, Department of Medicine, Imperial College London, London, UK
| | - Paolo Verze
- Department of Medicine and Surgery "Scuola Medica Salernitana", University of Salerno, Fisciano, Campania, Italy
| | - Suks Minhas
- Department of Urology, Imperial Healthcare NHS Trust, Charing Cross Hospital, London, UK
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17
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Chasland LC, Yeap BB, Maiorana AJ, Chan YX, Maslen BA, Cooke BR, Dembo L, Naylor LH, Green DJ. Testosterone and exercise: effects on fitness, body composition, and strength in middle-to-older aged men with low-normal serum testosterone levels. Am J Physiol Heart Circ Physiol 2021; 320:H1985-H1998. [PMID: 33739155 DOI: 10.1152/ajpheart.00010.2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
As men age, serum testosterone (T) concentrations decrease, as do fitness, strength, and lean mass. Whether testosterone treatment confers additive benefit to reverse these changes when combined with exercise training in middle-to-older aged men remains unclear. We assessed the effects of T treatment and exercise, alone and in combination, on aerobic capacity (V̇o2peak), body composition, and muscular strength in men 50-70 yr, waist circumference ≥95 cm and low-normal serum T (6-14 nmol·L-1). Participants (n = 80) were randomized to AndroForte5 (testosterone 5.0% wt/vol, 100 mg/2 mL) cream (T), or matching placebo (P), applied transdermally daily, and supervised center-based exercise (Ex) or no additional exercise (NEx), for 12-wk. Exercise increased V̇o2peak and strength versus nonexercise (V̇o2peak: T + Ex: +2.5 mL·kg-1·min-1, P + Ex: +3.2 mL·kg-1·min-1, P < 0.001; leg press: T + Ex: +31 kg, P + Ex: +24 kg, P = 0.006). T treatment did not affect V̇o2peak or strength. Exercise decreased total (T + Ex: -1.7, P + Ex: -2.3 kg, P < 0.001) and visceral fat (T + Ex: -0.1 kg, P + Ex: -0.3 kg, P = 0.003), and increased total (T + Ex: +1.4 kg, P + Ex: +0.7 kg, P = 0.008) and arm lean mass (T + Ex: +0.5 kg, P + Ex: +0.3 kg, P = 0.024). T treatment did not affect total or visceral fat, but increased total (T + Ex: +1.4 kg, T + NEx: +0.7 kg, P = 0.015), leg (T + Ex: +0.3 kg, T + NEx: +0.2 kg, P = 0.024), and arm lean mass (T + Ex: +0.5 kg, T + NEx: +0.2 kg, P = 0.046). T + Ex increased arm lean mass (T + Ex: +0.5 kg vs. P + NEx: -0.0 kg, P = 0.001) and leg strength (T + Ex: +31 kg vs. P + NEx: +12 kg, P = 0.032) compared with P + NEx, with no other additive effects. Exercise training was more effective than T treatment in increasing aerobic capacity and decreasing total and visceral fat mass. T treatment at therapeutic doses increased lean mass but conferred limited additional benefit when combined with exercise. Exercise should be evaluated as an antiaging intervention in preference to testosterone treatment in men.NEW & NOTEWORTHY We illustrate that exercise training generates superior outcomes to testosterone treatment for improving aerobic fitness, muscular strength, and total and visceral fat mass in men 50-70 yr with low-normal serum testosterone concentrations. Adding testosterone treatment to exercise did not provide any additive benefit for these variables. Testosterone treatment alone and exercise alone had similar impacts on lean mass. Therefore, men unable to exercise may obtain benefit from testosterone treatment alone to improve lean mass.
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Affiliation(s)
- Lauren C Chasland
- School of Human Sciences, Exercise and Sport Science, The University of Western Australia, Perth, Western Australia, Australia.,Allied Health Department, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Bu B Yeap
- Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Andrew J Maiorana
- Allied Health Department, Fiona Stanley Hospital, Perth, Western Australia, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Yi X Chan
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Barbara A Maslen
- School of Human Sciences, Exercise and Sport Science, The University of Western Australia, Perth, Western Australia, Australia
| | - Brian R Cooke
- PathWest Laboratory Medicine, Department of Clinical Biochemistry, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Lawrence Dembo
- Advanced Heart Failure and Cardiac Transplantation Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Louise H Naylor
- School of Human Sciences, Exercise and Sport Science, The University of Western Australia, Perth, Western Australia, Australia.,Allied Health Department, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Daniel J Green
- School of Human Sciences, Exercise and Sport Science, The University of Western Australia, Perth, Western Australia, Australia
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18
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Risks of Serious Injury with Testosterone Treatment. Am J Med 2021; 134:84-94.e6. [PMID: 32926849 DOI: 10.1016/j.amjmed.2020.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/31/2020] [Accepted: 07/31/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Injury causes significant morbidity and mortality that is sometimes attributed to testosterone and violence. We hypothesized that prescribed testosterone might be associated with the subsequent risk of serious injury. METHODS We conducted a self-matched individual-patient exposure-crossover analysis comparing injury risks before and after initiation of testosterone. We selected adults treated with testosterone in Ontario, Canada, from October 1, 2012, to October 1, 2017 (enrollment) and continued until October 1, 2018 (follow-up). The primary outcome was defined as an acute traumatic event that required emergency medical care. RESULTS A total of 64,386 patients were treated with testosterone of whom 89% were men with a median age of 52 years. We identified 34,439 serious injuries during the baseline interval before starting testosterone (584 per month) and 7349 serious injuries during the subsequent interval after starting testosterone (565 per month). Rates of injuries were substantially above the population norm in both intervals with no significant increased risk after starting testosterone (relative risk = 1.00; 95% confidence interval: 0.96-1.04, P = 0.850). The unchanged risk extended to diverse patients, was observed for different formulations and applied to all injury mechanisms. In contrast, testosterone treatment was associated with a 48% increased risk of a thromboembolic event (relative risk = 1.48; 95% confidence interval: 1.25-1.74, P < 0.001). CONCLUSIONS Testosterone treatment was associated with a substantial baseline risk of serious injury that did not increase further after starting therapy. Physicians prescribing testosterone could consider basic safety reminders to mitigate injury risks.
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19
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Anabolic-androgenic steroid administration increases self-reported aggression in healthy males: a systematic review and meta-analysis of experimental studies. Psychopharmacology (Berl) 2021; 238:1911-1922. [PMID: 33745011 PMCID: PMC8233285 DOI: 10.1007/s00213-021-05818-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 03/03/2021] [Indexed: 12/31/2022]
Abstract
RATIONALE Aggression and irritability are notable psychiatric side effects of anabolic-androgenic steroid (AAS) use. However, no previous study has systematically reviewed and quantitatively synthesized effects reported by experimental studies on this topic. OBJECTIVE We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effect of AAS administration on self-reported and observer-reported aggression. METHODS Twelve RCTs comprising a total of 562 healthy males were identified through systematic searches of MEDLINE, PsycInfo, ISI Web of Science, ProQuest, Google Scholar, and the Cochrane Library. RESULTS After excluding one outlier, AAS administration was associated with an increase in self-reported aggression under a random-effects model, albeit small (Hedges' g = 0.171, 95% CI: 0.029-0.312, k = 11, p = .018), and when restricting the analysis to the effect of acute AAS administration on self-reported aggression under a fixed-effect model (g = 0.291, 95% CI: 0.014-0.524, p = .014). However, the above effects were neither replicated in the analysis of observer-reported aggression nor after restricting the analysis to the effects of the administration of higher (over 500 mg) and long-term (3 days to 14 weeks) doses. CONCLUSIONS The present meta-analysis provides evidence of an increase, although small, in self-reported aggression in healthy males following AAS administration in RCTs. Ecologically rational RCTs are warranted to better explore the effect of AAS administration on aggression in humans.
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20
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Beecken WD, Kersting M, Kunert W, Blume G, Bacharidis N, Cohen DS, Shabeeh H, Allen MS. Thinking About Pathomechanisms and Current Treatment of Erectile Dysfunction-"The Stanley Beamish Problem." Review, Recommendations, and Proposals. Sex Med Rev 2020; 9:445-463. [PMID: 33358577 DOI: 10.1016/j.sxmr.2020.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/12/2020] [Accepted: 11/18/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Up to 50% of all men over 50 years of age suffer from erectile dysfunction. Since the late 1990s erectile dysfunction has been treated mostly with phosphodiesterase 5 inhibitors (PDE5I). Over the past 20 years, numerous scientific findings on the development of erectile dysfunction have been collected, which have so far received little attention in the treatment of erectile dysfunction. OBJECTIVES The objectives of this study were to review the existing medical literature on erectile dysfunction regarding physiology, pathophysiology, and especially therapeutic options beyond treatment with PDE5I and to enable a more effective and especially sustainable treatment for erectile dysfunction. METHODS A literature review was performed by using PubMed from 1985 to 2020 regarding the physiology, pathophysiology, and treatment of erectile dysfunction. RESULTS Since the end of the 1990s an enormous amount of knowledge has been gained about the physiology/pathophysiology of erection/erectile dysfunction. Based on these findings, numerous physical, drug, and holistic therapeutic options (beyond the application of PDE5I) have been developed for the treatment of erectile dysfunction. However, these are still relatively rarely used in the therapeutic concept of erectile dysfunction today. CONCLUSION Based on scientific findings of the last 20 years, there are numerous therapeutic approaches, including lifestyle modification, specific pelvic floor exercises, shock wave treatment, and the application of different supplements. The long-term treatment of erectile dysfunction should now go beyond the purely symptomatic use of PDE5I. W-D Beecken, M Kersting, W Kunert, et al. Thinking About Pathomechanisms and Current Treatment of Erectile Dysfunction-"The Stanley Beamish Problem." Review, Recommendations, and Proposals. Sex Med Rev 2021;9:445-463.
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Affiliation(s)
- Wolf-D Beecken
- UroGate, Practice for Urology, Frankfurt, Germany; Regimen/with O Inc, San Jose, CA, USA.
| | | | | | | | | | - Deborah S Cohen
- Regimen/with O Inc, San Jose, CA, USA; Fundamental Physical Therapy & Pelvic Wellness, Poway, CA, USA
| | - Husain Shabeeh
- Regimen/with O Inc, San Jose, CA, USA; Department of Cardiology, Croydon University Hospital, London, UK
| | - Mark S Allen
- Regimen/with O Inc, San Jose, CA, USA; Faculty of Social Sciences, University of Wollongong, Wollongong, Australia
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21
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Abstract
PURPOSE OF REVIEW Hypogonadism is highly prevalent among not only patients with a history of prior treatment for cancer, but also among those patients with a new oncologic diagnosis who have not yet received any cancer therapy. Hypogonadism can cause a wide array of signs and symptoms including: deceased muscle mass; increased fat mass; decreased energy, mood, and overall sense of well being; diminished bone mineral density; infertility; and impaired libido and sexual function. This purpose of this manuscript is to review the mechanisms by which cancer and oncologic treatment regimens can adversely affect the hypothalamic pituitary gonadal axis, resulting in hypogonadism. Risks and benefits associated with the treatment of testosterone deficiency are also discussed, which are important considerations for clinicians caring for affected patients. RECENT FINDINGS Hypogonadism has a high prevalence in the setting of cancer and is an important survivorship issue. Recent randomized controlled trials confirm testosterone's therapeutic benefits in terms of sexual function, mood body composition, and bone health, but the specific benefits in terms of quality of life are less clear. SUMMARY More prospective studies are needed to further delineate the risks, benefits, and overall outcomes of testosterone replacement therapy in patients with cancer and cancer survivors.
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Affiliation(s)
- Cory A Faw
- Northwestern University, Feinberg School of Medicine, Department of Urology, Chicago, Illinois, USA
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22
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Seppan P, Muhammed I, Mohanraj KG, Lakshmanan G, Premavathy D, Muthu SJ, Wungmarong Shimray K, Sathyanathan SB. Therapeutic potential of Mucuna pruriens (Linn.) on ageing induced damage in dorsal nerve of the penis and its implication on erectile function: an experimental study using albino rats. Aging Male 2020; 23:313-326. [PMID: 29447059 DOI: 10.1080/13685538.2018.1439005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To study the effect of ethanolic seed extract of Mucuna pruriens on damaged dorsal nerve of the penis (DNP) in aged rat in relation to penile erection. METHODS The rats were divided into four groups Young (3 months), Aged (24 - 28 months), Aged + M. pruriens, and Young + M. pruriens (200 mg/kg b.w/60 days) and were subjected to the hypophysial - gonadal axis, nerve conduction velocity (NCV), and penile reflex. DNP sections were stained with nitric oxide synthase (nNOS), nicotinamide adenine dinucleotide phosphate (NaDPH) diaphorase, androgen receptor (AR), and osmium tetroxide. Terminal deoxynucleotidyl transferase (TdT) dUTP Nick-End Labeling (TUNEL) staining, electron microscopy(EM) and histometric analyses were done. RESULTS Significant disturbance in hypophysial - gonadal axis was noted in aged rat. With reduced number of myelinated fibers, diameter, vacuolization, indentation of the myelin sheath, and degeneration. nNOS and its cofactor (NaDPH diaphorase) were reduced in aged rat DNP. NCV was slow in aged rats and concomitant poor penile reflex was also noted. AR showed reduced expression in aged rat DNP when compared to young and control groups. TUNEL positive cells were increased in aged rat DNP. These pathological changes were remarkably reduced or recovered in M. pruriens treated aged rats. CONCLUSIONS The results indicate a multi-factorial therapeutic activity in penile innervations towards sustaining the penile erection in the presence of the extract in aged rats and justifying the claim of traditional usage.
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Affiliation(s)
- Prakash Seppan
- Department of Anatomy, Dr. Arcot Lakshmanasamy Mudaliar Postgraduate Institute of Basic Medical Sciences, University of Madras, Taramani Campus, Chennai, India
| | - Ibrahim Muhammed
- Department of Anatomy, Dr. Arcot Lakshmanasamy Mudaliar Postgraduate Institute of Basic Medical Sciences, University of Madras, Taramani Campus, Chennai, India
| | - Karthik Ganesh Mohanraj
- Department of Anatomy, Dr. Arcot Lakshmanasamy Mudaliar Postgraduate Institute of Basic Medical Sciences, University of Madras, Taramani Campus, Chennai, India
- Department of Anatomy, Saveetha Dental College and Hospital, Chennai, India
| | - Ganesh Lakshmanan
- Department of Anatomy, Dr. Arcot Lakshmanasamy Mudaliar Postgraduate Institute of Basic Medical Sciences, University of Madras, Taramani Campus, Chennai, India
| | - Dinesh Premavathy
- Department of Anatomy, Dr. Arcot Lakshmanasamy Mudaliar Postgraduate Institute of Basic Medical Sciences, University of Madras, Taramani Campus, Chennai, India
| | - Sakthi Jothi Muthu
- Department of Anatomy, Dr. Arcot Lakshmanasamy Mudaliar Postgraduate Institute of Basic Medical Sciences, University of Madras, Taramani Campus, Chennai, India
| | - Khayinmi Wungmarong Shimray
- Department of Anatomy, Dr. Arcot Lakshmanasamy Mudaliar Postgraduate Institute of Basic Medical Sciences, University of Madras, Taramani Campus, Chennai, India
| | - Sathya Bharathy Sathyanathan
- Department of Electrical and Electronics Engineering, Loyola-ICAM College of Engineering and Technology, Chennai, India
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23
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Newman CB, Blaha MJ, Boord JB, Cariou B, Chait A, Fein HG, Ginsberg HN, Goldberg IJ, Murad MH, Subramanian S, Tannock LR. Lipid Management in Patients with Endocrine Disorders: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2020; 105:5909161. [PMID: 32951056 DOI: 10.1210/clinem/dgaa674] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This guideline will provide the practicing endocrinologist with an approach to the assessment and treatment of dyslipidemia in patients with endocrine diseases, with the objective of preventing cardiovascular (CV) events and triglyceride-induced pancreatitis. The guideline reviews data on dyslipidemia and atherosclerotic cardiovascular disease (ASCVD) risk in patients with endocrine disorders and discusses the evidence for the correction of dyslipidemia by treatment of the endocrine disease. The guideline also addresses whether treatment of the endocrine disease reduces ASCVD risk. CONCLUSION This guideline focuses on lipid and lipoprotein abnormalities associated with endocrine diseases, including diabetes mellitus, and whether treatment of the endocrine disorder improves not only the lipid abnormalities, but also CV outcomes. Based on the available evidence, recommendations are made for the assessment and management of dyslipidemia in patients with endocrine diseases.
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Affiliation(s)
- Connie B Newman
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, New York University Grossman School of Medicine, New York, New York
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Jeffrey B Boord
- Department of Administration and Parkview Physicians Group Endocrinology Section, Parkview Health System, Fort Wayne, Indiana
| | - Bertrand Cariou
- Department of Endocrinology, L'institut du thorax, INSERM, CNRS, UNIV Nantes, CHU Nantes, Nantes, France
| | - Alan Chait
- Department of Medicine, University of Washington, Seattle, Washington
| | - Henry G Fein
- Department of Medicine, Division of Endocrinology, Sinai Hospital, Baltimore, Maryland
| | - Henry N Ginsberg
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Ira J Goldberg
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, New York University Grossman School of Medicine, New York, New York
| | - M Hassan Murad
- Mayo Clinic Evidence-based Practice Center, Rochester, Minnesota
| | | | - Lisa R Tannock
- Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
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Abstract
Atherosclerosis is a chronic inflammatory vascular disease and the predominant cause of heart attack and ischemic stroke. Despite the well-known sexual dimorphism in the incidence and complications of atherosclerosis, there are relatively limited data in the clinical and preclinical literature to rigorously address mechanisms underlying sex as a biological variable in atherosclerosis. In multiple histological and imaging studies, overall plaque burden and markers of inflammation appear to be greater in men than women and are predictive of cardiovascular events. However, while younger women are relatively protected from cardiovascular disease, by the seventh decade, the incidence of myocardial infarction in women ultimately surpasses that of men, suggesting an interaction between sex and age. Most preclinical studies in animal atherosclerosis models do not examine both sexes, and even in those that do, well-powered direct statistical comparisons for sex as an independent variable remain rare. This article reviews the available data. Overall, male animals appear to have more inflamed yet smaller plaques compared to female animals. Plaque inflammation is often used as a surrogate end point for plaque vulnerability in animals. The available data support the notion that rather than plaque size, plaque inflammation may be more relevant in assessing sex-specific mechanisms since the findings correlate with the sex difference in ischemic events and mortality and thus may be more reflective of the human condition. Overall, the number of preclinical studies directly comparing plaque inflammation between the sexes is extremely limited relative to the vast literature exploring atherosclerosis mechanisms. Failure to include both sexes and to address age in mechanistic atherosclerosis studies are missed opportunities to uncover underlying sex-specific mechanisms. Understanding the mechanisms driving sex as a biological variable in atherosclerotic disease is critical to future precision medicine strategies to mitigate what is still the leading cause of death of men and women worldwide.
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Affiliation(s)
- Joshua J. Man
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA
| | - Joshua A. Beckman
- Cardiovascular Division, Vanderbilt University Medical Center, Nashville, TN
| | - Iris Z. Jaffe
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA
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25
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Chatzittofis A, Boström AE, Öberg KG, Flanagan JN, Schiöth HB, Arver S, Jokinen J. Normal Testosterone but Higher Luteinizing Hormone Plasma Levels in Men With Hypersexual Disorder. Sex Med 2020; 8:243-250. [PMID: 32173350 PMCID: PMC7261685 DOI: 10.1016/j.esxm.2020.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/22/2020] [Accepted: 02/05/2020] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Hypersexual disorder as suggested to be included in the Diagnostic and Statistical Manual of Mental Disorders-5 integrates aspects of sexual desire deregulation, impulsivity, and compulsivity. However, it is unknown how it affects gonadal activity and the function of the hypothalamus-pituitary-gonadal (HPG) axis. AIM The aim of this study was to investigate testosterone and luteinizing hormone (LH) levels in hypersexual men compared with healthy controls. Furthermore, we investigated associations between epigenetic markers and hormone levels. METHODS Basal morning plasma levels of testosterone, LH, and sex hormone-binding globulin (SHBG) were assessed in 67 hypersexual men (mean age: 39.2 years) compared with 39 age-matched healthy controls (mean age: 37.5 years). The Sexual Compulsivity Scale and the Hypersexual Disorder: Current Assessment Scale were used for assessing hypersexual behavior, the Montgomery-Åsberg Depression Scale-self rating was used for depression severity, and the Childhood Trauma Questionnaire (CTQ) was used for assessing history of childhood adversity. The genome-wide methylation pattern of more than 850 K CpG sites was measured in whole blood using the Illumina Infinium Methylation EPIC BeadChip. CpG sites located within 2,000 bp of the transcriptional start site of hypothalamus pituitary adrenal (HPA) and HPG axis-coupled genes were included. MAIN OUTCOME MEASURES Testosterone and LH plasma levels in association with clinical rating and a secondary outcome was the epigenetic profile of HPA and HPG axis-coupled CpG sites with testosterone and LH levels. RESULTS LH plasma levels were significantly higher in patients with hypersexual disorder than in healthy volunteers. No significant differences in plasma testosterone, follicle stimulating hormone, prolactin, and SHBG levels were found between the groups. There were no significant associations between DNA methylation of HPA and HPG axis-coupled genes and plasma testosterone or LH levels after multiple testing corrections. CONCLUSIONS Subtle dysregulation of the HPG axis, with increased LH plasma levels but no difference in testosterone levels may be present in hypersexual men. Chatzittofis A, Boström AE, Öberg KG, et al. Normal Testosterone but Higher Luteinizing Hormone Plasma Levels in Men With Hypersexual Disorder. Sex Med 2020;8:243-250.
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Affiliation(s)
- Andreas Chatzittofis
- Department of Clinical Sciences/Psychiatry, Umeå University, Umeå, Sweden; Medical School, University of Cyprus, Nicosia, Cyprus.
| | | | - Katarina Görts Öberg
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Sweden
| | - John N Flanagan
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Sweden
| | - Helgi B Schiöth
- Department of Neuroscience, Uppsala University, Uppsala, Sweden; Institute for Translational Medicine and Biotechnology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Stefan Arver
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Sweden
| | - Jussi Jokinen
- Department of Clinical Sciences/Psychiatry, Umeå University, Umeå, Sweden; Department of Clinical Neuroscience/Psychiatry, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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26
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Diem SJ, Greer NL, MacDonald R, McKenzie LG, Dahm P, Ercan-Fang N, Estrada A, Hemmy LS, Rosebush CE, Fink HA, Wilt TJ. Efficacy and Safety of Testosterone Treatment in Men: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Ann Intern Med 2020; 172:105-118. [PMID: 31905375 DOI: 10.7326/m19-0830] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Testosterone treatment rates in adult men have increased in the United States over the past 2 decades. PURPOSE To assess the benefits and harms of testosterone treatment for men without underlying organic causes of hypogonadism. DATA SOURCES English-language searches of multiple electronic databases (January 1980 to May 2019) and reference lists from systematic reviews. STUDY SELECTION 38 randomized controlled trials (RCTs) of at least 6 months' duration that evaluated transdermal or intramuscular testosterone therapies versus placebo or no treatment and reported prespecified patient-centered outcomes, as well as 20 long-term observational studies, U.S. Food and Drug Administration review data, and product labels that reported harms information. DATA EXTRACTION Data extraction by a single investigator was confirmed by a second, 2 investigators assessed risk of bias, and evidence certainty was determined by consensus. DATA SYNTHESIS Studies enrolled mostly older men who varied in age, symptoms, and testosterone eligibility criteria. Testosterone therapy improved sexual functioning and quality of life in men with low testosterone levels, although effect sizes were small (low- to moderate-certainty evidence). Testosterone therapy had little to no effect on physical functioning, depressive symptoms, energy and vitality, or cognition. Harms evidence reported in trials was judged to be insufficient or of low certainty for most harm outcomes. No trials were powered to assess cardiovascular events or prostate cancer, and trials often excluded men at increased risk for these conditions. Observational studies were limited by confounding by indication and contraindication. LIMITATION Few trials exceeded a 1-year duration, minimum important outcome differences were often not established or reported, RCTs were not powered to assess important harms, few data were available in men aged 18 to 50 years, definitions of low testosterone varied, and study entry criteria varied. CONCLUSION In older men with low testosterone levels without well-established medical conditions known to cause hypogonadism, testosterone therapy may provide small improvements in sexual functioning and quality of life but little to no benefit for other common symptoms of aging. Long-term efficacy and safety are unknown. PRIMARY FUNDING SOURCE American College of Physicians. (PROSPERO: CRD42018096585).
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Affiliation(s)
- Susan J Diem
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Nancy L Greer
- Minneapolis VA Health Care System, Minneapolis, Minnesota (N.L.G., R.M., L.G.M.)
| | - Roderick MacDonald
- Minneapolis VA Health Care System, Minneapolis, Minnesota (N.L.G., R.M., L.G.M.)
| | - Lauren G McKenzie
- Minneapolis VA Health Care System, Minneapolis, Minnesota (N.L.G., R.M., L.G.M.)
| | - Philipp Dahm
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Nacide Ercan-Fang
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Allison Estrada
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Laura S Hemmy
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Christina E Rosebush
- Minneapolis VA Health Care System and University of Minnesota School of Public Health, Minneapolis, Minnesota (C.E.R.)
| | - Howard A Fink
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
| | - Timothy J Wilt
- Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.)
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27
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Abstract
Background: Social identity theory proposes that people define themselves in terms of the social groups they belong to or aspire to belong to. Tobacco smoking and alcohol use in men have been hypothesized to be symbolic of adult male status. The current study examines whether adolescent personality characteristics linked to masculinity and nonconformity are associated with tobacco smoking and alcohol misuse in men. Methods: The analysis is based on the results of a cross-sectional study conducted in 2018 on a stratified, random sample of 703 adult male residents of Warsaw, Poland, with elementary- and secondary-school education. All survey data were collected through a paper-and-pencil questionnaire. A path model is employed to examine the direct and indirect effects of adolescent characteristics on tobacco smoking and alcohol consumption. Results: According to the path model, retrospective perceptions of self-reported character strength, rebellion against unjustified prohibitions and rules, ease in making decisions, willingness to differ from others, and interest in the opposite gender in adolescence had a significant direct effect on tobacco smoking in adolescence and a significant indirect effect on tobacco smoking in adulthood. The variables representing character strength, rebellion against unjustified prohibitions and rules, ease in making decisions, and interest in the opposite gender in adolescence also showed a significant direct effect on alcohol use in adolescence. Conclusion: Masculinity and nonconformity were related to addictive behaviors in men, which might have health policy implications. In this paper, associating traditional masculinity with health orientation in society is proposed as a possible preventive intervention.
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Affiliation(s)
- Krzysztof Czaderny
- Department of Cancer Epidemiology and Prevention, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland.,Institute of Statistics and Demography, Warsaw School of Economics, Warsaw, Poland
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28
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Effects of Testosterone Supplementation on Separate Cognitive Domains in Cognitively Healthy Older Men: A Meta-analysis of Current Randomized Clinical Trials. Am J Geriatr Psychiatry 2019; 27:1232-1246. [PMID: 31296441 DOI: 10.1016/j.jagp.2019.05.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND An increasing body of literature suggests a positive, neuroprotective effect for testosterone on cognition in older men. However, randomized clinical trials (RCTs) examining the effects of testosterone supplementation (TS) on cognitive function have been inconclusive. OBJECTIVE To investigate the potential for TS to prevent cognitive decline in otherwise cognitively healthy older men, by examining the differential effects of TS on cognitively healthy older men in RCTs. METHODS Comprehensive search of electronic databases, conference proceedings, and grey literature from 1990 to 2018 was performed to identify RCTs examining the effects of TS on cognition before and after supplementation, in cognitively healthy individuals. RESULTS A final sample of 14 eligible RCTs met inclusion criteria. Using pooled random effects expressed as Hedge's g, comparison of placebo versus treatment groups pre- and postsupplementation showed improvements in the treatment group in executive function (g (11) = 0.14, 95% confidence interval [CI]: 0.03-0.26, z = 0.56, p = 0.011). However, it was noted that two studies in our sample did not report a significant increase in mean serum total testosterone (TT) levels in the treatment group after supplementation. Following exclusion of these studies, analysis indicated improvement in the treatment group for the overall cognitive composite (g (11) = 0.18, 95% CI: 0.02-0.33, z = 2.18), psychomotor speed (g (3) = 0.22, 95% CI: 0.01-0.43, z = 2.07) and executive function (g (9) = 0.15, 95% CI: 0.03-0.28, z = 2.35). No significant differences were noted for the global cognition, attention, verbal memory, visuospatial ability or visuospatial memory domains. CONCLUSION Overall, our findings support the potential for TS as a preventative measure against cognitive decline, although the effect sizes were small. These findings warrant further observational studies and clinical trials of good methodological quality, to elucidate the effect of TS on cognition.
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Sex, Energy, Well-Being and Low Testosterone: An Exploratory Survey of U.S. Men's Experiences on Prescription Testosterone. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16183261. [PMID: 31491933 PMCID: PMC6765788 DOI: 10.3390/ijerph16183261] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/29/2019] [Accepted: 08/31/2019] [Indexed: 12/11/2022]
Abstract
Prescription testosterone sales in the United States have skyrocketed in the last two decades due to an aging population, direct-to-consumer advertising, and prescriber views of the benefits and risks to testosterone, among other factors. However, few studies have attempted to directly examine patient experiences on prescription testosterone therapy. The present exploratory study involved an online self-report survey of U.S. testosterone patients who were at least 21 years of age. The primary focus was on patient perspectives concerning motivations leading to the initiation of testosterone therapy and the perceived effects of treatment. Responses to open-ended questions drew upon a coding scheme incorporating both inductive and deductive approaches, influenced by the clinical, male life history theory, and behavioral endocrinology literature. Results indicated that the most frequent reasons men gave for taking prescription testosterone were low testosterone (37.1%), well-being (35.2%), energy (28.7%), libido (21.9%), and social energy (19.4%); older men claimed libido as a motivation for testosterone initiation more frequently than younger men (p < 0.001). Men most frequently claimed testosterone improved their energy (52.3%), libido (41.9%), and muscle (28.5%). Results are interpreted in the context of medical, life history theoretical and behavioral endocrinology approaches, including an emphasis on sex and energy.
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30
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Kruljac M, Finnbogadóttir H, Bobjer J, Giraldi A, Fugl-Meyer K, Giwercman A. Symptoms of sexual dysfunction among men from infertile couples: prevalence and association with testosterone deficiency. Andrology 2019; 8:160-165. [PMID: 31325248 DOI: 10.1111/andr.12678] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 05/30/2019] [Accepted: 06/14/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND This case control study aimed to investigate whether symptoms of sexual dysfunction are more common in males from infertile couples than in the general population and to explore whether symptoms of sexual dysfunction are associated to hypogonadism. OBJECTIVES Participants were 165 subfertile men in infertile heterosexual relationships, 18-50 years of age, with sperm concentrations < 15 × 106 /mL. The controls were 199 men from a population-based group, matched for age. MATERIAL AND METHODS Logistic regression was applied in order to calculate odds ratios (ORs) for seven different symptoms of sexual dysfunction. In a multivariate model, we tested independent effects of infertility and primary as well as secondary hypogonadism. RESULTS Statistically significant association between subfertility and symptoms of sexual dysfunction was found for lack of ability to control ejaculation (OR 2.2, 95% CI: 1.2-4.2). For hypogonadism, statistical significance was seen both in relation to low sexual interest/desire for sex (OR 2.3, 95% CI: 1.0-5.5) and for being worried about the size or shape of the penis (OR 3.6, 95% CI: 1.3-9.5). These associations remained statistically significant in males with primary but not those with secondary hypogonadism. DISCUSSION Our study showed that men from infertile couples have an increased risk of symptoms of sexual dysfunction and this risk is linked to androgen deficiency. CONCLUSION Assessment of reproductive hormone levels and sexual function should routinely be done in this group of males.
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Affiliation(s)
- M Kruljac
- Reproductive Medicine Center, Skåne University Hospital, Malmoe, Sweden
| | - H Finnbogadóttir
- Faculty of Health and Society, Department of Care Science, Malmoe University, Malmoe, Sweden
| | - J Bobjer
- Reproductive Medicine Center, Skåne University Hospital, Malmoe, Sweden
| | - A Giraldi
- Psychiatric Center Copenhagen, Sexologic Clinic & Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - K Fugl-Meyer
- Department of Neurobiology, Care Science and Society, Karolinska Institute and Function area Social Work in Health Care, Karolinska University Hospital, Stockholm, Sweden
| | - A Giwercman
- Reproductive Medicine Center, Skåne University Hospital, Malmoe, Sweden.,Molecular Reproductive Medicine, Department of Translational Medicine, Lund University, Malmoe, Sweden
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31
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Radujkovic A, Kordelas L, Krzykalla J, Benner A, Schult D, Majer-Lauterbach J, Beelen DW, Müller-Tidow C, Kasperk C, Dreger P, Luft T. Pre-transplant testosterone and outcome of men after allogeneic stem cell transplantation. Haematologica 2019; 105:1454-1464. [PMID: 31296579 PMCID: PMC7193480 DOI: 10.3324/haematol.2019.220293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 07/10/2019] [Indexed: 12/20/2022] Open
Abstract
Testosterone is an important determinant of endothelial function and vascular health in men. As both factors play a role in mortality after allogeneic stem cell transplantation (alloSCT), we retrospectively evaluated the impact of pre-transplant testosterone levels on outcome in male patients undergoing alloSCT. In the discovery cohort (n=346), an impact on outcome was observed only in the subgroup of patients allografted for acute myeloid leukemia (AML) (n=176, hereafter termed ‘training cohort’). In the training cohort, lower pre-transplant testosterone levels were significantly associated with shorter overall survival (OS) [hazard ratio (HR) for a decrease of 100 ng/dL: 1.11, P=0.045]. This was based on a higher hazard of non-relapse mortality (NRM) (cause-specific HR: 1.25, P=0.013), but not relapse (cause-specific HR: 1.06, P=0.277) in the multivariable models. These findings were replicated in a confirmation cohort of 168 male patients allografted for AML in a different center (OS, HR: 1.15, P=0.012 and NRM, cause-specific HR: 1.23; P=0.008). Next, an optimized cut-off point for pre-transplant testosterone was derived from the training set and evaluated in the confirmation cohort. In multivariable models, low pre-transplant testosterone status (<250 ng/dL) was associated with worse OS (hazard ratio 1.95, P=0.021) and increased NRM (cause-specific HR 2.68, P=0.011) but not with relapse (cause-specific HR: 1.28, P=0.551). Our findings may provide a rationale for prospective studies on testosterone/androgen assessment and supplementation in male patients undergoing alloSCT for AML.
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Affiliation(s)
| | - Lambros Kordelas
- Department of Bone Marrow Transplantation, University Hospital, Essen
| | - Julia Krzykalla
- Division of Biostatistics, German Cancer Research Center, Heidelberg
| | - Axel Benner
- Division of Biostatistics, German Cancer Research Center, Heidelberg
| | - David Schult
- Department of Internal Medicine V, University of Heidelberg, Heidelberg
| | | | - Dietrich W Beelen
- Department of Bone Marrow Transplantation, University Hospital, Essen
| | | | - Christian Kasperk
- Department of Internal Medicine I, University of Heidelberg, Heidelberg, Germany
| | - Peter Dreger
- Department of Internal Medicine V, University of Heidelberg, Heidelberg
| | - Thomas Luft
- Department of Internal Medicine V, University of Heidelberg, Heidelberg
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32
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Buskbjerg CR, Gravholt CH, Dalby HR, Amidi A, Zachariae R. Testosterone Supplementation and Cognitive Functioning in Men-A Systematic Review and Meta-Analysis. J Endocr Soc 2019; 3:1465-1484. [PMID: 31384712 PMCID: PMC6676074 DOI: 10.1210/js.2019-00119] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/31/2019] [Indexed: 01/08/2023] Open
Abstract
Testosterone supplementation (TS) is assumed important for cognitive functioning in men, but conflicting results have prevented firm conclusions. The current study systematically reviewed available randomized controlled trials (RCTs) on effects of TS on cognitive functioning in men, subjected the findings to meta-analysis, and explored between-study differences as possible moderators of the effects. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two authors independently searched for eligible records in the electronic databases of PubMed, PsycINFO, Web of Science, the Cochrane Library, Cumulative Index of Nursing and Allied Health, and Embase and determined eligibility using the following (population, intervention, comparison, outcome) criteria: population, male adults (>18 years); intervention, TS; comparison, placebo; and outcome, results of standardized neuropsychological tests. Following duplicate removal, 3873 records were screened with 92 remaining for full-text screening. Twenty-one papers reporting results of 23 independent RCTs were included, of which none treated samples of clinically hypogonadal men. The small improvement found in overall cognitive functioning (Hedges g = 0.09; CI 95%: −0.02 to 0.19) failed to reach statistical significance (P = 0.108) and approached zero when adjusting for possible publication bias (g = 0.04). The effects for the 11 individual cognitive domains did not reach statistical significance (g: −0.04 to 0.19, P: 0.061 to 0.989). Small statistically significant (P < 0.05) effects were found for five study subsets but failed to meet the fail-safe criterion. The available evidence indicates that effects of TS on cognitive functioning in men with testosterone levels within normal ranges are less robust and of insufficient magnitude to be of clinical relevance. The effects in clinically hypogonadal men remain to be investigated.
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Affiliation(s)
- Cecilie R Buskbjerg
- Unit for Psychooncology and Health Psychology, Department of Oncology, Aarhus University Hospital and Department of Psychology and Behavioral Science, Aarhus University, Aarhus, Denmark
| | - Claus H Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Helene R Dalby
- Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Ali Amidi
- Unit for Psychooncology and Health Psychology, Department of Oncology, Aarhus University Hospital and Department of Psychology and Behavioral Science, Aarhus University, Aarhus, Denmark
| | - Robert Zachariae
- Unit for Psychooncology and Health Psychology, Department of Oncology, Aarhus University Hospital and Department of Psychology and Behavioral Science, Aarhus University, Aarhus, Denmark
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Abstract
OBJECTIVE To describe the quality of online information on testosterone replacement therapy (TRT) in men. METHODS A quantitative content analysis was conducted on websites providing patient-directed information on TRT for the purpose of treating late onset hypogonadism (LOH). Websites were identified through Google in March 2017. The DISCERN instrument was used to determine the quality of health information. RESULTS A total of 20 websites met inclusion criteria. Websites were primarily from the United States (45%), United Kingdom (25%), and Australia (15%). Sources of information were cited by 40% of websites. Several websites (40%) claimed that TRT had benefits, with 25% claiming that TRT was effective for treating LOH. TRT was described as a safe therapy by one website (5%), with gynecomastia (35%) and increased hematocrit (35%) representing the most commonly described side effects. Prostate specific antigen (35%) and serum testosterone monitoring (30%) were the most commonly described monitoring parameters. The mean DISCERN score was 46.4, indicating fair quality information. The Flesh-Kincaid Grade Level was 12.2. CONCLUSION Online TRT information is incomplete, often failing to describe important safety information and the need for regular monitoring.
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Affiliation(s)
- Evan Sehn
- a Faculty of Pharmacy & Pharmaceutical Sciences , University of Alberta , Edmonton , Alberta , Canada
| | - Cassidy Mozak
- a Faculty of Pharmacy & Pharmaceutical Sciences , University of Alberta , Edmonton , Alberta , Canada
| | - Nese Yuksel
- a Faculty of Pharmacy & Pharmaceutical Sciences , University of Alberta , Edmonton , Alberta , Canada
| | - Cheryl A Sadowski
- a Faculty of Pharmacy & Pharmaceutical Sciences , University of Alberta , Edmonton , Alberta , Canada
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Jones TH, Kelly DM. Randomized controlled trials - mechanistic studies of testosterone and the cardiovascular system. Asian J Androl 2019; 20:120-130. [PMID: 29442075 PMCID: PMC5858094 DOI: 10.4103/aja.aja_6_18] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Testosterone deficiency is common in men with cardiovascular disease (CVD), and randomized placebo-controlled trials (RCTs) have reported beneficial effects of testosterone therapy on exercise-induced cardiac ischemia in chronic stable angina, functional exercise capacity, maximum oxygen consumption during exercise (VO2max) and muscle strength in chronic heart failure (CHF), shortening of the Q-T interval, and improvement of some cardiovascular risk factors. Testosterone deficiency is associated with an adverse CV risk profile and mortality. Clinical and scientific studies have provided mechanistic evidence to support and explain the findings of the RCTs. Testosterone is a rapid-onset arterial vasodilator within the coronary circulation and other vascular beds including the pulmonary vasculature and can reduce the overall peripheral systemic vascular resistance. Evidence has demonstrated that testosterone mediates this effect on vascular reactivity through calcium channel blockade (L-calcium channel) and stimulates potassium channel opening by direct nongenomic mechanisms. Testosterone also stimulates repolarization of cardiac myocytes by stimulating the ultra-rapid potassium channel-operated current. Testosterone improves cardiac output, functional exercise capacity, VO2max and vagally mediated arterial baroreceptor cardiac reflex sensitivity in CHF, and other mechanisms. Independent of the benefit of testosterone on cardiac function, testosterone substitution may also increase skeletal muscle glucose metabolism and enhance muscular strength, both factors that could contribute to the improvement in functional exercise capacity may include improved glucose metabolism and muscle strength. Testosterone improves metabolic CV risk factors including body composition, insulin resistance, and hypercholesterolemia by improving both glucose utilization and lipid metabolism by a combination of genomic and nongenomic actions of glucose uptake and utilization expression of the insulin receptor, glucose transporters, and expression on regulatory enzymes of key metabolic pathways. The effect on high-density lipoprotein-cholesterol (HDL-C) differs between studies in that it has been found to fall, rise, or have no change in levels. Testosterone replacement can suppress the levels of circulating pro-inflammatory cytokines and stimulate the production of interleukin-10 (IL-10) which has anti-inflammatory and anti-atherogenic actions in men with CVD. No effect on C-reactive protein has been detected. No adverse effects on clotting factors have been detected. RCTs have not clearly demonstrated any significant evidence that testosterone improves or adversely affects the surrogate markers of atherosclerosis such as reduction in carotid intima thickness or coronary calcium deposition. Any effect of testosterone on prevention or amelioration of atherosclerosis is likely to occur over years as shown in statin therapy trials and not months as used in testosterone RCTs. The weight of evidence from long-term epidemiological studies supports a protective effect as evidenced by a reduction in major adverse CV events (MACEs) and mortality in studies which have treated men with testosterone deficiency. No RCT where testosterone has been replaced to the normal healthy range has reported a significant benefit or adverse effect on MACE nor has any recent meta-analysis.
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Affiliation(s)
- T Hugh Jones
- Robert Hague Centre for Diabetes and Endocrinology, Barnsley Hospital NHS Foundation Trust, Barnsley, UK.,Academic Unit of Diabetes, Endocrinology and Metabolism, Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
| | - Daniel M Kelly
- Academic Unit of Diabetes, Endocrinology and Metabolism, Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK.,Biomedical Research Centre, Sheffield Hallam University, Sheffield, UK
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35
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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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Tharakan T, Miah S, Jayasena C, Minhas S. Investigating the basis of sexual dysfunction during late-onset hypogonadism. F1000Res 2019; 8. [PMID: 30984376 PMCID: PMC6436191 DOI: 10.12688/f1000research.16561.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2019] [Indexed: 12/29/2022] Open
Abstract
Late-onset hypogonadism (LOH) is the term used to describe the decline in serum testosterone levels associated with increasing age in men above 40 years. A number of symptoms are attributed to LOH, but the most common association is that of sexual dysfunction. LOH has recently come under greater scrutiny with the widespread use of testosterone therapy, and concerns regarding the efficacy and safety of testosterone replacement therapy have been raised. In particular, the cardiovascular safety and the beneficial effects of testosterone replacement therapy on general health have been questioned. This review will give an overview of the current evidence for the relationship of LOH and male sexual dysfunction.
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Affiliation(s)
- Tharu Tharakan
- Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK.,Section of Investigative Medicine, Department of Medicine, Imperial College London, London, UK
| | - Saiful Miah
- Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Channa Jayasena
- Section of Investigative Medicine, Department of Medicine, Imperial College London, London, UK
| | - Suks Minhas
- Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
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37
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Hackett G. Metabolic Effects of Testosterone Therapy in Men with Type 2 Diabetes and Metabolic Syndrome. Sex Med Rev 2019; 7:476-490. [PMID: 30803918 DOI: 10.1016/j.sxmr.2018.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/10/2018] [Accepted: 12/13/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Up to 40% of men with type 2 diabetes (T2DM) and metabolic syndrome (MetS) have hypogonadotrophic hypogonadism (HH). Men with HH are at increased risk of cardiovascular (CV) and all-cause mortality, as well as of the development of incident T2DM. AIM To review the current literature on the metabolic effects of testosterone therapy (TTh) in men with T2DM and MetS. METHODS We searched MEDLINE, Embase, and Cochrane Reviews for articles on T2DM, HH, testosterone deficiency, and CV and all-cause mortality published between May 2005 and July 2018, yielding 1817 articles, including 54 clinical trials and 32 randomized controlled trials (RCTs). MAIN OUTCOME MEASURES The main outcomes were glycemic control, insulin resistance, lipid profile, and metabolic markers associated with increased CV risk. RESULTS RCTs of TTh suggest significant benefits for sexual function, quality of life, glycemic control, insulin sensitivity, anemia, bone density, and fat and lean muscle mass that might be expected to translate into reduced long-term morbidity and mortality. Several longitudinal and observational studies suggest long-term sustained improvements in metabolic parameters and a trend toward reduced CV and all-cause mortality, especially in men at increased CV risk, such as those with T2DM and MetS. The greatest benefit is seen in those men treated with TTh to target levels and for longer durations. CONCLUSION Meta-analyses of RCTs, rather than providing clarification, may have further confused the issue by including underpowered studies of inadequate duration, multiple therapy regimens, some obsolete or withdrawn, and built-in bias in terms of studies included or excluded from analysis. Hackett G. Metabolic Effects of Testosterone Therapy in Men with Type 2 Diabetes and Metabolic Syndrome. Sex Med Rev 2019;7:476-490.
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Affiliation(s)
- Geoffrey Hackett
- Department of Urology, University Hospitals Birmingham NHS Foundation Trust and University of Aston, Birmingham, United Kingdom.
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38
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Swee DS, Gan EH. Late-Onset Hypogonadism as Primary Testicular Failure. Front Endocrinol (Lausanne) 2019; 10:372. [PMID: 31244778 PMCID: PMC6581721 DOI: 10.3389/fendo.2019.00372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/24/2019] [Indexed: 12/21/2022] Open
Affiliation(s)
- Du Soon Swee
- Endocrine Unit, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Earn H. Gan
- Institute of Genetic Medicine, International Centre for Life, Newcastle University, Newcastle upon Tyne, United Kingdom
- South Tyneside and Sunderland NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- *Correspondence: Earn H. Gan
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Walther A, Breidenstein J, Miller R. Association of Testosterone Treatment With Alleviation of Depressive Symptoms in Men: A Systematic Review and Meta-analysis. JAMA Psychiatry 2019; 76:31-40. [PMID: 30427999 PMCID: PMC6583468 DOI: 10.1001/jamapsychiatry.2018.2734] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Countering depressive disorders is a public health priority. Currently, antidepressants are the first-line treatment, although they show modest effects. In men, testosterone treatment is a controversial alternative or adjunct treatment option. OBJECTIVES To examine the association of testosterone treatment with alleviation of depressive symptoms in men and to clarify moderating effects of testosterone status, depression status, age, treatment duration, and dosage. DATA SOURCES English-language studies published in peer-reviewed journals identified from PubMed/Medline, Embase, Scopus, PsychINFO, and the Cochrane Controlled Trials Register from database inception to March 5, 2018, using the search terms testosterone, mood, administration, dosage, adverse effects, deficiency, standards, therapeutic use, therapy, treatment, and supplementation. STUDY SELECTION Randomized placebo-controlled clinical trials (RCTs) of testosterone treatment that together cover a broad age range and hypogonadal or eugonadal men reporting depressive symptoms on psychometrically validated depression scales. DATA EXTRACTION AND SYNTHESIS Of 7690 identified records, 469 were evaluated against full study inclusion criteria after removing duplicates, reviews, and studies that did not examine male patients or testosterone. Quality assessment and data extraction from the remaining 27 RCTs were performed. MAIN OUTCOMES AND MEASURES Primary outcomes were testosterone treatment effectiveness (standardized score difference after treatment), efficacy (proportion of patients who responded to testosterone treatment with a score reduction of 50% or greater), and acceptability (proportion of patients who withdrew for any reason). RESULTS Random-effects meta-analysis of 27 RCTs including 1890 men suggested that testosterone treatment is associated with a significant reduction in depressive symptoms compared with placebo (Hedges g, 0.21; 95% CI, 0.10-0.32), showing an efficacy of odds ratio (OR), 2.30 (95% CI, 1.30-4.06). There was no significant difference between acceptability of testosterone treatment and placebo (OR, 0.79; 95% CI, 0.61-1.01). Meta-regression models suggested significant interactions for testosterone treatment with dosage and symptom variability at baseline. In the most conservative bias scenario, testosterone treatment remained significant whenever dosages greater than 0.5 g/wk were administered and symptom variability was kept low. CONCLUSIONS AND RELEVANCE Testosterone treatment appears to be effective and efficacious in reducing depressive symptoms in men, particularly when higher-dosage regimens were applied in carefully selected samples. However, given the heterogeneity of the included RCTs, more preregistered trials are needed that explicitly examine depression as the primary end point and consider relevant moderators.
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Affiliation(s)
- Andreas Walther
- Department of Biological Psychology, Technische Universität Dresden, Dresden, Germany,Department of Clinical Psychology and Psychotherapy, University of Zurich, Zurich, Switzerland,Task Force on Men’s Mental Health of the World Federation of the Societies of Biological Psychiatry
| | - Jonas Breidenstein
- Department of Biological Psychology, Technische Universität Dresden, Dresden, Germany
| | - Robert Miller
- Department of Biological Psychology, Technische Universität Dresden, Dresden, Germany,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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40
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Kische H, Hoyer J, Pieper L, Venz J, Klotsche J, März W, Koch-Gromus U, Pittrow D, Lehnert H, Silber S, Stalla GK, Zeiher AM, Wittchen HU, Haring R. Testosterone is not associated with traits of optimism or pessimism: Observational evidence from the prospective DETECT study. PLoS One 2018; 13:e0207870. [PMID: 30496216 PMCID: PMC6264867 DOI: 10.1371/journal.pone.0207870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 11/06/2018] [Indexed: 11/18/2022] Open
Abstract
Background Previous experimental research on testosterone (T) and psychological traits is inconclusive. Thus, we performed the first large-scale observational study of the association between T and dispositional optimism / pessimism. Methods We used prospective data from 6,493 primary-care patients (3,840 women) of the DETECT study (Diabetes Cardiovascular Risk-Evaluation: Targets and Essential Data for Commitment of Treatment), including repeated immunoassay-based measurement of serum T and optimism / pessimism assessed by the revised Life-Orientation Test (LOT-R). Cross-sectional and longitudinal associations of baseline T and one-year change in T with optimism and pessimism were investigated using age- and multivariable-adjusted regression models. Results Cross-sectional analyses showed no association of T with optimism or pessimism in both sexes. Longitudinal analyses also showed no association of baseline T with optimism or pessimism at four-year follow-up. Multivariable analyses of total LOT-R score yielded similarly non-significant results (β-coefficient per unit change in T for men: -0.01 (95% CI: -0.24–0.22), women: 0.08 (-0.03–0.20)). Furthermore, change in T was not related to optimism or pessimism at four-year follow-up. Conclusions The present observational study of a large-scale prospective sample showed no association of T with optimism or pessimism. Integrating further experimental and interventional evidence from alternative methodological approaches would strengthen this conclusion and establish stronger evidence about the potential hormonal basis of psychological traits.
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Affiliation(s)
- Hanna Kische
- Behavioral Epidemiology, Institute of Clinical Psychology and Psychotherapy, Technical University of Dresden, Dresden, Germany
| | - Jürgen Hoyer
- Institute of Clinical Psychology and Psychotherapy, Technical University of Dresden, Dresden, Germany
| | - Lars Pieper
- Behavioral Epidemiology, Institute of Clinical Psychology and Psychotherapy, Technical University of Dresden, Dresden, Germany
| | - John Venz
- Behavioral Epidemiology, Institute of Clinical Psychology and Psychotherapy, Technical University of Dresden, Dresden, Germany
| | - Jens Klotsche
- German Rheumatism Research Centre Berlin, Berlin, Germany
| | - Winfried März
- Medical Clinic V, Medical Faculty Mannheim at Heidelberg University, Heidelberg, Germany
| | - Uwe Koch-Gromus
- Department of Medical Psychology, University Medical Center Eppendorf, Hamburg, Germany
| | - David Pittrow
- Institute of Clinical Pharmacology, Medical Faculty, Technical University of Dresden, Dresden, Germany
| | - Hendrik Lehnert
- Department of Medicine I, University of Schleswig-Holstein, Lübeck, Germany
| | | | | | - Andreas M. Zeiher
- Department of Medicine III Cardiology, Goethe University Frankfurt, Frankfurt, Germany
| | - Hans-Ulrich Wittchen
- Institute of Clinical Psychology and Psychotherapy, Technical University of Dresden, Dresden, Germany
| | - Robin Haring
- European University of Applied Sciences, Faculty of Applied Public Health, Rostock, Germany
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- * E-mail:
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41
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Korenman SG, Grotts JF, Bell DS, Elashoff DA. Depression in Nonclassical Hypogonadism in Young Men. J Endocr Soc 2018; 2:1306-1313. [PMID: 30430144 PMCID: PMC6223247 DOI: 10.1210/js.2018-00137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 09/18/2018] [Indexed: 01/28/2023] Open
Abstract
The specific objective of this study was to test the clinically derived hypothesis associating a high prevalence of depression in young men with nonclassical hypogonadism. We studied the entire population of men aged 18 to 40 years who had an outpatient visit at an academic health system in the years 2013 to 2015. The study group comprised 186 patients with a diagnosis of eugonadotropic hypogonadism and a testosterone value below 10.4 nmol/L with no apparent cause. We compared their demographic factors, other diagnoses, and treatments with those of (i) the entire population, (ii) a matched population of 930 controls, and (iii) 404 controls with normal testosterone determinations, and no hypogonadism diagnosis. Depression, defined as either an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis or treatment with an antidepressant medication, was found in 22.6% of cases vs 6.6% of population controls [P < 0.001; OR: 1.13 (1.09 to 1.17); 95% CI]. Obesity was also higher in the cases (P < 0.001). The matched controls had a depression rate of 13.4% compared with the case rate of 22.6% [P < 0.002; OR 1.14 (1.08 to 1.17)]. Controls with normal testosterone determinations had a depression rate of 16.8% [P = 0.121; OR: 1.04 (0.96 to 1.12)], suggesting that clinicians may have ordered a testosterone determination because of symptoms consistent with both depression and hypogonadism. The high incidence of depression in nonclassical hypogonadism in young men, although only associative, supports a depression evaluation and treatment as appropriate as well as investigation of the proximate causes of this form of hypogonadism.
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Affiliation(s)
- Stanley G Korenman
- Department of Medicine, David Geffen School of Medicine at UCLA and the UCLA Clinical and Translational Science Institute, Los Angeles, California
| | - Jonathan F Grotts
- Department of Medicine, David Geffen School of Medicine at UCLA and the UCLA Clinical and Translational Science Institute, Los Angeles, California
| | - Douglas S Bell
- Department of Medicine, David Geffen School of Medicine at UCLA and the UCLA Clinical and Translational Science Institute, Los Angeles, California
| | - David A Elashoff
- Department of Medicine, David Geffen School of Medicine at UCLA and the UCLA Clinical and Translational Science Institute, Los Angeles, California
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42
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Abstract
The finding of low circulating testosterone level in men is relatively frequent. The symptoms of hypogonadism are very frequent in the aging men. However, the diagnosis of hypogonadism is often neglected and the opportunity to replace low testosterone in older men is highly debated. The aim of this narrative review is to summarize the steps necessary to formulate a proper diagnosis and to guide toward an individualized treatment. While universally recognized the need to treat the young adults with known causes of pituitary or testicular failure, there are controversies on the cost-benefit of treating testosterone deficiency in older men. Discrepancies among the several available guidelines do not help to clarify the scenario, however, the recent larger clinical trials have shed some light on the fact that testosterone treatment carries some benefit, that is not free from risks. We provide an updated review of the diagnostic hallmarks, the several treatment modalities, with their advantages and disadvantages, and how to individualize and monitor treatment in order to maximize the benefits and minimize the risks. The treatment of male hypogonadism can no longer be downgraded and must become part of the cultural baggage of the endocrinologist.
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Affiliation(s)
- Christos P Tsametis
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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43
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Hackett G. Type 2 Diabetes and Testosterone Therapy. World J Mens Health 2018; 37:31-44. [PMID: 30079639 PMCID: PMC6305869 DOI: 10.5534/wjmh.180027] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/03/2018] [Accepted: 04/08/2018] [Indexed: 01/24/2023] Open
Abstract
A third of men with type 2 diabetes (T2DM) have hypogonadotrophic hypogonadism (HH) and associated increased risk of cardiovascular and all-cause mortality. Men with HH are at increased risk of developing incident T2DM. We conducted MEDLINE, EMBASE, and COCHRANE reviews on T2DM, HH, testosterone deficiency, cardiovascular and all-cause mortality from May 2005 to October 2017, yielding 1,714 articles, 52 clinical trials and 32 randomized controlled trials (RCT). Studies with testosterone therapy suggest significant benefits in sexual function, quality of life, glycaemic control, anaemia, bone density, fat, and lean muscle mass. Meta-analyses of RCT, rather than providing clarification, have further confused the issue by including under-powered studies of inadequate duration, multiple regimes, some discontinued, and inbuilt bias in terms of studies included or excluded from analysis.
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Affiliation(s)
- Geoffrey Hackett
- Department of Urology, Good Hope Hospital, Heart of England Foundation Trust and University of Aston, Birmingham, UK.
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44
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Debate position: cognition and mood are not improved in men administered exogenous testosterone therapy. Curr Opin Urol 2018; 27:525-531. [PMID: 28863017 DOI: 10.1097/mou.0000000000000435] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to provide an overview of the increasing evidence suggesting that exogenous testosterone therapy is not associated with improvements in cognition or mood. This article is part of a series, in this issue, in which authors are assigned opinion pieces on controversial topics pertaining to testosterone replacement. RECENT FINDINGS Testosterone is increasingly being prescribed. Particularly in the setting of recent data suggestive of possible cardiovascular risk associated with its use; a clear understanding of the domains of health that improve with exogenous testosterone use is important. Data on endogenous and exogenous testosterone with cognition and mood are mixed, likely partly related to methodological differences of type of testosterone, patient population, and dosing. SUMMARY Overall, available data are not suggestive of a clear benefit of testosterone supplementation in multiple domains of cognition and in mood. Supraphysiologic testosterone has been associated with adverse psychological outcomes, albeit not uniformly in studies.
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46
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Coutinho J, Field JB, Sule AA. Armour® Thyroid Rage - A Dangerous Mixture. Cureus 2018; 10:e2523. [PMID: 29942726 PMCID: PMC6015989 DOI: 10.7759/cureus.2523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 04/24/2018] [Indexed: 11/17/2022] Open
Abstract
Armour® Thyroid (Forest Pharmaceuticals, LLC; affiliate of Allergan, Dublin, Ireland) is a natural porcine derivative thyroid supplement that is frequently used without physician monitoring by health enthusiasts as a weight loss supplement. Although there are no publications associating Armour Thyroid and major coronary events, significant drug interactions may exist. A 32-year-old male with a history of hypothyroidism, cystic acne, and solitary congenital kidney presented to the emergency room after experiencing crushing substernal chest pain radiating to his left shoulder, accompanied by diaphoresis and shortness of breath. The patient denied any tobacco use or family history of heart disease. He was self-administering 120 mg of Armour Thyroid daily. On examination, the patient was well-developed with cystic acne and a flushed appearance. His vital signs on admission were a blood pressure of 171/106 mmHg, heart rate of 88 beats per minute (bpm), and respiratory rate of 16 breaths/min. The electrocardiogram revealed marked ST-segment elevation in the anterior chest leads. Laboratory studies revealed elevated troponins. Urine drug screen was negative. The patient underwent an emergent coronary angiogram, which confirmed an occluded left anterior descending artery. He was treated successfully by thrombectomy and stenting of his left anterior descending artery. Evaluation for other causes of thrombosis was negative: glycosylated hemoglobin (HbA1C) 5.5%, low-density lipoprotein (LDL) 127 mg/dL, high-density lipoprotein (HDL) 33 mg/dL, hypercoagulable evaluation negative, and hemoglobin (Hgb) 17.1 gm/dL. Luteinizing hormone (LH) and follicle stimulating hormone (FSH) were < 0.20 miu/mL. Thyroid profile results were thyroid-stimulating hormone (TSH) 0.20 miu/mL (low), T3 free 4.08 pg/mL (high), and T4 total 1.2 mcg/dL (low), which were consistent with exogenous thyroid hormone administration. Focused questioning triggered by his cystic acne led to the discovery that the patient was self-administering exogenous testosterone replacement therapy. The patient declined to share specifics with the healthcare team. This was confirmed by a high testosterone level of 1,311 ng/dL. Hyperthyroidism increases the risk of cardiovascular events two to three times through the propagation of a hypercoagulable, hypofibrinolytic state possibly via an increase in clotting factors, a decrease in fibrinolytic enzymes, and an increased inhibition of the protein C pathway. The effect of androgens on cardiovascular mortality is uncertain. Androgens stimulate the hemostatic system, increase adverse lipid profile, and erythropoiesis. The combined therapy likely resulted in a synergistic potentiation of hypercoagulable, hypofibrinolytic effects of both agents. Given the absence of other cardiovascular risk factors, the cause of the myocardial infarction in our patient was likely due to drug interaction between Armour Thyroid and exogenous testosterone therapy. Due to the potential drug interaction between both natural and prescribed thyroid hormone and testosterone supplements, patients should be discouraged from self-administration of thyroid or anabolic steroids. Due to the lack of standardization in the T3 content, the use of Armour Thyroid should be avoided.
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Affiliation(s)
- Joshua Coutinho
- Internal Medicine, St. Joseph Mercy Oakland Hospital, Oakland, USA
| | - Justin B Field
- Internal Medicine, St. Joseph Mercy Oakland Hospital, Oakland, USA
| | - Anupam A Sule
- Internal Medicine, St. Joseph Mercy Oakland Hospital, Oakland, USA
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[Androgens and cardiovascular risk: A series of case report in the French and Canadian pharmacovigilance databases]. Prog Urol 2018; 28:315-321. [PMID: 29650456 DOI: 10.1016/j.purol.2018.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 11/12/2017] [Accepted: 03/16/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Age-related androgenic deficiency (DALA) is a pathology that is increasingly cited in recent publications. The cardiovascular risk of testosterone is debated: present for the FDA, absent for the European Medicines Agency in 2015. Our objective was to analyze the association between androgens and vascular pathologies in adverse reactions reported in pharmacovigilance databases. MATERIAL AND METHOD We conducted a retrospective case series study of the French and Canadian pharmacovigilance databases for the period 2005-2015. Cases were defined as the association of the occurrence of a cardiovascular event (myocardial infarction or stroke) and the presence of testosterone in the treatment of patients. RESULTS Of the 10 years analyzed, 12 French cases and 6 Canadian cases (representing 13 MIs and 5 strokes) were recorded in men aged 55 years on average. All were doubtful: differential diagnoses were possible (2.4 confounding conditions on average per patient) and overall cardiovascular risk was high for the majority of cases. CONCLUSION Our study shows a very low report of cardiovascular effects under testosterone, all doubtful. Pending further studies, it seems reasonable to consider the cardiovascular risk of patients who are candidates for hormone therapy for age-related androgen deficiency. LEVEL OF EVIDENCE 3.
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Elgendy AY, Elgendy IY, Mahmoud AN, Al-Ani M, Moussa M, Mahmoud A, Mojadidi MK, Anderson RD. Statin Use in Men and New Onset of Erectile Dysfunction: A Systematic Review and Meta-Analysis. Am J Med 2018; 131:387-394. [PMID: 29146233 DOI: 10.1016/j.amjmed.2017.10.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 10/20/2017] [Accepted: 10/20/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Erectile dysfunction has been reported as an adverse effect of statin therapy. METHODS We performed a meta-analysis of randomized trials and observational studies that compared statin users versus non-statin users and reported data regarding new onset of erectile dysfunction in men with established cardiovascular disease or cardiovascular disease risk factors. We used DerSimonian-Laird and Peto models to construct the summary estimates risk ratio. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess the overall quality of evidence for new-onset erectile dysfunction. RESULTS Three randomized trials and 3 observational studies were identified, with 69,448 men, of whom 24,661 were statin users. Statin use was not associated with an increased risk of new onset of erectile dysfunction by random effects model or fixed effect model (risk ratio 0.96; 95% confidence interval, 0.84-1.10; P = .58; and odds ratio 0.95; 95% confidence interval, 0.88-1.02; P = .20, respectively). This effect was similar in randomized trials and observational studies (Pinteraction = .86). Randomized trials provided a moderate quality of evidence, and observational studies provided a very low quality of evidence by the GRADE assessment. Random effects meta-regression analyses revealed no difference in treatment effect according to age or diabetes mellitus (P = .83 and P = .74, respectively). CONCLUSIONS Among men with established cardiovascular disease or cardiovascular disease risk factors, statin use does not seem to be associated with a new onset of erectile dysfunction. Adequately powered and high-quality randomized trials are recommended to confirm these findings.
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Affiliation(s)
- Akram Y Elgendy
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville
| | - Ahmed N Mahmoud
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville
| | - Mohammad Al-Ani
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville
| | - Mohamed Moussa
- Department of Medicine, North Florida/South Georgia Veterans Health System, Gainesville
| | - Ahmad Mahmoud
- Department of Medicine, University of Florida, Gainesville
| | - Mohammad K Mojadidi
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville
| | - R David Anderson
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville.
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Nam YS, Lee G, Yun JM, Cho B. Testosterone Replacement, Muscle Strength, and Physical Function. World J Mens Health 2018; 36:110-122. [PMID: 29623702 PMCID: PMC5924952 DOI: 10.5534/wjmh.182001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 12/19/2017] [Accepted: 12/26/2017] [Indexed: 12/15/2022] Open
Abstract
Muscle strength and physical function decrease in older men, as do testosterone levels. Nonetheless, the effects of testosterone replacement therapy on muscle strength and physical function remain inconclusive and equivocal. We conducted a rapid systematic review, the results of which showed that testosterone replacement does not affect muscle strength (measured by hand grip strength and leg muscle strength), although it may increase physical function (measured by the 6-minute walk test, Physical Activity Scale for the Elderly score, and other physical performance tests). However, most of the studies were conducted in the United States or Europe and did not include participants from Asian or other ethnic backgrounds; therefore, further studies are needed to evaluate the effects of testosterone replacement in a broader population.
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Affiliation(s)
- You Seon Nam
- Department of Family Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Gyeongsil Lee
- Department of Family Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jae Moon Yun
- Department of Family Medicine, Seoul National University Hospital, Seoul, Korea
| | - Belong Cho
- Department of Family Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Family Medicine, Seoul National University Hospital, Seoul, Korea.,Advanced Institutes of Convergence Technology, Seoul National University, Suwon, Korea.,Institute on Aging, Seoul National University College of Medicine, Seoul, Korea.
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Ponce OJ, Spencer-Bonilla G, Alvarez-Villalobos N, Serrano V, Singh-Ospina N, Rodriguez-Gutierrez R, Salcido-Montenegro A, Benkhadra R, Prokop LJ, Bhasin S, Brito JP. The efficacy and adverse events of testosterone replacement therapy in hypogonadal men: A systematic review and meta-analysis of randomized, placebo-controlled trials. J Clin Endocrinol Metab 2018; 103:4939466. [PMID: 29562341 DOI: 10.1210/jc.2018-00404] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 02/27/2018] [Indexed: 02/13/2023]
Abstract
CONTEXT The efficacy and safety of testosterone replacement therapy (TRT) in hypogonadal men remain incompletely understood. OBJECTIVE To conduct a systematic review and meta-analysis of randomized clinical trials (RCT) to determine the effects of TRT on patient-important outcomes and adverse events in hypogonadal men. DATA SOURCES We searched Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Database of Systematic Reviews, Ovid Cochrane Central Register of Controlled Trials, and Scopus from inception to March 2th, 2017. STUDY SELECTION RCTs that assessed the efficacy and adverse events of TRT of at least 12 weeks compared with placebo in adult men with hypogonadism, defined by morning testosterone ≤300 ng/dL and at least one symptom or sign of hypogonadism. DATA EXTRACTION Reviewers working independently and in duplicate assessed the quality of the trials and collected data on patient characteristics, interventions, and outcomes. DATA SYNTHESIS We found 11 publications, reporting on 4 eligible trials (including 1,779 patients) at low risk of bias. Compared to placebo, TRT was associated with a small but significant increase in sexual desire or libido [standardized mean difference (SMD): 0.17, 95% CI 0.01, 0.34] (n=1383), erectile function [SMD: 0.16, 95% CI 0.06, 0.27] (n=1344), and sexual satisfaction [SMD: 0.16, 95% CI 0.01, 0.31] (n=676), but had no effect on energy or mood. TRT was associated with an increased risk of developing erythrocytosis [relative risk: 8.14, 95% CI: 1.87, 35.40] (n=1579) compared to placebo, but had no significant effect on lower urinary tract symptoms (LUTS). CONCLUSION In hypogonadal men TRT improves sexual desire, erectile function, and sexual satisfaction, however it increases the risk of erythrocytosis.
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Affiliation(s)
- Oscar J Ponce
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
- CONEVID, Unidad de Conocimiento y Evidencia, Universidad Peruana Cayetano Heredia, Lima, Peru
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Gabriela Spencer-Bonilla
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Neri Alvarez-Villalobos
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Universidad Autonoma de Nuevo Leon, Hospital Universitario "Dr. José E. Gonzalez", Plataforma INVEST-KER Mexico, Monterrey, Nuevo León, México
| | - Valentina Serrano
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Nutrition, Diabetes and Metabolism, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Naykky Singh-Ospina
- Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, Florida, USA
| | - Rene Rodriguez-Gutierrez
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Universidad Autonoma de Nuevo Leon, Hospital Universitario "Dr. José E. Gonzalez", Plataforma INVEST-KER Mexico, Monterrey, Nuevo León, México
| | - Alejandro Salcido-Montenegro
- Universidad Autonoma de Nuevo Leon, Hospital Universitario "Dr. José E. Gonzalez", Plataforma INVEST-KER Mexico, Monterrey, Nuevo León, México
| | - Raed Benkhadra
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Larry J Prokop
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota, USA
| | - Shalender Bhasin
- Section of Men's Health: Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's Hospital-Harvard Medical School, Boston, Massachusetts, USA
| | - Juan P Brito
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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