Clinical efficiency of combination therapy using testosterone replacement therapy, phosphodiesterase 5 inhibitors and Kampo herbal medicine for eugonadal patients with late-onset hypogonadism syndrome

Trans Dermal Testosterone Compared to Intramuscular Testosterone for Young Males with Delayed Puberty: A PRISMA Guided Systematic Review

Background

Challenges in selecting the right formulation of testosterone (TE) for young males with delayed puberty (DP) arise from the fact that there is limited evidence based guidelines in recommending the most efficient and safe formulation of TE.

Objective

To evaluate the existing evidence and systematically review the interventional effects of transdermal TE to other modes of TE administration for the treatment of DP among young and adolescent males.

Methods

All types of methodologies published in English were searched from the data sources including MEDLINE, Embase, Cochrane Reviews, Web of Science, AMED and Scopus from 2015 till 2022. Boolean operators with keywords "types of TE", "modes of TE administration", "DP", "transdermal TE", "constitutional delay of growth and puberty, (CDGP)" "adolescent boys" and "hypogonadism" to optimize the search results. The main outcomes of concern were optimal serum TE level, body mass index, height velocity, testicular volume, pubertal stage (Tanner), The secondary outcomes included in this study were adverse events and patient satisfaction.

Results

After screening 126 articles, 39 full texts were reviewed. Only five studies could be included after careful screening and rigid quality assessments. Most studies were at high or unclear risk of bias with short duration and follow up periods. Only one study was a clinical trial covering all the outcomes of interests.

Conclusion

This study points out the favorable effects of transdermal TE treatment for DP in boys, while the existence of the vast gap in research needs to be acknowledged. Despite the utmost demand in an appropriate TE treatment for young males with DP, scarce efforts and trials are being undertaken to provide clear clinical guidance of treatment. Quality of life, cardiac events, metabolic parameters, coagulation profiles are important aspects of the treatment are overlooked and under evaluated in most studies.

Systematic Review Registration

PROSPERO CRD 42022369699.

Late-Onset Hypogonadism in a Male Patient with Long COVID Diagnosed by Exclusion of ME/CFS

After the acute phase of COVID-19, some patients have been reported to have persistent symptoms including general fatigue. We have established a COVID-19 aftercare clinic (CAC) to provide care for an increasing number of these patients. Here, we report the case of a 36-year-old man who developed post-COVID fatigue after acute infection with SARS-CoV-2. In the acute phase of COVID-19, the patient’s fever resolved within four days; however, general fatigue persisted for three months, and he visited our CAC 99 days after the initial infection. Examination revealed a high Aging Male’s Symptoms (AMS) score of 44 and low free testosterone (FT) level of 5.5 pg/mL, which meet the Japanese criteria of late-onset hypogonadism (LOH) syndrome. Imaging studies revealed an atrophic pituitary in addition to fatty liver and low bone mineral density. Anterior pituitary function tests showed a low follicle-stimulating hormonelevel and delayed reaction of luteinizing hormone (LH) after gonadotropin-releasing hormone (GnRH) stimulation, indicating the possibility of hypothalamic hypogonadism in addition to primary hypogonadism seen in patients with post-COVID-19 conditions. After the initiation of Japanese traditional medicine (Kampo medicine: hochuekkito followed by juzentaihoto), the patient’s symptoms as well as his AMS score and serum FT level were noticeably improved. Furthermore, follow-up tests of GnRH stimulation revealed improvements in LH responsiveness. Although many patients have been reported to meet the criteria of ME/CFS such as our case, we emphasize the possibility of other underlying pathologies including LOH syndrome. In conclusion, LOH syndrome should be considered a cause of general fatigue in patients with post-COVID-19 conditions and herbal treatment might be effective for long COVID symptoms due to LOH (264 words).