Hypogonadism: Easy to define, hard to diagnose, and controversial to treat

Analysis of the association between testosterone and cardiovascular disease potential risk factor apolipoprotein B in adult males without cancer: national health and nutrition examination survey 2011-2016

Background

Over the years, there has been extensive exploration of the association between testosterone and lipid profiles, yet the precise mechanisms underlying their interaction remain incompletely elucidated. Similarly, there is a dearth of research on the correlation between serum apolipoprotein B (apoB) and serum total testosterone (TT), particularly within specific populations.

Methods

We conducted a cross-sectional study to assess the relationship between serum TT concentration and serum apoB concentration. Using the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2016, we employed weighted generalized linear models, weighted univariate, weighted multivariate analysis, and smooth curve fitting to assist in exploring the relationship between serum TT and apoB. Serum apoB concentration served as the independent variable, and serum TT concentration as the dependent variable. ApoB was divided into four quartiles-Q1 (<0.7g/L, N=691), Q2 (≥0.7g/L to <0.9g/L, N=710), Q3 (≥0.9g/L to <1.1g/L, N=696), and Q4 (≥1.1g/L, N=708)-thereby further solidifying the stable association between the two. Additionally, the application of smooth curve fitting will contribute to a more detailed elucidation of the specific relationship between serum TT concentration and serum apoB concentration under different factors (Drinking, Smoke, Diabetes, Hypertension, and High cholesterol level.).

Results

The results indicate a negative correlation between serum TT concentration and apoB concentration (β=-113.4; 95% CI: -146.6, -80.2; P<0.001). After adjusting for confounding variables, the negative correlation between apoB concentration and TT concentration remains significant (β=-61.0; 95% CI: -116.7, -5.2; P=0.040). When apoB concentration was converted from a continuous variable to a categorical variable (quartiles: Q1<0.7g/L; Q2:≥0.7g/L to<0.9g/L; Q3:≥0.9g/L to <1.1g/L; Q4: ≥1.1g/L), TT level of participants in the highest quartile (≥1.1g/L) was -47.2 pg/mL (95% CI: -91.2, -3.3; P=0.045) lower than that in the lowest quartile (<0.7g/L). The smooth curve fitting diagram revealed differences in the relationship between TT concentration and apoB among individuals with different cardiovascular disease (CVD) risk factors.

Conclusions

This study elucidates a robust inverse correlation between serum TT concentration and apoB concentration, maintaining statistical significance even upon adjustment for confounding factors. These findings present a promising avenue for addressing the prevention and treatment of low testosterone and CVD.

Muscle Strength and Male Sexual Function

Sexual dysfunction, in particular erectile dysfunction, is a common complaint among aging men. Obesity, diabetes, hypertension, and smoking are shown to be independent risk factors for erectile dysfunction, while cardiorespiratory fitness is shown to be protective. Less is known about the role of muscle strength in male sexual function. Our objective was to study the association between male sexual function and typical cardiovascular risk factors, together with exercise and muscle strength. We included data from the fourth wave of the RHINE study. Data on anthropometrics, exercise habits, diseases, muscle strength, and sexual function were collected using questionnaires, including the Aging Males' Symptoms (AMS) scale. We used multivariable logistic regression analysis to measure the association between sexual function and body mass index (BMI), age, smoking, diabetes, hypertension, exercise and muscle strength status. We included 2116 men aged 48-75 from four Nordic-Baltic countries. BMI, age, smoking, diabetes, and hypertension were found to be associated with higher odds of reporting decreased sexual function, while reporting intact muscle strength was associated with lower odds. In a large Nordic-Baltic male study population, we show that known cardiovascular risk factors are associated with decreased sexual function, while reporting intact muscle strength is associated with lower odds of reporting decreased sexual function.

Comparison of Intratesticular Testosterone between Men Receiving Nasal, Intramuscular, and Subcutaneous Pellet Testosterone Therapy: Evaluation of Data from Two Single-Center Randomized Clinical Trials

PURPOSE

Testosterone replacement therapy (TRT) can potentially cause decreased spermatogenesis and subsequent infertility. Recent studies have suggested that 17-hydroxyprogesterone (17-OHP) is a reliable surrogate for intratesticular testosterone (ITT) that is essential for spermatogenesis. We evaluated data from two ongoing open-label, randomized, two-arm clinical trials amongst different treatment preparations (Trial I) subcutaneous testosterone pellets (TP) and (Trial II) intranasal testosterone (NT) or intramuscular testosterone cypionate (TC).

MATERIALS AND METHODS

Seventy-five symptomatic hypogonadal men (2 serum testosterone <300 ng/dL) were randomized into open label randomized clinical trials. Eligible subjects received 800 mg TP, 11 mg TID NT or 200 mg ×2 weeks TC. 17-OHP and Serum testosterone were evaluated at baseline and follow-up. The primary outcome was changes in 17-OHP. Secondary outcome was changes in serum testosterone. Data was analyzed by two-sample and single-sample t-tests, and determination of equal or unequal variances was computed using F-tests.

RESULTS

Median participant age was 45 years old, with overall baseline 17-OHP of 46 and serum testosterone of 223.5 ng/dL. 17-OHP significantly decreased in subjects prescribed long-acting TP or TC. The 4-month change in 17-OHP in the NT group (-33.3% from baseline) was less than the change seen in TC (-65.3% from baseline) or TP (-44% from baseline) (p=0.005). All testosterone formulations increased serum testosterone levels at follow-up, with the largest increase seen in TC (+157.6%), followed by NT (+114.3%) and TP (+79.6%) (p=0.005).

CONCLUSIONS

Short-acting nasal testosterone appear to have no impact on serum 17-OHP especially in comparison to long-acting testosterone formulations. All modalities saw significant increases in serum testosterone levels at follow-up. NT and other short acting testosterone formulations may better preserve ITT and be beneficial for hypogonadal men seeking to maintain fertility potential while on TRT.

Ketogenic state improves testosterone serum levels-results from a systematic review and meta-analysis

BACKGROUND

It is widely demonstrated that obesity and hypogonadism are bi-directionally correlated, since the hypogonadism prevalence is higher in obese population, while weight loss increases testosterone serum levels. Several approaches are available to contrast weight excess, from simple dietary regimens to more complex surgical procedures. Ketogenic diets (KD) fit in this context and their application is growing year after year, aiming to improve the metabolic and weight patterns in obese patients. However, KD influence on testosterone levels is still poorly investigated.

OBJECTIVES

To systematically evaluate the potential effect of KD on testosterone levels.

METHODS

A systematic literature search was performed until April 2022 including studies investigating testosterone levels before and after KD. Secondary endpoints were body weight, estradiol and sex-hormone binding globulin serum levels. Any kind of KD was considered eligible, and no specific criteria for study populations were provided.

RESULTS

Seven studies (including eight trials) were included in the analysis for a total of 230 patients, five using normocaloric KD and three very low calories KD (VLCKD). Only three studies enrolled overweight/obese men. A significant total testosterone increase was recorded after any kind of KD considering 111 patients (2.86 [0.95, 4.77], p = 0.003). This increase was more evident considering VLCKD compared to normocaloric KD (6.75 [3.31, 10.20], p < 0.001, versus 0.98 [0.08, 1.88], p = 0.030). Meta-regression analyses highlighted significant correlations between the post-KD testosterone raise with patients' age (R-squared 36.4, p < 0.001) and weight loss (R-squared 73.6, p < 0.001).

CONCLUSIONS

Comprehensively, KD improved testosterone levels depending on both patients' age and KD-induced weight loss. However, the lack of information in included studies on hormones of the hypothalamic-pituitary-gonadal axis prevents an exhaustive comprehension about mechanisms connecting ketosis and testosterone homeostasis.

Hypogonadism and urologic surgeries: a narrative review

Background and Objective

Previous studies indicated that the treatment of male hypogonadism can be beneficial for intraoperative and postsurgical outcomes. In this study, we aimed to determine the impact of male hypogonadism on urologic surgeries. We provided an overview of the key studies in the field with the focus on the outcomes of urologic surgeries in hypogonadal men with/without testosterone replacement therapy (TRT).

Methods

We performed a literature review in PubMed and Google Scholar databases for the most relevant articles pertaining to the outlined topics without placing any limitations on publication years or study designs. We included full-text English articles published in peer reviewed journals between January 1970 and March 2022.

Key Content and Findings

Androgen deficiency is a common finding after major urologic surgeries. Although guidelines recommend against TRT in men with prostate carcinoma, recent investigations showed no association between TRT and disease progression and recurrence. Indeed, recent evidence suggested that low androgen levels could be related to high grade prostate carcinoma and increased risk of upgrading from low to high grade disease. Investigations on the application of TRT in benign prostatic hyperplasia (BPH) patients also revealed contrasting results. While some studies suggested higher rates of prostate-related events in men who received TRT, others showed that TRT could alleviate urinary symptoms in hypogonadal men with BPH. Decreased testosterone level is commonly seen in bladder cancer patients. The treatment of perioperative androgen deficiency can reduce postoperative morbidities and lower the risk of recurrence in these patients. Low testosterone levels are observed in approximately half of the men who undergo artificial urinary sphincter (AUS) placement and can increase the risk of complications.

Conclusions

The role of testosterone treatment in patients with urologic diseases such as prostate carcinoma and BPH is controversial. Further investigations are needed to determine the impact of hypogonadism and TRT on the outcomes of urologic surgeries in patients with androgen deficiency.

The association between caffeine intake and testosterone: NHANES 2013-2014

Background

Caffeine is one of the most commonly used psychoactive drugs in the world, and provides many health benefits including alertness, improved memory, and reducing inflammation. Despite these benefits, caffeine has been implicated in a number of adverse health outcomes possibly due to effects within the endocrine system, effects that may contribute to impaired reproductive function and low testosterone in men. Previous studies have investigated associations between caffeine consumption and testosterone levels in men, although the quantity and generalizability of these studies is lacking, and the results between studies are conflicting and inconclusive.

Methods

Using data from a cross-sectional study of 372 adult men in the 2013–2014 NHANES survey cycle, the researchers set out to characterize the association between serum testosterone levels, caffeine, and 14 caffeine metabolites.

Results

Multivariable, weighted linear regression revealed a significant inverse association between caffeine and testosterone. Multivariable, linear regression revealed significant, inverse associations between 6 xanthine metabolic products of caffeine and testosterone. Inverse associations were observed between 5-methyluric acid products and testosterone, as well as between 5-acetlyamino-6-amino-3-methyluracil and testosterone. A significant, positive association was observed for 7-methyl xanthine, 3,7-dimethyluric acid, and 7-methyluric acid. Logistic regression models to characterize the association between 2 biologically active metabolites of caffeine (theobromine and theophylline) and odds of low testosterone (< 300 ng/dL) were non-significant.

Conclusions

These findings suggest a potential role for caffeine’s contribution to the etiology of low testosterone and biochemical androgen deficiency. Future studies are warranted to corroborate these findings and elucidate biological mechanisms underlying this association.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12937-022-00783-z.

The association between 2,4-D and serum testosterone levels: NHANES 2013-2014

BACKGROUND

Previous studies have investigated associations between herbicides such as 2,4-Dichlorophenoxyacetic acid (2,4-D) and dyshormonogenesis, specifically low testosterone, in human, rodent, and cell models, but results have been conflicting and inconclusive.

METHODS

Using data from a cross-sectional study of 456 adult men in the 2013-2014 NHANES survey cycle, we examined the relationship between urinary concentrations of 2,4-D and serum testosterone levels.

RESULTS

Multivariable regression models adjusting for potential confounders revealed a significant, negative association between urinary 2,4-D and mean serum testosterone among U.S. adult males (β =  - 11.4 ng/dL, p = 0.02). Multivariable logistic regression models using a cutoff defining abnormally low testosterone (i.e., serum testosterone < 300 ng/dL) revealed no significant associations between 2,4-D and the odds of low testosterone.

CONCLUSION

These findings expand on previous literature implicating a role for 2,4-D in the etiology of low testosterone and dyshormonogenesis. Future studies are warranted to corroborate these findings, determine clinical significance, and to investigate the proposed potential biological mechanisms underlying this association.

Multi-channel Fusion LSTM for Medical Event Prediction using HERs

Automatic medical event prediction (MEP), e.g. diagnosis prediction, medication prediction, using electronic health records (EHRs) is a popular research direction in health informatics. In many cases, MEP relies on the determinations from different types of medical events, which demonstrates the heterogeneous nature of EHRs. However, most existing methods for MEP fail to distinguishingly model the type of event that is highly associated with the prediction task, i.e. task-wise event, which usually plays a more significant role than other events. In this paper, we proposed a Long Short-Term Memory network (LSTM)-based method for MEP, named Multi-Channel Fusion LSTM (MCF-LSTM), which models the correlations between different types of medical events using multiple network channels. To this end, we designed a task-wise fusion module, in which a gated network is applied to select how much information can be transferred between events. Furthermore, the irregular temporal interval between adjacent medical visits is also modeled in an individual channel, which is combined with other events in a unified manner. We compared MCF-LSTM with state-of-the-art methods on four MEP tasks on two public datasets: MIMIC-III and eICU. Experimental results show that MCF-LSTM achieves promising results on AUC(receiver operating characteristic curve), AUPR (area under the precision-recall curve), and top-k recall, and outperforms other methods with high stability.

Correction of Androgen Deficiency in Men with Type 2 Diabetes

BACKGROUND

In men with low levels of testosterone in the blood, it is believed that the symptoms can be regarded as an association between testosterone deficiency syndrome and related comorbidities.

AIM

To investigate the effectiveness of testosterone therapy in patients with type 2 diabetes (T2D) and androgen deficiency.

MATERIALS AND METHODS

Testosterone replacement therapy was carried out in 26 men with T2D and clinically or laboratory-confirmed androgen deficiency. The age of the subjects ranged from 35 to 69 years old. Laboratory studies included determinations of the concentration of the hormones estradiol, luteinizing hormone (LH), and prostate-specific antigen (PSA). The observation period was 9 months.

RESULTS

The average level of total blood testosterone in the subjects before treatment was 9.4 mol/l and was likely lower than that of the control group (19.3 ± 1.6 nmol/l). The levels of total testosterone in the subjects ranged from 3.9 nmol/l to 10.7 nmol/l, and hormone levels measuring less than 8.0 nmol/l were observed in only 11 patients. After a course of testosterone replacement therapy, a stabilization in total testosterone levels at the level of reference values (as compared to the start of treatment) was observed in the blood of men with T2D after 9 months of observation and the administration of the fourth injection (16.83 ± 0.75 nmol/l).

CONCLUSION

The use of long-acting injectable testosterone undecanoate leads to normalization of total testosterone levels in the blood of men with T2D and androgen deficiency, and LH levels in these patients are unlikely to change.

The importance of SHBG and calculated free testosterone for the diagnosis of symptomatic hypogonadism in HIV-infected men: a single-centre real-life experience

PURPOSE

The prevalence of low testosterone and symptoms of hypogonadism in HIV-infected men is still debated. We aimed to estimate the prevalence and type of hypogonadism in HIV-infected males complaining about sexual symptoms, and to evaluate the role of calculated free testosterone (cFT) vs total testosterone (TT) for diagnosis. Furthermore, we evaluated relationship between sex hormone-binding globulin (SHBG), gonadal status and clinical and virologic parameters.

METHODS

We retrospectively evaluated 169 HIV-infected men with sexual symptoms, with TT available. Among them, we selected 94 patients with TT, SHBG, cFT, and luteinizing hormone (LH) available, and classified hypogonadism into overt (low TT and/or low cFT) and compensated (high LH, normal TT and cFT). Comparison was performed by non-parametric Kruskal-Wallis test and Spearman's correlation was calculated to verify the possible associations.

RESULTS

Overt and compensated hypogonadism were found in 20.2% and 13.8% of patients, respectively. With reliance on TT alone, only 10.6% of patients would have met diagnosis. SHBG values were elevated in one third of patients, and higher in men with compensated hypogonadism. Significant positive correlation was found between SHBG and HIV infection duration, TT and LH.

CONCLUSION

Only a complete hormonal profile can properly diagnose and classify hypogonadism in HIV-infected men complaining about sexual symptoms. TT alone reliance may lead to half of diagnoses missing, while lack of gonadotropin prevents the identification of compensated hypogonadism. This largely comes from high SHBG, which seems to play a central role in the pathogenesis of hypogonadism in this population.

Hypogonadism and bone health in men with HIV

The advent of new classes of antiretroviral drugs has improved the survival of people with HIV, and several ageing-related conditions, including hypogonadism and osteoporosis, have emerged. However, both are silent conditions, and are underestimated, underdiagnosed, and not adequately treated. Several factors, including the effects of the virus, antiretroviral therapy, lifestyle factors, and comorbidities, contribute to testicular dysfunction, which in turn has important effects on bone health. The prevalence of hypogonadism is approximately 20% among men with HIV, but extreme variability in the laboratory and clinical assessment of hypogonadism is reported. The prevalence of osteoporosis is 10-30%, but the poor quality of most studies does not allow definitive conclusions on clinical management. Nonetheless, the early and detailed evaluation of gonadal function and bone health is crucial for improving the quality of life of men with HIV.

Age-Related Male Hypogonadism and Cognitive Impairment in the Elderly: Focus on the Effects of Testosterone Replacement Therapy on Cognition

BACKGROUND

Epidemiological data report that male hypogonadism may play a role in cognitive impairment in elderly. However, the effect of testosterone replacement therapy (TRT) on cognitive abilities in this cluster of patients has not been well established. Methods. PubMed/MEDLINE, Google Scholar, Cochrane Library, and Web of Science were searched by using free text words and medical subject headings terms related with "male hypogonadism", "late-onset hypogonadism", elderly, cognition, "mild cognitive impairment", memory, "testosterone replacement therapy" used in various combinations according to the specific clinical questions. Original articles, reviews, and randomized controlled trials written in English were selected. Results. A long-term TRT could improve specific cognitive functions, such as verbal and spatial memory, cognitive flexibility, and physical vitality. However, randomized controlled trials do not provide positive results, and in most of the cases TRT might not induce beneficial effects on cognitive function in elderly men. Discussion and conclusions. Since the lengthening of life expectancy, the prevalence rate of cognitive decline in elderly men is expected to increase remarkably over the next decade with considerable healthcare and economical concerns. Therefore, this remains a relevant clinical topic and further investigations are needed for clarifying the role of TRT especially in elderly men with hypogonadism.

Hypogonadism Is Associated With Increased Risks of Postoperative Complications Following Total Hip Arthroplasty

BACKGROUND

Despite being a relatively common problem among aging men, hypogonadism has not been previously studied as a potential risk factor for postoperative complications following total hip arthroplasty (THA).

METHODS

In total, 3903 male patients with a diagnosis of hypogonadism who underwent primary THA from 2006 to 2012 were identified using a national insurance database and compared to 20:1 matched male controls using a logistic regression analysis.

RESULTS

Hypogonadism was associated with an increased risk of major medical complications (odds ratio [OR] 1.24, P = .022), urinary tract infection (OR 1.43, P < .001), wound complications (OR 1.33, P = .011), deep vein thrombosis (OR 1.64, P < .001), emergency room visit (OR 1.24, P < .001), readmission (OR 1.14, P = .015), periprosthetic joint infection (OR 1.37 and 1.43, P < .05), dislocation (OR 1.51 and 1.48, P < .001), and revision (OR 1.54 and 1.56, P < .001) following THA. A preoperative diagnosis of hypogonadism was associated with increased total reimbursement and charges by $390 (P < .001) and $4514 (P < .001), respectively.

CONCLUSION

The diagnosis of hypogonadism is associated with an elevated risk of postoperative complications and increased cost of care following primary THA. Data from this study should influence the discussion between the patient and the provider prior to undergoing joint replacement and serve as the basis for further research.

Hypogonadism in Exercising Males: Dysfunction or Adaptive-Regulatory Adjustment?

For decades researchers have reported men who engaged in intensive exercise training can develop low resting testosterone levels, alterations in their hypothalamic-pituitary-gonadal (HPG) axis, and display hypogonadism. Recently there is renewed interest in this topic since the International Olympic Committee (IOC) Medical Commission coined the term "Relative Energy Deficiency in Sports" (RED-S) as clinical terminology to address both the female-male occurrences of reproductive system health disruptions associated with exercise. This IOC Commission action attempted to move beyond the sex-specific terminology of the "Female Athlete Triad" (Triad) and heighten awareness/realization that some athletic men do have reproductive related physiologic disturbances such as lowered sex hormone levels, HPG regulatory axis alterations, and low bone mineral density similar to Triad women. There are elements in the development and symptomology of exercise-related male hypogonadism that mirror closely that of women experiencing the Triad/RED-S, but evidence also exists that dissimilarities exist between the sexes on this issue. Our research group postulates that the inconsistency and differences in the male findings in relation to women with Triad/RED-S are not just due to sex dimorphism, but that there are varying forms of exercise-related reproductive disruptions existing in athletic men resulting in them displaying a relative hypogonadism condition. Specifically, such conditions in men may derive acutely and be associated with low energy availability (Triad/RED-S) or excessive training load (overtraining) and appear transient in nature, and resolve with appropriate clinical interventions. However, manifestations of a more chronic based hypogonadism that persists on a more permanent basis (years) exist and is termed the "Exercise Hypogonadal Male Condition." This article presents an up-to-date overview of the various types of acute and chronic relative hypogonadism found in athletic, exercising men and proposes mechanistic models of how these various forms of exercise relative hypogonadism develop.

Correlations of Self-Reported Androgen Deficiency in Ageing Males (ADAM) with Stress and Sleep among Young Adult Males

Androgen deficiency in males has traditionally been predominantly limited to older men aged 50+ years. However, little is known of the correlation between hormonal disruption, stress, and sleep in college-aged males. This cross-sectional study investigates lifestyle behavior patterns in young men and a screening for potential androgen deficiency. A survey of 409 male students, as part of a larger USDA-funded GetFruved study, was analyzed for this subproject. Survey instruments used include the Androgen Deficiency in the Aging Male Questionnaire (ADAM) to assess for inadequate ADAM scores, the Perceived Stress Scale to measure stress levels and the Pittsburgh Sleep Quality Index to evaluate sleep quality. In total, 144 male participants (35%) met criteria for potential androgen deficiency defined by the ADAM questionnaire. Correlation was found between having a positive ADAM score and both increased stress levels (p < 0.001) and poor sleep quality (p < 0.001), with stress displaying the strongest effect (p < 0.001 vs p = 0.124). An increased prevalence of having a positive ADAM score versus established norms for this age group was also noted. These findings highlight the need for investigation of endocrine disruptions in young men.

The association between physiologic testosterone levels, lean mass, and fat mass in a nationally representative sample of men in the United States

Testosterone deficiency leads to increased muscle loss with aging and increased fat mass. Supraphysiologic levels cause an increase in muscle mass and decrease in fat mass. The difference in lean and fat mass across physiologic levels of testosterone has been under examined in men.

OBJECTIVE

Examine the association between physiologic testosterone levels with lean and fat mass.

METHODS

Data from the 1999-2000 NHANES were used (n=252 men; 18-85yrs). Testosterone and SHBG values were obtained by a morning blood sample. Body composition was measured by DXA. Multivariable linear regression was used to compute unadjusted, minimally adjusted, and extended models of relative upper- and lower-body lean and fat mass.

RESULTS

In the extended model, men with total testosterone levels in the highest 25% (4th quartile) had more lower-body lean mass (LBLM) (β=22.1(%), 95%CI: 9.0, 35.3, p=0.003) and upper-body lean mass (UBLM) (β=5.6(%), 95%CI: 0.1, 11.2, p=0.046), and less lower-body fat mass (LBFM) (β=-9.9(%), 95%CI: -17.7, -2.1, p=0.016) and upper-body fat mass (UBFM) (β=-6.1(%), 95%CI: -10.1, -2.1, p=0.005) than those in the 1st quartile. Men in the 3rd quartile had more LBLM (β=14.2, 95%CI: 5.3, 23.1, p=0.004), UBLM (β=5.6, 95%CI: 2.0, 9.2, p=0.004), and less LBFM (β=-9.7(%), 95%CI: -16.7, -2.7, p=0.010) and UBFM (β=-4.7(%), 95%CI: -8.3, -1.2, p=0.012) than those in the 1st quartile.

CONCLUSION

These findings suggest that, at physiologic levels, an association exists between higher levels of testosterone and favorable lean and fat measures.