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De Silva NL, Papanikolaou N, Grossmann M, Antonio L, Quinton R, Anawalt BD, Jayasena CN. Male hypogonadism: pathogenesis, diagnosis, and management. Lancet Diabetes Endocrinol 2024; 12:761-774. [PMID: 39159641 DOI: 10.1016/s2213-8587(24)00199-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/09/2024] [Accepted: 07/09/2024] [Indexed: 08/21/2024]
Abstract
Organic male hypogonadism due to irreversible hypothalamic-pituitary-testicular (HPT) pathology is easily diagnosed and treated with testosterone-replacement therapy. However, controversy surrounds the global practice of prescribing testosterone to symptomatic men with low testosterone and non-gonadal factors reducing health status, such as obesity, type 2 diabetes, and ageing (ie, functional hypogonadism), but without identifiable HPT axis pathology. Health optimisation remains the gold-standard management strategy. Nevertheless, in the last decade large clinical trials and an individual patient data meta-analysis of smaller clinical trials confirmed that testosterone therapy induces modest, yet statistically significant, improvements in sexual function without increasing short-term to medium-term cardiovascular or prostate cancer risks in men with functional hypogonadism. Although testosterone improves bone mineral density and insulin sensitivity in these men, trials from the last decade suggest insufficient evidence to determine the safety and effectiveness of use of this hormone for the prevention of fractures or type 2 diabetes. This Review discusses the pathogenesis and diagnosis of male hypogonadism and appraises the evidence underpinning the management of this condition.
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Affiliation(s)
- Nipun Lakshitha De Silva
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK; Faculty of Medicine, General Sir John Kotelawala Defence University, Colombo, Sri Lanka
| | - Nikoleta Papanikolaou
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Mathis Grossmann
- Department of Medicine (Austin Health), The University of Melbourne, Melbourne, VIC, Australia; Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
| | - Leen Antonio
- Department of Chronic Diseases and Metabolism (CHROMETA), Laboratory of Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium; Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Richard Quinton
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK; Northern Regional Gender Dysphoria Service, Cumbria Northumberland Tyne & Wear NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Bradley David Anawalt
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Channa N Jayasena
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK.
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Bribiescas RG. Reproductive endocrinology and aging in human males: An evolutionary perspective. Neurosci Biobehav Rev 2024; 167:105898. [PMID: 39293503 DOI: 10.1016/j.neubiorev.2024.105898] [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: 04/29/2024] [Revised: 08/19/2024] [Accepted: 09/15/2024] [Indexed: 09/20/2024]
Abstract
Due to its important role in fertility, reproductive endocrine function has been subject to natural selection in all organisms including human males. Moreover, reproductive endocrine function is subject to change as males age. Indeed, the biology of aging is also subject to natural selection. As males age, hormone function such as variation in testosterone can change as the result of general somatic degradation. However these changes are not universal and can differ between human male populations depending on lifestyle and ecological context. The degree to which this variation is adaptive remains an open question but recent evolutionary anthropology research has provided some clarity. While knowledge of evolutionary approaches has limitations, the benefits of understanding the origins and comparative context of reproductive endocrine function in older human males are significant. This paper discusses our present comprehension of reproductive endocrinology and aging in human males, with a focus on human diversity across varied lifestyles, ecologies, and environments. In addition, comparative great ape research is examined. Current research challenges and future directions related to the importance of evolutionary biology and human diversity for understanding human male aging are discussed.
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Affiliation(s)
- R G Bribiescas
- Yale University, Department of Anthropology, 10 Sachem Street, New Haven, CT 06520, USA.
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Swislocki ALM, Eisenberg ML. A Review on Testosterone: Estradiol Ratio-Does It Matter, How Do You Measure It, and Can You Optimize It? World J Mens Health 2024; 42:42.e75. [PMID: 39344113 DOI: 10.5534/wjmh.240029] [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: 02/06/2024] [Revised: 05/15/2024] [Accepted: 06/12/2024] [Indexed: 10/01/2024] Open
Abstract
There is a natural balance between the major sex steroids, testosterone and estradiol, controlled by gonadal secretion and peripheral conversion by aromatase. This balance is impacted by a variety of inborn and acquired conditions, and, more recently, by a growing use of exogenous testosterone therapy and off-label aromatase use under the guise of "men's health." We summarize reported testosterone:estradiol ratios, both naturally occurring and with pharmacologic manipulation and consider the ramifications of significant changes in these ratios. However, significant limitations exist in terms of steroid separation and measurement techniques, timing of samples, and lack of consistency from one assay to another, as well as definition of normative data. Limited data on the testosterone:estradiol ratio in men exists, particularly due to the scan data on concurrent estradiol values in men receiving testosterone therapy or aromatase inhibitors. Nonetheless, there seems to be a range of apparently beneficial values of the testosterone: estradiol radio at between 10 and 30, calculated as: testosterone in ng/dL/estradiol in pg/mL. Higher values appear to be associated with improved spermatogenesis and reduced bone density while lower values are associated with thyroid dysfunction. While there is growing awareness of the significance of the testosterone:estradiol ratio, and a sense of a desired range, the optimal value has not yet been determined. Further work is needed to clarify the measurement strategies and clearly-defined outcome measures related to the testosterone:estradiol ratio.
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Affiliation(s)
- Arthur L M Swislocki
- Medical Service, VA Northern California Health Care System, Martinez, CA, USA
- Department of Medicine, UC Davis School of Medicine, Sacramento, CA, USA.
| | - Michael L Eisenberg
- Urology Department, Stanford University School of Medicine, Stanford, CA, USA
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Selinger S, Thallapureddy A. Cross-sectional analysis of national testosterone prescribing through prescription drug monitoring programs, 2018-2022. PLoS One 2024; 19:e0309160. [PMID: 39196907 PMCID: PMC11355536 DOI: 10.1371/journal.pone.0309160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 08/07/2024] [Indexed: 08/30/2024] Open
Abstract
BACKGROUND For two decades preceding the COVID-19 pandemic, testosterone therapy (TT) became more prevalent in the US. Given the forced shift in practice patterns and healthcare accessibility during the pandemic, it was unclear how TT utilization would change. OBJECTIVE To assess the change in testosterone prescriptions nationally. DESIGN Cross-sectional study. DATA SOURCES State prescription drug monitoring program data between 2018 and 2022. PARTICIPANTS All individuals filling testosterone prescriptions in participating states. MEASUREMENTS Unique people filling testosterone prescriptions annually, demographic information on gender and age as available. RESULTS In 2022 there was a 27% relative increase of subjects treated with TT (+439,659 cases compared with 2018). The increase was more evident in the pandemic period with a rise in prevalence most notable for people 45-54 (114,114 people, 35% increase) and 35-44 (97,263 people, 58% increase). All regions except the Midwest increased the total population treated, led by the South (52%) followed by the West (28%) and Northeast (23%). Available data indicated men accounted for most patients treated in all age groups except under 24 years. LIMITATIONS Study population limited to those in participating states with no diagnostic information and limited demographics available. CONCLUSION Between 2018 and 2022, and primarily after the start of the pandemic in 2020, nationally there was a substantial increase in the number of people using TT. The largest increases occurred in a younger demographic, primarily men, than have previously been reported or studied. These results echo other findings showing increased use of controlled substances during the pandemic period and warrant further study regarding the factors behind this rise.
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Affiliation(s)
- Scott Selinger
- Department of Internal Medicine, Division of General Internal Medicine, University of Texas at Austin Dell Medical School, Austin, Texas, United States of America
| | - Aneesh Thallapureddy
- University of Texas at Austin Dell Medical School, Austin, Texas, United States of America
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Handelsman DJ, Wittert GA. Testosterone and Depression Symptoms in Aging Men. J Clin Endocrinol Metab 2024; 109:e1798-e1799. [PMID: 38366772 DOI: 10.1210/clinem/dgae093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/12/2024] [Indexed: 02/18/2024]
Affiliation(s)
- David J Handelsman
- ANZAC Research Institute, University of Sydney, Concord Hospital, Concord, NSW 2139, Australia
| | - Gary A Wittert
- Freemasons Centre for Male Health and Wellbeing, South Australian Health and Medical Research Institute, and University of Adelaide, Adelaide, SA 5001, Australia
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Nickel B, Heiss R, Shih P, Gram EG, Copp T, Taba M, Moynihan R, Zadro J. Social Media Promotion of Health Tests With Potential for Overdiagnosis or Overuse: Protocol for a Content Analysis. JMIR Res Protoc 2024; 13:e56899. [PMID: 38833693 PMCID: PMC11185923 DOI: 10.2196/56899] [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] [Received: 01/30/2024] [Revised: 03/19/2024] [Accepted: 05/02/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND In recent years, social media have emerged as important spaces for commercial marketing of health tests, which can be used for the screening and diagnosis of otherwise generally healthy people. However, little is known about how health tests are promoted on social media, whether the information provided is accurate and balanced, and if there is transparency around conflicts of interest. OBJECTIVE This study aims to understand and quantify how social media is being used to discuss or promote health tests with the potential for overdiagnosis or overuse to generally healthy people. METHODS Content analysis of social media posts on the anti-Mullerian hormone test, whole-body magnetic resonance imaging scan, multicancer early detection, testosterone test, and gut microbe test from influential international social media accounts on Instagram and TikTok. The 5 tests have been identified as having the following criteria: (1) there are evidence-based concerns about overdiagnosis or overuse, (2) there is evidence or concerns that the results of tests do not lead to improved health outcomes for generally healthy people and may cause harm or waste, and (3) the tests are being promoted on social media to generally healthy people. English language text-only posts, images, infographics, articles, recorded videos including reels, and audio-only posts are included. Posts from accounts with <1000 followers as well as stories, live videos, and non-English posts are excluded. Using keywords related to the test, the top posts were searched and screened until there were 100 eligible posts from each platform for each test (total of 1000 posts). Data from the caption, video, and on-screen text are being summarized and extracted into a Microsoft Excel (Microsoft Corporation) spreadsheet and included in the analysis. The analysis will take a combined inductive approach when generating key themes and a deductive approach using a prespecified framework. Quantitative data will be analyzed in Stata SE (version 18.0; Stata Corp). RESULTS Data on Instagram and TikTok have been searched and screened. Analysis has now commenced. The findings will be disseminated via publications in peer-reviewed international medical journals and will also be presented at national and international conferences in late 2024 and 2025. CONCLUSIONS This study will contribute to the limited evidence base on the nature of the relationship between social media and the problems of overdiagnosis and overuse of health care services. This understanding is essential to develop strategies to mitigate potential harm and plan solutions, with the aim of helping to protect members of the public from being marketed low-value tests, becoming patients unnecessarily, and taking resources away from genuine needs within the health system. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/56899.
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Affiliation(s)
- Brooke Nickel
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Raffael Heiss
- Center for Social & Health Innovation, Management Centre Innsbruk, Innsbruk, Austria
| | - Patti Shih
- Australian Centre for Health Engagement Evidence and Values, School of Health and Society, University of Wollongong, Wollongong, Australia
| | - Emma Grundtvig Gram
- Center for General Practice, Department of Public Health, University of Copenhagen, Denmark, Australia
| | - Tessa Copp
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Melody Taba
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Ray Moynihan
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Joshua Zadro
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Tran C, Yeap BB, Ball J, Clayton-Chubb D, Hussain SM, Brodtmann A, Tonkin AM, Neumann JT, Schneider HG, Fitzgerald S, Woods RL, McNeil JJ. Testosterone and the risk of incident atrial fibrillation in older men: further analysis of the ASPREE study. EClinicalMedicine 2024; 72:102611. [PMID: 38707912 PMCID: PMC11067494 DOI: 10.1016/j.eclinm.2024.102611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/09/2024] [Accepted: 04/09/2024] [Indexed: 05/07/2024] Open
Abstract
Background A cardiovascular safety trial of testosterone in men with cardiovascular risk factors or disease found no difference in rates of major adverse cardiovascular events (MACE) or death but noted more atrial fibrillation (AF) events in testosterone-treated men. We investigated the relationship between endogenous testosterone concentrations with risk of developing AF in healthy older men. Methods Post-hoc analysis of 4570 male participants in the ASPirin in Reducing Events in the Elderly (ASPREE) study. Men were aged ≥ 70 years, had no history of cardiovascular disease (including AF), thyroid disease, prostate cancer, dementia, or life-threatening illnesses. Risk of AF was modelled using Cox proportional hazards regression. Findings Median (IQR) age was 73.7 (71.6-77.1) years and median (IQR) follow-up 4.4 (3.3-5.5) years, during which 286 men developed AF (15.3 per 1000 participant-years). Baseline testosterone was higher in men who developed incident AF compared men who did not [17.0 (12.4-21.2) vs 15.7 (12.2-20.0) nmol/L]. There was a non-linear association of baseline testosterone with incident AF. The risk for AF was higher in men with testosterone in quintiles (Q) 4&5 (Q4:Q3, HR = 1.91; 95%CI = 1.29-2.83 and Q5:Q3HR = 1.98; 95%CI = 1.33-2.94). Results were similar after excluding men who experienced MACE or heart failure during follow-up. Interpretation Circulating testosterone concentrations within the high-normal range are independently associated with an increased risk of incident AF amongst healthy older men. This suggests that AF may be an adverse consequence of high-normal total testosterone concentrations. Funding National Institute on Aging and National Cancer Institute at the National Institutes of Health; Australian Government (NHMRC, CSIRO); Monash University; and AlfredHealth.
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Affiliation(s)
- Cammie Tran
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Bu B. Yeap
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jocasta Ball
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Daniel Clayton-Chubb
- Department of Gastroenterology, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Sultana Monira Hussain
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Amy Brodtmann
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Andrew M. Tonkin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Johannes T. Neumann
- University Heart and Vascular Center Hamburg, University Medical Center Hamburg – Eppendorf, Hamburg, Germany
- German Center of Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lubeck, Germany
| | - Hans G. Schneider
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Clinical Biochemistry Unit Alfred Pathology Service Alfred Health Melbourne, Victoria, Australia
| | - Sharyn Fitzgerald
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Robyn L. Woods
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - John J. McNeil
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Novaes LF, Flores JM, Benfante N, Schofield E, Katz DJ, Nelson CJ, Mulhall JP. Analysis of diurnal variation in serum testosterone levels in men with symptoms of testosterone deficiency. J Sex Med 2024; 21:408-413. [PMID: 38481019 DOI: 10.1093/jsxmed/qdae026] [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] [Received: 06/06/2023] [Revised: 01/24/2024] [Accepted: 01/27/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Testosterone (T) plays a crucial role in various physiological functions in men, and understanding the variations in T levels during the day is essential for diagnosing and treating testosterone deficiency (TD). AIM We sought to evaluate the reduction in serum total T (TT) levels throughout the day in men with symptoms of testosterone deficiency and to determine the variables having an impact on the extent of this decline. METHODS The study population consisted of a group of men who within 3 months of each other had all undergone both early morning and afternoon TT level measurements. We did not include patients with a history of a prior orchiectomy, testosterone levels below 100 ng/dL or above 1000 ng/dL, a history of androgen deprivation therapy, or patients on T therapy. Statistical analyses were conducted using descriptive statistics, t-tests, chi-square tests, and correlation calculations. Liquid chromatography-tandem mass spectrometry was used to measure TT, and a change in TT levels greater than 100 ng/dL was considered significant. Using multivariable and univariable analysis, we attempted to define predictors of a decrease in afternoon TT levels. OUTCOMES The majority of men showed no significant difference in T levels between morning and afternoon. RESULTS In total, 506 men with a median age of 65 years were analyzed. The most common comorbidities were hypertension and hyperlipidemia. Levels of TT were measured in the morning and afternoon, and no significant differences in mean T levels based on the time of the test were found. Age was not significantly associated with T levels. CLINICAL IMPLICATIONS There was a weak negative correlation between age and the difference between morning and afternoon T levels, with younger men showing more significant variations in T levels. The most considerable differences in T levels were observed in men younger than 30 years. There were no predictors of the magnitude of the T decrease in the afternoon. STRENGTHS AND LIMITATIONS Strengths of the study include the number of subjects and the use of liquid chromatography-tandem mass spectrometry for T measurement. Limitations include failure to measure morning and afternoon T levels on the same day, the retrospective nature of the study, and a smaller sample size of patients younger than 30 years. CONCLUSION In this study we found no strong link between age and daily T fluctuation, but we observed a decrease in the magnitude of variation with aging. The group experiencing the most significant decline in daily T had higher morning and consistently normal afternoon T levels.
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Affiliation(s)
- Luis F Novaes
- Sexual & Reproductive Medicine Program, Urology Service, Memorial Sloan Kettering Cancer Center, NewYork, NY 10022, United States
| | - Jose M Flores
- Sexual & Reproductive Medicine Program, Urology Service, Memorial Sloan Kettering Cancer Center, NewYork, NY 10022, United States
| | - Nicole Benfante
- Sexual & Reproductive Medicine Program, Urology Service, Memorial Sloan Kettering Cancer Center, NewYork, NY 10022, United States
| | - Elizabeth Schofield
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY 10017, United States
| | - Darren J Katz
- Sexual & Reproductive Medicine Program, Urology Service, Memorial Sloan Kettering Cancer Center, NewYork, NY 10022, United States
| | - Chris J Nelson
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY 10017, United States
| | - John P Mulhall
- Sexual & Reproductive Medicine Program, Urology Service, Memorial Sloan Kettering Cancer Center, NewYork, NY 10022, United States
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Green DJ, Chasland LC, Yeap BB, Naylor LH. Comparing the Impacts of Testosterone and Exercise on Lean Body Mass, Strength and Aerobic Fitness in Aging Men. SPORTS MEDICINE - OPEN 2024; 10:30. [PMID: 38563849 PMCID: PMC10987448 DOI: 10.1186/s40798-024-00703-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 03/20/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Based on the largely untested premise that it is a restorative hormone that may reverse the detrimental impacts of aging, prescription of testosterone (T) has increased in recent decades despite no new clinical indications. It is apparent that middle-aged and older men with low-normal serum T levels are considering T supplementation as an anti-aging strategy. At the same time, there is evidence that physical activity (PA) is at historical lows in the Western world. In this review, we compare the impacts of T treatment aimed at achieving physiological T concentrations in middle-aged and older men, alongside the impacts of ecologically relevant forms of exercise training. The independent, and possible combined, effects of T and exercise therapy on physiological outcomes such as aerobic fitness, body composition and muscular strength are addressed. MAIN BODY Our findings suggest that both T treatment and exercise improve lean body mass in healthy older men. If improvement in lean body mass is the primary aim, then T treatment could be considered, and the combination of T and exercise may be more beneficial than either in isolation. In terms of muscle strength in older age, an exercise program is likely to be more beneficial than T treatment (where the dose is aimed at achieving physiological concentrations), and the addition of such T treatment does not provide further benefit beyond that of exercise alone. For aerobic fitness, T at doses aimed at achieving physiological concentrations has relatively modest impacts, particularly in comparison to exercise training, and there is limited evidence as to additive effects. Whilst higher doses of T, particularly by intramuscular injection, may have larger impacts on lean body mass and strength, this must be balanced against potential risks. CONCLUSION Knowing the impacts of T treatment and exercise on variables such as body composition, strength and aerobic fitness extends our understanding of the relative benefits of physiological and pharmacological interventions in aging men. Our review suggests that T has impacts on strength, body composition and aerobic fitness outcomes that are dependent upon dose, route of administration, and formulation. T treatment aimed at achieving physiological T concentrations in middle-aged and older men can improve lean body mass, whilst exercise training enhances lean body mass, aerobic fitness and strength. Men who are physically able to exercise safely should be encouraged to do so, not only in terms of building lean body mass, strength and aerobic fitness, but for the myriad health benefits that exercise training confers.
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Affiliation(s)
- Daniel J Green
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, WA, 6009, Australia.
| | - Lauren C Chasland
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, WA, 6009, Australia
- Allied Health Department, Fiona Stanley Hospital, Perth, WA, Australia
| | - Bu B Yeap
- Medical School, University of Western Australia, Perth, WA, Australia
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, WA, Australia
| | - Louise H Naylor
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, WA, 6009, Australia
- Allied Health Department, Fiona Stanley Hospital, Perth, WA, Australia
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Luther PM, Spillers NJ, Talbot NC, Sinnathamby ES, Ellison D, Kelkar RA, Ahmadzadeh S, Shekoohi S, Kaye AD. Testosterone replacement therapy: clinical considerations. Expert Opin Pharmacother 2024; 25:25-35. [PMID: 38229462 DOI: 10.1080/14656566.2024.2306832] [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] [Received: 08/07/2023] [Accepted: 01/15/2024] [Indexed: 01/18/2024]
Abstract
INTRODUCTION As an increasingly popular therapeutic option, testosterone replacement therapy (TRT) has gained significant notoriety for its health benefits in indicated populations, such as those suffering from hypogonadism. AREAS COVERED Benefits such as improved libido, muscle mass, cognition, and quality of life have led to widened public interest in testosterone as a health supplement. No therapy exists without side effects; testosterone replacement therapy has been associated with side effects such as an increased risk of polycythemia, benign prostate hypertrophy (BPH), prostate cancer, gynecomastia, testicular atrophy, and infertility. Testosterone replacement therapy is often accompanied by several prophylactic co-therapies aimed at reducing the prevalence of these side effects. Literature searches for sections on the clinical benefits and risks associated with TRT were performed to include clinical trials, meta-analyses, and systematic reviews from the last 10 years. EXPERT OPINION Data from clinical studies over the last decade suggest that the benefits of this therapy outweigh the risks and result in overall increased quality of life and remission of symptoms related to hypogonadism. With this in mind, the authors of this review suggest that carefully designed clinical trials are warranted for the investigation of TRT in symptomatic age-related hypogonadism.
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Affiliation(s)
- Patrick M Luther
- School of Medicine, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, USA
| | - Noah J Spillers
- School of Medicine, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, USA
| | - Norris C Talbot
- School of Medicine, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, USA
| | - Evan S Sinnathamby
- School of Medicine, LSU Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Dakota Ellison
- School of Medicine, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, USA
| | - Rucha A Kelkar
- School of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, USA
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, USA
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Handelsman DJ, Grossmann M, Yeap BB, Stuckey BGA, Shankara-Narayana N, Conway AJ, Inder WJ, McLachlan RI, Allan C, Jenkins AJ, Jesudason D, Bracken K, Wittert GA. Long-term Outcomes of Testosterone Treatment in Men: A T4DM Postrandomization Observational Follow-up Study. J Clin Endocrinol Metab 2023; 109:e25-e31. [PMID: 37623257 DOI: 10.1210/clinem/dgad485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/07/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023]
Abstract
CONTEXT The T4DM study randomized 1007 men with impaired glucose tolerance or newly diagnosed diabetes to testosterone undecanoate (TU, 1000 mg) or matching placebo (P) injections every 12 weeks for 24 months with a lifestyle program with testosterone (T) treatment reducing diabetes diagnosis by 40%. BACKGROUND The long-term effects on new diagnosis of diabetes, cardiovascular and prostate disease, sleep apnea, weight maintenance trajectory and androgen dependence were not yet described. METHODS A follow-up email survey after a median of 5.1 years since last injection obtained 599 (59%) completed surveys (316 T, 283 P), with participants in the follow-up survey compared with nonparticipants in 23 anthropometric and demographic variables. RESULTS Randomization to was TU associated with stronger belief in study benefits during (64% vs 49%, P < .001) but not after the study (44% vs 40%, P = .07); there is high interest in future studies. At T4DM entry, 25% had sleep apnea with a new diagnosis more frequent on TU (3.0% vs 0.4%, P = .03) during, but not after, the study. Poststudy, resuming prescribed T treatment was more frequent among TU-treated men (6% vs 2.8%, P = .03). Five years after cessation of TU treatment there was no difference in self-reported rates of new diagnosis of diabetes, and prostate or cardiovascular disease, nor change in weight maintenance or weight loss behaviors. CONCLUSION We conclude that randomized T treatment for 24 months in men with impaired glucose tolerance or new diabetes but without pathological hypogonadism was associated with higher levels of self-reported benefits and diagnosis of sleep apnea during, but not after, the study as well as more frequent prescribed poststudy T treatment consistent with androgen dependence in some men receiving prolonged injectable TU.
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Affiliation(s)
- David J Handelsman
- ANZAC Research Institute, University of Sydney and Department of Andrology, Concord Hospital, Sydney, NSW 2139, Australia
| | - Mathis Grossmann
- Department of Medicine Austin Health, The University of Melbourne and Department of Endocrinology, Austin Health, Heidelberg, VIC 3084, Australia
| | - Bu B Yeap
- Medical School, University of Western Australia, Perth, WA 6009, Australia
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, WA 6150, Australia
| | - Bronwyn G A Stuckey
- Keogh Institute for Medical Research, and Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Medical School, University of Western Australia, Nedlands, WA 6009, Australia
| | - Nandini Shankara-Narayana
- ANZAC Research Institute, University of Sydney and Department of Andrology, Concord Hospital, Sydney, NSW 2139, Australia
| | - Ann J Conway
- ANZAC Research Institute, University of Sydney and Department of Andrology, Concord Hospital, Sydney, NSW 2139, Australia
| | - Warrick J Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, and PA-Southside Clinical Unit, Medical School, the University of Queensland, Woolloongabba, QLD 4102, Australia
| | - Robert I McLachlan
- Hudson Institute of Medical Research, Monash University, Clayton, VIC 3168, Australia
| | - Carolyn Allan
- Hudson Institute of Medical Research, Monash University, Clayton, VIC 3168, Australia
| | - Alicia J Jenkins
- Baker Heart and Diabetes Institute, Melbourne, VIC 3004, Australia
| | - David Jesudason
- Department of Endocrinology, The Queen Elizabeth Hospital, Adelaide, SA 5011, Australia
| | - Karen Bracken
- Kolling Institute, University of Sydney, Sydney, NSW 2064, Australia
| | - Gary A Wittert
- Freemasons Centre for Male Health and Wellbeing, South Australian Health and Medical Research Institute and University of Adelaide, Adelaide, SA 506, Australia
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12
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Trumble BC, Negrey J, Koebele SV, Thompson RC, Samuel Wann L, Allam AH, Beheim B, Linda Sutherland M, Sutherland JD, Eid Rodriguez D, Michalik DE, Rowan CJ, Lombardi GP, Garcia AR, Cummings DK, Seabright E, Alami S, Kraft TS, Hooper P, Buetow K, Irimia A, Gatz M, Stieglitz J, Gurven MD, Kaplan H, Thomas GS. Testosterone is positively associated with coronary artery calcium in a low cardiovascular disease risk population. Evol Med Public Health 2023; 11:472-484. [PMID: 38145005 PMCID: PMC10746324 DOI: 10.1093/emph/eoad039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 10/11/2023] [Indexed: 12/26/2023] Open
Abstract
Background In industrialized populations, low male testosterone is associated with higher rates of cardiovascular mortality. However, coronary risk factors like obesity impact both testosterone and cardiovascular outcomes. Here, we assess the role of endogenous testosterone on coronary artery calcium in an active subsistence population with relatively low testosterone levels, low cardiovascular risk and low coronary artery calcium scores. Methodology In this cross-sectional community-based study, 719 Tsimane forager-horticulturalists in the Bolivian Amazon aged 40+ years underwent computed tomography (49.8% male, mean age 57.6 years). Results Coronary artery calcium levels were low; 84.5% had no coronary artery calcium. Zero-inflated negative binomial models found testosterone was positively associated with coronary artery calcium for the full sample (Incidence Rate Ratio [IRR] = 1.477, 95% Confidence Interval [CI] 1.001-2.170, P = 0.031), and in a male-only subset (IRR = 1.532, 95% CI 0.993-2.360, P = 0.053). Testosterone was also positively associated with clinically relevant coronary atherosclerosis (calcium >100 Agatston units) in the full sample (Odds Ratio [OR] = 1.984, 95% CI 1.202-3.275, P = 0.007) and when limited to male-only sample (OR = 2.032, 95% CI 1.118-4.816, P = 0.024). Individuals with coronary artery calcium >100 had 20% higher levels of testosterone than those with calcium <100 (t = -3.201, P = 0.007). Conclusions and Implications Among Tsimane, testosterone is positively associated with coronary artery calcium despite generally low normal testosterone levels, minimal atherosclerosis and rare cardiovascular disease (CVD) events. Associations between low testosterone and CVD events in industrialized populations are likely confounded by obesity and other lifestyle factors.
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Affiliation(s)
- Benjamin C Trumble
- Arizona State University, School of Human Evolution and Social Change, Center for Evolution and Medicine, Institute of Human Origins, Tempe, AZ, USA
| | - Jacob Negrey
- Arizona State University, School of Human Evolution and Social Change, Center for Evolution and Medicine, Institute of Human Origins, Tempe, AZ, USA
| | - Stephanie V Koebele
- Arizona State University, School of Human Evolution and Social Change, Center for Evolution and Medicine, Institute of Human Origins, Tempe, AZ, USA
| | - Randall C Thompson
- Saint Luke’s Mid America Heart Institute, Department of Cardiology, Kansas City, MO, USA
| | - L Samuel Wann
- University of New Mexico, School of Medicine, Albuquerque, NM, USA
| | - Adel H Allam
- Al Azhar University, School of Medicine, Cairo, Egypt
| | - Bret Beheim
- Max Planck Institute for Evolutionary Anthropology, Department of Human Behavior, Ecology and Culture, Leipzig, Germany
| | | | | | | | - David E Michalik
- University of California Irvine, School of Medicine, Irvine, CA, USA
- Miller Women’s and Children’s Hospital Long Beach, CA, USA
| | | | - Guido P Lombardi
- Universidad Peruana Cayetano Heredia, Laboratorio de Paleopatología, Lima, Peru
| | - Angela R Garcia
- Arizona State University, School of Human Evolution and Social Change, Center for Evolution and Medicine, Institute of Human Origins, Tempe, AZ, USA
| | | | - Edmond Seabright
- Mohammed VI Polytechnic University, School of Collective Intelligence, Ben Guerir, Morocco
| | - Sarah Alami
- Mohammed VI Polytechnic University, School of Collective Intelligence, Ben Guerir, Morocco
| | - Thomas S Kraft
- University of Utah, Anthropology Department, Salt Lake City, UT, USA
| | - Paul Hooper
- Chapman University, Economic Science Institute, Orange, CA, USA
| | - Kenneth Buetow
- Arizona State University, School of Human Evolution and Social Change, Center for Evolution and Medicine, Institute of Human Origins, Tempe, AZ, USA
| | - Andrei Irimia
- University of Southern California, Psychology Department, Los Angeles, CA, USA
| | - Margaret Gatz
- University of Southern California, Psychology Department, Los Angeles, CA, USA
| | - Jonathan Stieglitz
- Toulouse Scool of Economics, Institute for Advanced Study Toulouse, Toulouse, France
| | - Michael D Gurven
- University of California Santa Barbara, Department of Anthropology, Santa Barbara, CA, USA
| | - Hillard Kaplan
- Chapman University, Economic Science Institute, Orange, CA, USA
| | - Gregory S Thomas
- MemorialCare Health System, Fountain Valley, CA, USA
- University of California Irvine, Division of Cardiology, Orange, CA, USA
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13
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Hudson J, Cruickshank M, Quinton R, Aucott L, Wu F, Grossmann M, Bhasin S, Snyder PJ, Ellenberg SS, Travison TG, Brock GB, Gianatti EJ, van der Schouw YT, Emmelot-Vonk MH, Giltay EJ, Hackett G, Ramachandran S, Svartberg J, Hildreth KL, Antonic KG, Tenover JL, Tan HM, Ho Chee Kong C, Tan WS, Marks LS, Ross RJ, Schwartz RS, Manson P, Roberts SA, Skovsager Andersen M, Velling Magnussen L, Aceves-Martins M, Gillies K, Hernández R, Oliver N, Dhillo WS, Bhattacharya S, Brazzelli M, Jayasena CN. Symptomatic benefits of testosterone treatment in patient subgroups: a systematic review, individual participant data meta-analysis, and aggregate data meta-analysis. THE LANCET. HEALTHY LONGEVITY 2023; 4:e561-e572. [PMID: 37804846 DOI: 10.1016/s2666-7568(23)00169-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 10/09/2023] Open
Abstract
BACKGROUND Testosterone replacement therapy is known to improve sexual function in men younger than 40 years with pathological hypogonadism. However, the extent to which testosterone alleviates sexual dysfunction in older men and men with obesity is unclear, despite the fact that testosterone is being increasingly prescribed to these patient populations. We aimed to evaluate whether subgroups of men with low testosterone derive any symptomatic benefit from testosterone treatment. METHODS We did a systematic review and meta-analysis to evaluate characteristics associated with symptomatic benefit of testosterone treatment versus placebo in men aged 18 years and older with a baseline serum total testosterone concentration of less than 12 nmol/L. We searched major electronic databases (MEDLINE, Embase, Science Citation Index, and the Cochrane Central Register of Controlled Trials) and clinical trial registries for reports published in English between Jan 1, 1992, and Aug 27, 2018. Anonymised individual participant data were requested from the investigators of all identified trials. Primary (cardiovascular) outcomes from this analysis have been published previously. In this report, we present the secondary outcomes of sexual function, quality of life, and psychological outcomes at 12 months. We did a one-stage individual participant data meta-analysis with a random-effects linear regression model, and a two-stage meta-analysis integrating individual participant data with aggregated data from studies that did not provide individual participant data. This study is registered with PROSPERO, CRD42018111005. FINDINGS 9871 citations were identified through database searches. After exclusion of duplicates and publications not meeting inclusion criteria, 225 full texts were assessed for inclusion, of which 109 publications reporting 35 primary studies (with a total 5601 participants) were included. Of these, 17 trials provided individual participant data (3431 participants; median age 67 years [IQR 60-72]; 3281 [97%] of 3380 aged ≥40 years) Compared with placebo, testosterone treatment increased 15-item International Index of Erectile Function (IIEF-15) total score (mean difference 5·52 [95% CI 3·95-7·10]; τ2=1·17; n=1412) and IIEF-15 erectile function subscore (2·14 [1·40-2·89]; τ2=0·64; n=1436), reaching the minimal clinically important difference for mild erectile dysfunction. These effects were not found to be dependent on participant age, obesity, presence of diabetes, or baseline serum total testosterone. However, absolute IIEF-15 scores reached during testosterone treatment were subject to thresholds in patient age and baseline serum total testosterone. Testosterone significantly improved Aging Males' Symptoms score, and some 12-item or 36-item Short Form Survey quality of life subscores compared with placebo, but it did not significantly improve psychological symptoms (measured by Beck Depression Inventory). INTERPRETATION In men aged 40 years or older with baseline serum testosterone of less than 12 nmol/L, short-to-medium-term testosterone treatment could provide clinically meaningful treatment for mild erectile dysfunction, irrespective of patient age, obesity, or degree of low testosterone. However, due to more severe baseline symptoms, the absolute level of sexual function reached during testosterone treatment might be lower in older men and men with obesity. FUNDING National Institute for Health and Care Research Health Technology Assessment Programme.
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Affiliation(s)
- Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Richard Quinton
- Translational & Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, UK
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Frederick Wu
- Division of Diabetes, Endocrinology & Gastroenterology, University of Manchester, Manchester, UK
| | - Mathis Grossmann
- University of Melbourne Austin Health, Heidelberg, VIC, Australia
| | | | - Peter J Snyder
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Susan S Ellenberg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Gerald B Brock
- Department of Surgery, Western University and Omega Fertility Center, London, ON, Canada
| | - Emily J Gianatti
- Department of Endocrinology, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Yvonne T van der Schouw
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Marielle H Emmelot-Vonk
- Department of Geriatrics, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Erik J Giltay
- Department of Psychiatry, Leiden University Medical Centre, Leiden, Netherlands
| | - Geoff Hackett
- School of Health and Life Sciences, Aston University, Birmingham, UK
| | | | - Johan Svartberg
- Division of Internal Medicine, Section of Endocrinology, University Hospital of North Norway, Tromsø, Norway; Tromsø Endocrine Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Kerry L Hildreth
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kristina Groti Antonic
- Department of Endocrinology, University Medical Centre, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Joyce Lisa Tenover
- Geriatric Medicine, VA Palo Alto Health Care System, Palo Alto, CA, USA; School of Medicine, Stanford University, Stanford, CA, USA
| | - Hui Meng Tan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Wei Shen Tan
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Leonard S Marks
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Richard J Ross
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Robert S Schwartz
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Paul Manson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | | | | | | | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Nick Oliver
- Faculty of Medicine, Imperial College London, London, 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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14
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Inder WJ, Grossmann M. Obesity and "functional hypogonadism"-mechanisms and management: commentary on EJE-22-1110 "leflutrozole in male obesity-associated hypogonadotropic hypogonadism: Ph 2b double-blind RCT". Eur J Endocrinol 2023; 189:R7-R9. [PMID: 37548170 DOI: 10.1093/ejendo/lvad100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/22/2023] [Indexed: 08/08/2023]
Affiliation(s)
- Warrick J Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, QLD 4102, Australia
- PA-Southside Clinical Unit Medical School, The University of Queensland, 199 Ipswich Rd, Woolloongabba, QLD 4102, Australia
| | - Mathis Grossmann
- Department of Medicine, Austin Health University of Melbourne, 145 Studley Road, Heidelberg, VIC 3084, Australia
- Department of Endocrinology, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia
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15
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Sankar A, Everhart AO, Jena AB, Jeffery MM, Ross JS, Shah ND, Karaca-Mandic P. Longitudinal Patterns in Testosterone Prescribing After US FDA Safety Communication in 2014. Jt Comm J Qual Patient Saf 2023; 49:458-466. [PMID: 37380503 DOI: 10.1016/j.jcjq.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND The objective of this study was to describe changes in testosterone prescribing following a 2014 US Food and Drug Administration (FDA) safety communication and how changes varied by physician characteristics. METHODS Data were extracted from a 20% random sample of Medicare fee-for-service administrative claims data from 2011 through 2019. The sample included 1,544,604 unique male beneficiaries who received evaluation and management (E&M) services from 58,819 unique physicians that prescribed testosterone between 2011 and 2013. Patients were categorized based on presence of coronary artery disease (CAD) and non-age-related hypogonadism. Physician characteristics were identified in the OneKey database and included specialty and affiliations with teaching hospitals, for-profit hospitals, hospitals in integrated delivery networks, and hospitals in the top decile of case mix index. Linear segmented models described how testosterone prescriptions changed following a 2014 FDA safety communication and how changes were associated with physician and organizational characteristics. RESULTS Among 65,089,560 physician-patient-quarter-year observations, mean (standard deviation) age ranged from 72.16 (5.84) years for observations without CAD or non-age-related hypogonadism to 75.73 (6.92) years with CAD and without non-age-related hypogonadism. Following the safety communication, immediate changes in off-label testosterone prescription levels fell by 0.22 percentage points (pp) (95% confidence interval [CI] -0.33 to -0.11) for patients with CAD and by -0.16 pp (95% CI -0.19 to -0.16) for patients without CAD. A similar change was noticed in on-label prescribing levels. Off-label testosterone prescription quarterly trend, however, increased for patients with CAD and without CAD; on-label testosterone prescription trends declined for both groups. Declines in off-label prescribing were larger when treated by primary care physicians vs. non-primary care physicians, and physicians affiliated with teaching compared to nonteaching hospitals. Physician and organizational characteristics were not associated with changes in on-label prescribing. CONCLUSION On-label and off-label testosterone therapy declined following the FDA safety communication. Certain physician characteristics were associated with changes in off-label, but not on-label, prescribing.
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16
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Green DJ, Chasland LC, Naylor LH, Yeap BB. New Horizons: Testosterone or Exercise for Cardiometabolic Health in Older Men. J Clin Endocrinol Metab 2023; 108:2141-2153. [PMID: 36964918 PMCID: PMC10438896 DOI: 10.1210/clinem/dgad175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/14/2023] [Accepted: 03/22/2023] [Indexed: 03/27/2023]
Abstract
Middle-aged and older men have typically accumulated comorbidities, are increasingly sedentary, and have lower testosterone concentrations (T) compared to younger men. Reduced physical activity (PA) and lower T both are associated with, and may predispose to, metabolically adverse changes in body composition, which contribute to higher risks of cardiometabolic disease. Exercise improves cardiometabolic health, but sustained participation is problematic. By contrast, rates of T prescription have increased, particularly in middle-aged and older men without organic diseases of the hypothalamus, pituitary, or testes, reflecting the unproven concept of a restorative hormone that preserves health. Two recent large randomized trials of T, and meta-analyses of randomized trials, did not show a signal for adverse cardiovascular (CV) events, and T treatment on a background of lifestyle intervention reduced type 2 diabetes by 40% in men at high risk. Men with both higher endogenous T and higher PA levels have lower CV risk, but causality remains unproven. Exercise training interventions improve blood pressure and endothelial function in middle-aged and older men, without comparable benefits or additive effects of T treatment. Therefore, exercise training improves cardiometabolic health in middle-aged and older men when effectively applied as a supervised regimen incorporating aerobic and resistance modalities. Treatment with T may have indirect cardiometabolic benefits, mediated via favorable changes in body composition. Further evaluation of T as a pharmacological intervention to improve cardiometabolic health in aging men could consider longer treatment durations and combination with targeted exercise programs.
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Affiliation(s)
- Daniel J Green
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, WA, 6009, Australia
| | - Lauren C Chasland
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, WA, 6009, Australia
- Allied Health Department, Fiona Stanley Hospital, Perth, WA, 6150, Australia
| | - Louise H Naylor
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, WA, 6009, Australia
- Allied Health Department, Fiona Stanley Hospital, Perth, WA, 6150, Australia
| | - Bu B Yeap
- Medical School, The University of Western Australia, Perth, WA, 6009, Australia
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, WA, 6150, Australia
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Cappola AR, Auchus RJ, El-Hajj Fuleihan G, Handelsman DJ, Kalyani RR, McClung M, Stuenkel CA, Thorner MO, Verbalis JG. Hormones and Aging: An Endocrine Society Scientific Statement. J Clin Endocrinol Metab 2023; 108:1835-1874. [PMID: 37326526 DOI: 10.1210/clinem/dgad225] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Indexed: 06/17/2023]
Abstract
Multiple changes occur across various endocrine systems as an individual ages. The understanding of the factors that cause age-related changes and how they should be managed clinically is evolving. This statement reviews the current state of research in the growth hormone, adrenal, ovarian, testicular, and thyroid axes, as well as in osteoporosis, vitamin D deficiency, type 2 diabetes, and water metabolism, with a specific focus on older individuals. Each section describes the natural history and observational data in older individuals, available therapies, clinical trial data on efficacy and safety in older individuals, key points, and scientific gaps. The goal of this statement is to inform future research that refines prevention and treatment strategies in age-associated endocrine conditions, with the goal of improving the health of older individuals.
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Affiliation(s)
- Anne R Cappola
- Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Richard J Auchus
- Departments of Pharmacology and Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
- Endocrinology and Metabolism Section, Medical Service, LTC Charles S. Kettles Veteran Affairs Medical Center, Ann Arbor, MI 48015, USA
| | - Ghada El-Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Division of Endocrinology, Department of Internal Medicine, American University of Beirut, Beirut 1107-2020, Lebanon
| | - David J Handelsman
- ANZAC Research Institute, University of Sydney and Andrology Department, Concord Repatriation General Hospital, Sydney 2139, Australia
| | - Rita R Kalyani
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Michael McClung
- Oregon Osteoporosis Center, Portland, OR 97213, USA
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC 3000, Australia
| | - Cynthia A Stuenkel
- Department of Medicine, University of California, San Diego, School of Medicine, La Jolla, CA 92093, USA
| | - Michael O Thorner
- Division of Endocrinology and Metabolism, University of Virginia, Charlottesville, VA 22903, USA
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Joseph G Verbalis
- Division of Endocrinology and Metabolism, Georgetown University Medical Center, Washington, DC 20057, USA
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18
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Georges E, Cedarbaum V, Bisno DI, Marshall I. Sexual precocity in the setting of parental use of a compounded testosterone cream: case report and review of the literature. J Pediatr Endocrinol Metab 2023; 36:323-326. [PMID: 36607835 DOI: 10.1515/jpem-2022-0521] [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: 10/11/2022] [Accepted: 12/07/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Person-to-person transmission of transdermal testosterone - termed secondary exposure - is a rare but important cause of precocious puberty. CASE PRESENTATION A 3.5-year-old male was evaluated for precocious puberty based on a 6 month history of penile growth, development of secondary sexual characteristics, and growth spurt. Total testosterone level was significantly elevated at 1,460 ng/dL with normal prepubertal gonadotropin levels. Further history revealed that the father had been using transdermal testosterone for about 1 year. Within 2 months of discontinuation, total testosterone level was 20 ng/dL. CONCLUSIONS Given the recent increase in transdermal testosterone prescriptions, clinicians must consider exogenous hormonal exposure as an etiology for precocious puberty. Prescribers should counsel their patients about the significant risk of secondary exposure.
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Affiliation(s)
- Elena Georges
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | | | | | - Ian Marshall
- Division of Pediatric Endocrinology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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19
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Vabre C, Johnson K, Montastruc F, Vezzosi D, Yu OH, Renoux C. Testosterone treatment and the risk of osteonecrosis: a pharmacovigilance analysis in Vigibase. Eur J Clin Pharmacol 2023; 79:383-388. [PMID: 36602591 DOI: 10.1007/s00228-022-03440-w] [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: 09/14/2022] [Accepted: 12/07/2022] [Indexed: 01/06/2023]
Abstract
PURPOSE Recent reports have raised concerns about a potential risk of osteonecrosis associated with testosterone treatment (TT). The aim of this pharmacovigilance study was to assess the risk of reporting osteonecrosis associated with the use of TT compared with use of any other medication. METHODS We performed a disproportionality analysis to investigate the risk of reporting osteonecrosis with TT using the WHO database VigiBase®. We estimated the reporting odds ratio (ROR) and 95% confidence interval (CI) of reporting osteonecrosis with use of TT vs all other drugs, and the adjusted ROR with use of TT vs use of drugs for benign prostatic hyperplasia (BPH). RESULTS Among men at least 18 years of age between January 1, 2000, and December 31, 2019, we identified 3479 reports of osteonecrosis, 84 of which were associated with TT use, out of a total of 4,667,754 adverse event reports. Reports of osteonecrosis in TT users occurred with both transdermal and injectable forms, and the mean age at report was 55.4 years. TT use was associated with a greater risk of reporting osteonecrosis compared to all other drugs (ROR, 5.13; 95% CI, 4.13-6.37) and compared with use of drugs for BPH (ROR, 3.00; 95% CI, 2.08-4.30). Half of the osteonecrosis reports associated with TT indicated concomitant use of corticosteroids. CONCLUSION TT was associated with a greater risk of reports of osteonecrosis compared to use of any other drug and use of drugs for BPH. This signal should be confirmed in complementary studies.
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Affiliation(s)
- Clémentine Vabre
- Department of Medical and Clinical Pharmacology, Centre of Pharmaco Vigilance and Pharmacoepidemiology, Toulouse University Hospital, Faculty of Medicine, 37 Allées Jules Guesde, Toulouse, 31000, France.,Centre d'Investigation Clinique CIC 1436 - INSERM, University Paul Sabatier Toulouse, Toulouse University Hospital, Toulouse, France
| | - Kyle Johnson
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada.,Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, Québec, Canada
| | - François Montastruc
- Department of Medical and Clinical Pharmacology, Centre of Pharmaco Vigilance and Pharmacoepidemiology, Toulouse University Hospital, Faculty of Medicine, 37 Allées Jules Guesde, Toulouse, 31000, France. .,Centre d'Investigation Clinique CIC 1436 - INSERM, University Paul Sabatier Toulouse, Toulouse University Hospital, Toulouse, France.
| | - Delphine Vezzosi
- Department of Endocrinology, Larrey Hospital, CardioMet Institute, University Hospital Centre of Toulouse, Toulouse, France
| | - Oriana H Yu
- Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, Québec, Canada.,Division of Endocrinology, Jewish General Hospital, Montreal, Québec, Canada
| | - Christel Renoux
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada.,Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, Québec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada
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20
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Gurayah AA, Dullea A, Weber A, Masterson JM, Khodamoradi K, Mohamed AI, Ramasamy R. Long vs Short Acting Testosterone Treatments: A Look at the Risks. Urology 2023; 172:5-12. [PMID: 36455678 PMCID: PMC9925408 DOI: 10.1016/j.urology.2022.11.016] [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] [Received: 08/17/2022] [Revised: 11/12/2022] [Accepted: 11/15/2022] [Indexed: 11/29/2022]
Abstract
Prescriptions for testosterone therapy (TT) to treat testosterone deficiency have increased in recent years. The purpose of this review was to evaluate the risks of several treatment modalities to better counsel patients. Both short-acting and long-acting TT has been shown to restore normal serum testosterone levels and improve symptoms of testosterone deficiency. Short-acting pharmacology mimics normal physiology more closely than long-acting TT but requires multiple doses per day. Long-acting TT has a higher rate of patient adherence but is more likely to create supraphysiologic serum testosterone and pathologic sequelae.
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Affiliation(s)
| | - Alexandra Dullea
- Department of Urology, University of Miami Miller School of Medicine, University of Miami, Miami, FL
| | | | - John M Masterson
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Kajal Khodamoradi
- Department of Urology, University of Miami Miller School of Medicine, University of Miami, Miami, FL
| | | | - Ranjith Ramasamy
- Department of Urology, University of Miami Miller School of Medicine, University of Miami, Miami, FL.
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21
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Butler EN, Zhou CK, Curry M, McMenamin Ú, Cardwell C, Bradley MC, Graubard BI, Cook MB. Testosterone therapy and cancer risks among men in the SEER-Medicare linked database. Br J Cancer 2023; 128:48-56. [PMID: 36307648 PMCID: PMC9814238 DOI: 10.1038/s41416-022-02019-7] [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] [Received: 02/04/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND We examined associations between two forms of testosterone therapy (TT) and risks of seven cancers among men. METHODS SEER-Medicare combines cancer registry data from the Surveillance, Epidemiology, and End Results programme with Medicare claims. Our population-based case-control study included incident cancer cases diagnosed between 1992-2015: prostate (n = 130,713), lung (n = 105,466), colorectal (n = 56,433), bladder (n = 38,873), non-Hodgkin lymphoma (n = 17,854), melanoma (n = 14,241), and oesophageal (n = 9116). We selected 100,000 controls from a 5% random sample of Medicare beneficiaries and used logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS TT was associated with lower risk of distant-stage prostate cancer (injection/implantation OR = 0.72, 95% CI: 0.60-0.86; topical OR = 0.50, 95% CI: 0.24-1.03). We also observed inverse associations for distant-stage colorectal cancer (injection/implantation OR = 0.75, 95% CI: 0.62-0.90; topical OR = 0.11, 95% CI: 0.05-0.24). Risks of distant-stage colorectal and prostate cancers decreased with time after initiating TT by injection/implantation. By contrast, TT was positively associated with distant-stage melanoma (injection/implantation OR = 1.70, 95% CI: 1.37-2.11). TT was not associated with bladder cancer, oesophageal cancer, lung cancer or non-Hodgkin lymphoma. CONCLUSION TT was inversely associated with distant-stage prostate and colorectal cancers but was positively associated with distant-stage melanoma. These observations may suggest an aetiologic role for TT or the presence of residual confounding.
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Affiliation(s)
- Eboneé N Butler
- Integrative Tumor Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA.
- University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA.
| | - Cindy Ke Zhou
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Michael Curry
- Information Management Services, Inc, Calverton, MD, USA
| | - Úna McMenamin
- Cancer Epidemiology Research Group, Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Christopher Cardwell
- Cancer Epidemiology Research Group, Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Marie C Bradley
- Integrative Tumor Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Barry I Graubard
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Michael B Cook
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
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22
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Gagliano-Jucá T, Alvarez M, Basaria S. The medicalization of testosterone: reinventing the elixir of life. Rev Endocr Metab Disord 2022; 23:1275-1284. [PMID: 35999482 DOI: 10.1007/s11154-022-09751-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2022] [Indexed: 01/11/2023]
Abstract
The pursuit of longevity, which during the Renaissance era was limited to longing for miraculous ways of rejuvenation, such as bathing in the fountain of youth, took a scientific turn in 1889 with the publication of Brown-Sequard's self-experiments with an extract of animal testes, which apparently improved his vitality, physical strength and cognition. This extract, marketed then as the "Elixir of Life", was sold for decades throughout Europe and North America. However, recent replication of Brown-Sequard's experiments demonstrated that such an extract only contains homeopathic concentrations of testosterone that are insufficient to exert any biological effect. Thus, the birth of Andrology began with a placebo effect. Over the past few decades, the quest for compounds that might lead to rejuvenation has regained traction, with testosterone being at the forefront. Though clinical practice guidelines advocate testosterone therapy in men with organic hypogonadism-the only indication approved by the Food and Drug Administration-testosterone continues to be marketed as a wonder drug with rejuvenating effects on sexual function, vitality, and a host of other unproven benefits. Additionally, the epidemic of obesity and diabetes, conditions associated with low testosterone, has further brought testosterone into the limelight. Although the number of testosterone prescriptions written have increased several-fold in the past two decades, carefully conducted randomized trials suggest modest benefits of testosterone therapy. At the same time, safety concerns, particularly in older men, remain valid.
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Affiliation(s)
- Thiago Gagliano-Jucá
- Northwestern Medicine McHenry Hospital, Chicago Medical School, Rosalind Franklin University of Medicine and Science, McHenry, IL, United States
| | - Mauricio Alvarez
- Section of Endocrinology, Hospital Militar Central, Bogota, Colombia
| | - Shehzad Basaria
- Section On Men's Health, Endocrinology Division, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave, BLI 541, Boston, MA, 02115, United States.
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23
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Isidori AM, Aversa A, Calogero A, Ferlin A, Francavilla S, Lanfranco F, Pivonello R, Rochira V, Corona G, Maggi M. Adult- and late-onset male hypogonadism: the clinical practice guidelines of the Italian Society of Andrology and Sexual Medicine (SIAMS) and the Italian Society of Endocrinology (SIE). J Endocrinol Invest 2022; 45:2385-2403. [PMID: 36018454 PMCID: PMC9415259 DOI: 10.1007/s40618-022-01859-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/29/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE To provide the evidence-based recommendations on the role of testosterone (T) on age-related symptoms and signs remains. METHODS The Italian Society of Andrology and Sexual Medicine (SIAMS) and the and the Italian Society of Endocrinology (SIE) commissioned an expert task force to provide an updated guideline on adult-onset male hypogonadism. Derived recommendations were based on Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. RESULTS Clinical diagnosis of adult-onset hypogonadism should be based on a combination of clinical and biochemical parameters. Testosterone replacement therapy (TRT) should be offered to all symptomatic subjects with hypogonadism after the exclusion of possible contraindications. T gels and the long-acting injectable T are currently available preparations showing the best efficacy/safety profile. TRT can improve all aspects of sexual function, although its effect is limited in more complicated patients. Body composition (reducing fat mass and increasing lean mass) is improved after TRT, either in subjects with or without metabolic syndrome or type 2 diabetes. Conversely, the role of TRT in improving glycometabolic control is more conflicting. TRT can result in increasing bone mineral density, particularly at lumbar site, but no information on fracture risk is available. Limited data support the use of TRT for improving other outcomes, including mood frailty and mobility. CONCLUSIONS TRT can improve sexual function and body composition particularly in less complicated adult and in aging subjects with hypogonadism. When hypogonadism is adequately diagnosed, T appropriately prescribed and subjects correctly followed up, no short-term increased risk of adverse events is observed. Longer and larger studies are advisable to better clarify TRT long-term efficacy/safety profile.
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Affiliation(s)
- A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome - Policlinico Umberto I Hospital, Rome, Italy
| | - A Aversa
- Department of Experimental and Clinical Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - A Calogero
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - A Ferlin
- Unit of Andrology and Reproductive Medicine, Department of Medicine, University of Padova, Padua, Italy
| | - S Francavilla
- Andrology Unit, Department of Clinical Medicine, Public Health, Life and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - F Lanfranco
- Division of Endocrinology, Andrology and Metabolism, Humanitas Gradenigo, Department of Medical Sciences, University of Turin, Turin, Italy
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e della Sessualità Maschile e Femminile, Università Federico II di Napoli, Naples, Italy
- Staff of UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - V Rochira
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - G Corona
- Endocrinology Unit, Medical Department, Azienda Usl Bologna Maggiore-Bellaria Hospital, Largo Nigrisoli, 2, 40133, Bologna, Italy.
| | - M Maggi
- Endocrinology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
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24
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Muncey W, Omil-Lima D, Jesse E, Gupta K, ElShafei A, Heflick C, Loeb A, Thirumavalavan N. Assessment of public interest and current trends in testosterone replacement therapy. Int J Impot Res 2022; 34:753-756. [PMID: 34007065 DOI: 10.1038/s41443-021-00445-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 04/19/2021] [Accepted: 04/29/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Wade Muncey
- Case Western Reserve University School of Medicine, Cleveland, OH, USA. .,University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| | - Danly Omil-Lima
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Erin Jesse
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Karishma Gupta
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Ahmed ElShafei
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Chad Heflick
- Elson S. Floyd College of Medicine, Spokane, WA, USA
| | - Aram Loeb
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Nannan Thirumavalavan
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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25
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Alemany M. The Roles of Androgens in Humans: Biology, Metabolic Regulation and Health. Int J Mol Sci 2022; 23:11952. [PMID: 36233256 PMCID: PMC9569951 DOI: 10.3390/ijms231911952] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 11/17/2022] Open
Abstract
Androgens are an important and diverse group of steroid hormone molecular species. They play varied functional roles, such as the control of metabolic energy fate and partition, the maintenance of skeletal and body protein and integrity and the development of brain capabilities and behavioral setup (including those factors defining maleness). In addition, androgens are the precursors of estrogens, with which they share an extensive control of the reproductive mechanisms (in both sexes). In this review, the types of androgens, their functions and signaling are tabulated and described, including some less-known functions. The close interrelationship between corticosteroids and androgens is also analyzed, centered in the adrenal cortex, together with the main feedback control systems of the hypothalamic-hypophysis-gonads axis, and its modulation by the metabolic environment, sex, age and health. Testosterone (T) is singled out because of its high synthesis rate and turnover, but also because age-related hypogonadism is a key signal for the biologically planned early obsolescence of men, and the delayed onset of a faster rate of functional losses in women after menopause. The close collaboration of T with estradiol (E2) active in the maintenance of body metabolic systems is also presented Their parallel insufficiency has been directly related to the ravages of senescence and the metabolic syndrome constellation of disorders. The clinical use of T to correct hypoandrogenism helps maintain the functionality of core metabolism, limiting excess fat deposition, sarcopenia and cognoscitive frailty (part of these effects are due to the E2 generated from T). The effectiveness of using lipophilic T esters for T replacement treatments is analyzed in depth, and the main problems derived from their application are discussed.
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Affiliation(s)
- Marià Alemany
- Facultat de Biologia, Universitat de Barcelona, Av. Diagonal, 635, 08028 Barcelona, Catalonia, Spain;
- Institut de Biomedicina, Universitat de Barcelona, 08028 Barcelona, Catalonia, Spain
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26
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Dobs AS, Campbell KJ. An Individualized Approach to Managing Testosterone Therapy in the Primary Care Setting. Int J Gen Med 2022; 15:7719-7733. [PMID: 36238539 PMCID: PMC9552794 DOI: 10.2147/ijgm.s364189] [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: 02/26/2022] [Accepted: 06/08/2022] [Indexed: 11/23/2022] Open
Abstract
The incidence of testosterone deficiency and the use of testosterone therapy have increased in recent years, and currently the majority of testosterone prescriptions in the United States and Canada are written by primary care physicians. Meanwhile, the range of available testosterone therapy formulations has widened to include buccal tablets, intramuscular injections, transdermal gels, intranasal gel, subcutaneous injections, oral capsules, and subdermal pellets, each with unique pharmacokinetic and clinical characteristics. Despite the growing use of testosterone therapy and its overall efficacy and safety as demonstrated in clinical trials, concerns exist about the potential impact of testosterone therapy on spermatogenesis and fertility, development of prostate cancer, and risk of polycythemia and cardiovascular events. In addition, ongoing research aims to better characterize the effects of testosterone therapy in specific populations, such as patients aged 65 years and older, patients with obesity and type 2 diabetes, and transgender patients. The range of treatment options and the diversity of patients' goals, preferences, comorbidities, and risk factors necessitate an individualized approach to testosterone therapy that considers each patient's clinical needs alongside the distinct features of different testosterone formulations.
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Affiliation(s)
- Adrian Sandra Dobs
- Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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27
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Narinx N, David K, Walravens J, Vermeersch P, Claessens F, Fiers T, Lapauw B, Antonio L, Vanderschueren D. Role of sex hormone-binding globulin in the free hormone hypothesis and the relevance of free testosterone in androgen physiology. Cell Mol Life Sci 2022; 79:543. [PMID: 36205798 DOI: 10.1007/s00018-022-04562-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/12/2022] [Accepted: 09/17/2022] [Indexed: 11/03/2022]
Abstract
According to the free hormone hypothesis, biological activity of a certain hormone is best reflected by free rather than total hormone concentrations. A crucial element in this theory is the presence of binding proteins, which function as gatekeepers for steroid action. For testosterone, tissue exposure is governed by a delicate equilibrium between free and total testosterone which is determined through interaction with the binding proteins sex hormone-binding globulin and albumin. Ageing, genetics and various pathological conditions influence this equilibrium, hereby possibly modulating hormonal exposure to the target tissues. Despite ongoing controversy on the subject, strong evidence from recent in vitro, in vivo and human experiments emphasizes the relevance of free testosterone. Currently, however, clinical possibilities for free hormone diagnostics are limited. Direct immunoassays are inaccurate, while gold standard liquid chromatography with tandem mass spectrometry (LC-MS/MS) coupled equilibrium dialysis is not available for clinical routine. Calculation models for free testosterone, despite intrinsic limitations, provide a suitable alternative, of which the Vermeulen calculator is currently the preferred method. Calculated free testosterone is indeed associated with bone health, frailty and other clinical endpoints. Moreover, the added value of free testosterone in the clinical diagnosis of male hypogonadism is clearly evident. In suspected hypogonadal men in whom borderline low total testosterone and/or altered sex hormone-binding globulin levels are detected, the determination of free testosterone avoids under- and overdiagnosis, facilitating adequate prescription of hormonal replacement therapy. As such, free testosterone should be integrated as a standard biochemical parameter, on top of total testosterone, in the diagnostic workflow of male hypogonadism.
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Affiliation(s)
- N Narinx
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000, Leuven, Belgium.,Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - K David
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000, Leuven, Belgium.,Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - J Walravens
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - P Vermeersch
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - F Claessens
- Laboratory of Molecular Endocrinology, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - T Fiers
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - B Lapauw
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium.,Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - L Antonio
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000, Leuven, Belgium.,Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - D Vanderschueren
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000, Leuven, Belgium. .,Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium.
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28
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Irwig MS. Battling the Testosterone Clinics and Websites. J Gen Intern Med 2022; 37:3477-3478. [PMID: 35790665 PMCID: PMC9551007 DOI: 10.1007/s11606-022-07718-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/17/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Michael S Irwig
- Division of Endocrinology, Beth Israel Deaconess Medical Center & Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
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29
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Testosterone therapy in prostate cancer: is it still a controversy? Curr Opin Urol 2022; 32:598-606. [PMID: 36081393 DOI: 10.1097/mou.0000000000001039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The benefits of testosterone therapy (TTh) in the hypogonadal male can be dramatic. Historically, TTh has been contraindicated in prostate cancer (PCa). Current evidence has redefined our understanding of the influence serum testosterone has on prostatic androgen activity. Increasing numbers of hypogonadal men with coexisting PCa emphasizes the importance of describing those who may safely receive TTh. This review aims to present literature that evaluates the efficacy and safety of TTh in men with coexisting PCa. RECENT FINDINGS Our study, a comprehensive review of published literature regarding TTh in men with a history of PCa, consisted of studies conducted from the 1940s to 2022. Our review discusses evidence in accordance with previous studies that TTh has a role in patients with localized PCa as it has not been reported to increase rates of recurrence or progression of PCa. SUMMARY The use of TTh in hypongonadal men with a localized PCa has been shown to have positive clinical outcomes without increasing the rate of disease progression or recurrence. Further research, in a randomized controlled setting, is warranted.
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30
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Rajan P, Tharakan T, Chen R. Safety of androgen therapy in men with prostate cancer. Best Pract Res Clin Endocrinol Metab 2022; 36:101628. [PMID: 35248487 DOI: 10.1016/j.beem.2022.101628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Prostate cancer is one of the most frequently diagnosed malignancies in men worldwide and the life expectancy for men with prostate cancer is improving due to advancements in diagnostics and treatment. Male hypogonadism is associated with obesity, diabetes, and other comorbidities and also has been linked with increasing age; the primary therapy modality for this condition is testosterone replacement therapy (TRT). There are concerns that testosterone therapy may cause prostate cancer disease progression. However, contemporary evidence suggests that testosterone replacement therapy may be safe in specific groups of patients with prostate cancer. This chapter will summarise the contemporary literature regarding TRT use in hypogonadal men with prostate cancer, including limitations and future research goals.
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Affiliation(s)
- Prabhakar Rajan
- Centre for Cancer Cell and Molecular Biology, Barts Cancer Institute, Queen Mary University of London, London EC1M 6BQ, UK.
| | - Tharu Tharakan
- Urology Department, Charing Cross Hospital, Fulham Palace Rd, London W6 8RF, UK.
| | - Runzhi Chen
- Sir Alexander Fleming Building, Imperial College Rd, London SW7 2AZ, UK.
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31
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Handelsman DJ. History of androgens and androgen action. Best Pract Res Clin Endocrinol Metab 2022; 36:101629. [PMID: 35277356 DOI: 10.1016/j.beem.2022.101629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- David J Handelsman
- Professor of Reproductive Endocrinology and Andrology, ANZAC Research Institute, University of SydneyHead, Andrology Department, Concord RG Hospital, Australia.
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32
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Wu FCW. Ageing male (part 2): Management of functional hypogonadism in older men, a patient-centric holistic approach. Best Pract Res Clin Endocrinol Metab 2022; 36:101626. [PMID: 35461757 DOI: 10.1016/j.beem.2022.101626] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The diagnosis of functional hypogonadism should prompt a thorough assessment and optimization of general health, including lifestyle changes, weight reduction, care of comorbidities and cessation of offending medications, some of which can lead to meaningful gains in endogenous testosterone (T) concentrations. Having excluded or addressed reversible causes and contra-indications, patients with functional hypogonadism can be offered a trial of testosterone replacement therapy (TRT) after full discussion on the anticipated benefits and potential risks. T treatment improves libido but may be less effective for erectile dysfunction (ED). T treatment can also have modest positive effects on insulin resistance, bone strength, some measures of physical strength, and mild depressive symptoms but the clinical significance of these relatively short-term improvements remain uncertain in terms of longer-term patient-important outcomes. Initiation of TRT is a joint decision between patient and clinician since longer-term benefits and risks have not been adequately defined.
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Affiliation(s)
- Frederick C W Wu
- Division of Endocrinology, Diabetes & Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9WL, UK.
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33
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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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Goldman A, Kathrins M. Optimized Use of the Electronic Health Record and Other Clinical Resources to Enhance the Management of Hypogonadal Men. Endocrinol Metab Clin North Am 2022; 51:217-228. [PMID: 35216718 DOI: 10.1016/j.ecl.2021.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Electronic health records (EHRs) have enabled electronic documentation of a tremendous amount of clinical data. EHRs have the potential to improve communication between patients and their providers, facilitate quality improvement and outcomes research, and reduce medical errors. Conversely, EHRs have also increased clinician burnout, information clutter, and depersonalization of the interactions between patients and their providers. Increasing clinician input into EHR design, providing access to technical help, streamlining of workflow, and the use of custom templates that have fewer requirements for evaluation and management coding can reduce this burnout and increase the utility of this advancing technology.
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Affiliation(s)
- Anna Goldman
- Division of Endocrinology, Diabetes and Hypertension, Harvard Medical School, Brigham and Women's Hospital, 221 Longwood Avenue, RFB-2, Boston, MA 02115, USA.
| | - Martin Kathrins
- Division of Urology, Harvard Medical School, Brigham and Women's Hospital, 45 Francis Street, ASB-II, Boston, MA 02115, USA
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Abstract
All approved testosterone replacement methods, when used according to recommendations, can restore normal serum testosterone concentrations, and relieve symptoms in most hypogonadal men. Selection of the method depends on the patient's preference with advice from the physician. Dose adjustment is possible with most delivery methods but may not be necessary in all hypogonadal men. The use of hepatotoxic androgens must be avoided. Testosterone treatment induces reversible suppression of spermatogenesis; if fertility is desired in the near future, human chronic gonadotropin, selective estrogen receptor modulator, estrogen antagonist, or an aromatase inhibitor that stimulates endogenous testosterone production may be used.
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Affiliation(s)
- Christina Wang
- Division of Endocrinology, Clinical and Translational Science Institute, The Lundquist Institute at Harbor-UCLA Medical Center, Harbor-UCLA Medical Center, 1124 West Carson Street, Torrance, CA 90502, USA.
| | - Ronald S Swerdloff
- Division of Endocrinology, The Lundquist Institute and Harbor-UCLA Medical Center, 1124 West Carson Street, Torrance, CA 90502, USA
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Sreeramaneni PGA, Yalamanchi A, Konda MR, Cherukuri SHV, Maroon JC. A Proprietary Herbal Blend Containing Extracts of Punica granatum Fruit Rind and Theobroma cocoa Seeds Increases Serum Testosterone Level in Healthy Young Males: A Randomized, Double-Blind Placebo-Controlled Study. J Diet Suppl 2022; 20:411-427. [PMID: 35129040 DOI: 10.1080/19390211.2022.2035037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
LN18178 is a proprietary herbal blend containing extracts of Punica granatum fruit rind and Theobroma cocoa seeds. The objective of the present study was to evaluate the effect of LN18178 on serum testosterone levels in healthy young adults in a randomized, double-blind, placebo-controlled study. One hundred and twenty male volunteers (age 21-35 years) were randomized into three groups. Each group (n = 40) received a daily dose of either placebo or 200 or 400 mg LN18178 for fifty-six days. An increase in serum testosterone (free and total) was the primary efficacy measure of the study. The secondary measures included dihydrotestosterone (DHT), cortisol, Luteinizing hormone (LH), 17β-Estradiol (E2), hand grip strength, and the mid-upper arm circumferences (MUAC). The vital signs and clinical chemistry parameters in blood and urine were performed to determine product safety. Post-intervention, both doses of LN18178 significantly increased free testosterone (p < 0.0001 vs. baseline; p = 0.0268 and p < 0.0001, respectively vs. placebo). The high dose group showed significant increases in total testosterone (p < 0.0001 vs. baseline; p = 0.0184 vs. placebo) and luteinizing hormone (p < 0.0007 vs. baseline; p = 0.0470 vs. placebo). The changes in other hormones were not significant. At post-trial, the LN18178-400 group showed significant improvements in the hand grip strength and mid-upper arm circumference. The hemato-biochemical parameters, urinalysis, and vital signs of the participants were within the normal range. Together, these observations suggest that LN18178 is a safe and tolerable herbal blend; it increases testosterone level and increases muscle strength and MUAC in young, healthy males.Supplemental data for this article is available online at https://doi.org/10.1080/19390211.2022.2035037 .
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Affiliation(s)
| | - Amulya Yalamanchi
- Yalamanchi Hospitals and Research Centre Pvt. Ltd, Vijayawada, India
| | | | | | - Joseph C Maroon
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Sharma A, Ul-Haq Z, Sindi E, Al-Sharefi A, Kamalati T, Dhillo WS, Minhas S, Jayasena CN. Clinical characteristics and comorbidities associated with testosterone prescribing in men. Clin Endocrinol (Oxf) 2022; 96:227-235. [PMID: 34816471 DOI: 10.1111/cen.14643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 10/12/2021] [Accepted: 10/31/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Testosterone replacement therapy (TRT) is recommended for the treatment of symptomatic hypogonadism in men. Data on prescription behaviours are, however, limited and conflicting. The objective of this study was to investigate clinical characteristics associated with the likelihood of being prescribed TRT by general practitioners (GP) in North-West London (NWL). DESIGN Retrospective cohort study using Discover database of GP-registered patients in NWL between 2015 and 2019. PATIENTS We identified 20,299 men aged ≥18 years with serum total testosterone measurement (TT) and without prior TRT prescription records. MEASUREMENTS We determined whether TRT was subsequently commenced, while analysing clinical characteristics related to hypogonadism. RESULTS Of all men having TT measurement, 19,583 (96.4%) were not commenced on TRT (Group A) and 716 (3.5%) men were commenced on TRT (Group B). Men prescribed TRT (Group B) had higher mean age, body mass index (BMI) and higher risks of hypertension, depression type 2 diabetes and ischaemic heart disease; conversely, men in Group B had lower mean pretreatment TT and were less likely to have prostate cancer. Four-hundred and thirty-six men (24.3%) with TT < 8 nmol/L and symptoms of low libido were not prescribed TRT. CONCLUSIONS Our study highlights several factors which may influence the decisions made by clinicians when initiating TRT in primary care. Clearer guidance for clinicians may help to improve the consistency of treatment of men with hypogonadism.
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Affiliation(s)
- Aditi Sharma
- Section of Investigative Medicine, Imperial College London, London, UK
| | - Zia Ul-Haq
- Imperial College Health Partners, London, UK
| | - Emad Sindi
- Section of Investigative Medicine, Imperial College London, London, UK
| | - Ahmed Al-Sharefi
- Section of Investigative Medicine, Imperial College London, London, UK
| | | | - Waljit S Dhillo
- Section of Investigative Medicine, Imperial College London, London, UK
| | - Suks Minhas
- Department of Urology, Charing Cross Hospital, Imperial Healthcare NHS Trust, London, UK
| | - Channa N Jayasena
- Section of Investigative Medicine, Imperial College London, London, UK
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Trends in testosterone prescription amongst medical specialties: a 5-year CMS data analysis. Int J Impot Res 2022:10.1038/s41443-021-00497-6. [PMID: 34992225 DOI: 10.1038/s41443-021-00497-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 10/21/2021] [Accepted: 11/02/2021] [Indexed: 11/08/2022]
Abstract
Testosterone Therapy (TTh) trends have changed as a result of clinical research and market forces over the past several years. Understanding the trends or preferences regarding testosterone prescriptions remains unknown. Our objective was to assess both regional and national trends in TTh prescriptions amongst medical specialties within the United States between 2013 and 2017. Publicly available data from the Center for Medicare and Medicaid Services (CMS) Part D Prescriber database with regards to TTh prescriptions across a 5-year span (January 1, 2013-December 31, 2017) were analyzed. TTh therapies were consolidated into four categories: Topical, Oral, Injection and Pellet. Statistical analysis utilizing R 4.0.2 was performed on the resulting data. Trends in prescription modality claim count and cost were plotted over the study period while statistical analysis evaluated associations between TTh modality and medical specialist. We found that Endocrinologists and Urologists prescribed topical testosterone more than all other specialties (60.4% and 53.5%, respectively), while Family and Internal medicine physicians were more likely to prescribe injections (59.82% and 50.69%, respectively). Oral and pellet testosterone were rarely prescribed across all specialties. In conclusion, the wide variation in modalities of testosterone prescriptions illustrates an opportunity for treatment guidelines to be streamlined across all specialists to improve patient outcomes.
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The Effect of Testosterone on Cardiovascular Disease and Cardiovascular Risk Factors in Men: A Review of Clinical and Preclinical Data. CJC Open 2021; 3:1238-1248. [PMID: 34888506 PMCID: PMC8636244 DOI: 10.1016/j.cjco.2021.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/09/2021] [Indexed: 11/20/2022] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of death worldwide. The effects of testosterone, the primary male sex hormone, on cardiovascular risk have been of special interest due to the increased risk of CVD in men. Although it is well established that testosterone levels decline and cardiovascular mortality increases with age, the association between testosterone and CVD remains unclear. Observational and randomized studies on the effects of endogenous and exogenous testosterone have produced conflicting data, and meta-analyses have been inconclusive, suggesting significant study heterogeneity. Despite a lack of adequately powered randomized controlled trials, large observational studies in the early 2010s led to advisories on the use of testosterone replacement therapy. Similar advisories have been mandated for certain types of androgen deprivation therapy. Additional research suggests that testosterone shortens the heart-rate-corrected QT interval, improves glycemic control, induces vasodilation, is prothrombotic, and has anti-obesity effects, whereas associations with atherosclerosis and inflammation are less clear. Despite inconclusive evidence on cardiovascular risk and inconsistencies among clinical practice guidelines, millions of men continue to use testosterone replacement and androgen deprivation therapy. In addition to summarizing clinical and preclinical data, this review provides insight on potential mechanisms of action of testosterone on CVD, applications of this knowledge to clinical settings, and avenues for future research.
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Tijerina AN, Srivastava AV, Patel VR, Osterberg EC. Current use of testosterone therapy in LGBTQ populations. Int J Impot Res 2021; 34:642-648. [PMID: 34815551 DOI: 10.1038/s41443-021-00490-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/14/2021] [Accepted: 10/25/2021] [Indexed: 01/23/2023]
Abstract
Testosterone therapy (TT) is a type of gender-affirming hormone therapy (GAHT) in lesbian, gay, bisexual, transgender, and genderqueer (LGBTQ) populations for gender dysphoria (GD), body uneasiness, and sexual dysfunction. The physical and physiological effects of TT vary widely depending on the dosing regimen and duration of treatment. An individualized approach prioritizing patient-specific desired effects in the context of pre-existing characteristics and health history is strongly recommended. Although TT is an effective treatment for many patients, there has been an increase in the illegitimate acquisition of TT in recent years. Non-judicious prescribing and lack of physician surveillance increases the risk of unintended side effects and potential serious health consequences.
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Affiliation(s)
- A N Tijerina
- University of Texas Dell Medical School, Austin, TX, 78712, USA.
| | - A V Srivastava
- University of Texas Dell Medical School, Austin, TX, 78712, USA
| | - V R Patel
- University of Texas Dell Medical School, Austin, TX, 78712, USA
| | - E C Osterberg
- University of Texas Dell Medical School, Austin, TX, 78712, USA.,Dell Medical School Department of Surgery and Perioperative Care and Ascension Seton Hospital Network, Austin, TX, 78712, USA
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Akseh S, Karimi MA, Safaie N, Valizadeh A, Rahmanpour D, Pezeshkian M, Nouri M, Faridvand Y, Jodati A. The serum levels of testosterone in coronary artery disease patients; relation to NO, eNOS, endothelin-1, and disease severity. Horm Mol Biol Clin Investig 2021; 43:55-61. [PMID: 34496169 DOI: 10.1515/hmbci-2021-0026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The changes in testosterone level and its correlation with the endothelial nitric oxide systems balance in patients with coronary artery disease (CAD) remains uncertain. Therefore, in our study, we aimed to evaluate the levels of testosterone, endothelin-1 (ET-1), nitric oxide (NO), and endothelial NOS (eNOS) in CAD patients, and control group to find the relationship between these parameters and disease severity. METHODS Forty-four patients as CAD group with significant (≥50%) stenosis confirmed by angiography was included in the study, and 40 healthy men were included as the control group. According to the number of vessels obstruction, CAD severity was determined. The serum indicated parameters were assessed to discriminate between patients and controls. RESULTS It was found that testosterone levels in the CDA group were significantly lower than those of the control group (p<0.05). In addition, the level of ET-1 in the CAD group was higher than that in the control group, but levels of NO and eNOS in observation were significantly lower than those in the control group (p<0.05). The correlation analysis revealed that testosterone was passivity correlated with serum NO levels (r=0.550, p=0.001). CONCLUSIONS The current study reports that serum levels of testosterone are closely related to endothelial NO levels and might be of relevance to the pathogenesis of endothelial dysfunction and disease severity in CAD patients.
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Affiliation(s)
- Saeideh Akseh
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad-Ali Karimi
- Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Nasser Safaie
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amir Valizadeh
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Dara Rahmanpour
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Masoud Pezeshkian
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Nouri
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Yousef Faridvand
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Biochemistry and Clinical Laboratories, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ahmadreza Jodati
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Abstract
Androgens are potent drugs requiring prescription for valid medical indications but are misused for invalid, unproven, or off-label reasons as well as being abused without prescription for illicit nonmedical application for performance or image enhancement. Following discovery and first clinical application of testosterone in the 1930s, commercialization of testosterone and synthetic androgens proliferated in the decades after World War II. It remains among the oldest marketed drugs in therapeutic use, yet after 8 decades of clinical use, the sole unequivocal indication for testosterone remains in replacement therapy for pathological hypogonadism, organic disorders of the male reproductive system. Nevertheless, wider claims assert unproven, unsafe, or implausible benefits for testosterone, mostly representing wishful thinking about rejuvenation. Over recent decades, this created an epidemic of testosterone misuse involving prescription as a revitalizing tonic for anti-aging, sexual dysfunction and/or obesity, where efficacy and safety remains unproven and doubtful. Androgen abuse originated during the Cold War as an epidemic of androgen doping among elite athletes for performance enhancement before the 1980s when it crossed over into the general community to become an endemic variant of drug abuse in sufficiently affluent communities that support an illicit drug industry geared to bodybuilding and aiming to create a hypermasculine body physique and image. This review focuses on the misuse of testosterone, defined as prescribing without valid clinical indications, and abuse of testosterone or synthetic androgens (androgen abuse), defined as the illicit use of androgens without prescription or valid indications, typically by athletes, bodybuilders and others for image-oriented, cosmetic, or occupational reasons.
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Affiliation(s)
- David J Handelsman
- ANZAC Research Institute, University of Sydney, Sydney, Australia.,Andrology Department, Concord Hospital, Sydney, Australia
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Chasland LC, Green DJ, Schlaich MP, Maiorana AJ, Cooke BR, Cox KL, Naylor LH, Yeap BB. Effects of testosterone treatment, with and without exercise training, on ambulatory blood pressure in middle-aged and older men. Clin Endocrinol (Oxf) 2021; 95:176-186. [PMID: 33580564 DOI: 10.1111/cen.14442] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/21/2021] [Accepted: 02/11/2021] [Indexed: 11/28/2022]
Abstract
CONTEXT With age, testosterone (T) and physical activity levels often decline in parallel. The effect of combining T treatment and exercise training on ambulatory blood pressure (ABP) is unclear. OBJECTIVE To assess T and exercise effects, alone and in combination, on ABP in men aged 50-70 years, waist circumference ≥ 95 cm and low-normal serum T (6-14 nmol/L), without organic hypogonadism. DESIGN A 2 × 2 factorial randomised, placebo-controlled study. INTERVENTION Randomization to daily transdermal AndroForte5® (Testosterone 5.0%w/v, 100 mg in 2 ml) cream (T), or matching placebo (P) (double-blind), and to supervised exercise (Ex) or no additional exercise (NEx), for 12 weeks. RESULTS Average 24-h systolic blood pressure (SBP) increased with T treatment (testosterone*time, p = .035). Average 24-h SBP increased in T+Ex (T+Ex:+3.0 vs. P+NEx: -3.0 mmHg, p = .026) driven by day-time changes (T+Ex:+3.5 vs. P+NEx: -3.0 mmHg, p = .026). There was an effect of T for 24-h average diastolic blood pressure (DBP, testosterone*time, p = .044) driven by the decrease in P+Ex (P+Ex: -3.9 vs. T+NEx: -0.5 mmHg, p = .015). Night-time DBP was lower with exercise (P+Ex: -4.0 vs. P+NEx: +0.7 mmHg, p = .032). The effect of exercise to lower night-time DBP was not apparent in the presence of T (T+Ex: -0.4 vs. P+NEx: +0.7 mmHg, p > .05). Ex increased average 24-h pulse pressure (PP, exercise*time, p = .022), largely during daytime hours (exercise*time, p = .013). CONCLUSIONS There was a main effect of T to increase 24-h SBP, primarily seen when T was combined with Ex. Exercise alone decreased 24-h and night-time DBP; an effect attenuated by T. BP should be carefully assessed and monitored, when prescribing T treatment to middle-aged and older men, especially when combined with exercise training.
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Affiliation(s)
- Lauren C Chasland
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, WA, Australia
- Allied Health Department, Fiona Stanley Hospital, Perth, WA, Australia
| | - Daniel J Green
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, WA, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, Royal Perth Hospital Unit, Medical School, University of Western Australia, Perth, WA, Australia
- Neurovascular Hypertension & Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, Vic., Australia
| | - Andrew J Maiorana
- Allied Health Department, Fiona Stanley Hospital, Perth, WA, Australia
- School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia
| | - Brian R Cooke
- PathWest Laboratory Medicine, Department of Clinical Biochemistry, Fiona Stanley Hospital, Perth, WA, Australia
| | - Kay L Cox
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Louise H Naylor
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, WA, Australia
- Allied Health Department, Fiona Stanley Hospital, Perth, WA, Australia
| | - Bu B Yeap
- Medical School, University of Western Australia, Perth, WA, Australia
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, WA, Australia
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Testosterone, HIV, and cardiovascular disease risk. Cardiovasc Endocrinol Metab 2021; 10:72-79. [PMID: 34124602 PMCID: PMC8189608 DOI: 10.1097/xce.0000000000000236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/04/2020] [Indexed: 11/26/2022]
Abstract
There has been a recent increase in the use of testosterone supplementation among young adults in the United States, despite the controversy of testosterone replacement therapy (TRT) and cardiovascular safety. The lower testosterone levels and earlier age of TRT use in persons living with HIV (PLHIV) is of particular relevance for this population because cardiovascular disease (CVD) comorbidities are known to be increased among PLHIV. There is very limited data on TRT in PLHIV, as such, in this article, we sought to compile current evidence regarding the diagnosis and management of testosterone deficiency and its link to CVD risk including among PLHIV.
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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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47
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Chasland LC, Naylor LH, Yeap BB, Maiorana AJ, Green DJ. Testosterone and Exercise in Middle-to-Older Aged Men: Combined and Independent Effects on Vascular Function. Hypertension 2021; 77:1095-1105. [PMID: 33611937 DOI: 10.1161/hypertensionaha.120.16411] [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] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Lauren C Chasland
- School of Human Sciences (Exercise and Sport Science) (L.C.C., L.H.N., D.J.G.), The University of Western Australia, Perth
| | - Louise H Naylor
- School of Human Sciences (Exercise and Sport Science) (L.C.C., L.H.N., D.J.G.), The University of Western Australia, Perth.,Allied Health Department, Fiona Stanley Hospital, Perth (L.C.C., L.H.N., A.J.M.)
| | - Bu B Yeap
- Medical School (B.B.Y.), The University of Western Australia, Perth.,Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia (B.B.Y.)
| | - Andrew J Maiorana
- Allied Health Department, Fiona Stanley Hospital, Perth (L.C.C., L.H.N., A.J.M.).,and School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia (A.J.M.)
| | - Daniel J Green
- School of Human Sciences (Exercise and Sport Science) (L.C.C., L.H.N., D.J.G.), The University of Western Australia, Perth
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Ayele HT, Brunetti VC, Renoux C, Tagalakis V, Filion KB. Testosterone replacement therapy and the risk of venous thromboembolism: A systematic review and meta-analysis of randomized controlled trials. Thromb Res 2021; 199:123-131. [PMID: 33486321 DOI: 10.1016/j.thromres.2020.12.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 01/20/2023]
Abstract
INTRODUCTION The cardiovascular safety of testosterone replacement therapy (TRT) is controversial. While several studies have investigated the association between TRT and the risk of arterial thrombosis, limited information is available regarding its risk of venous thromboembolism (VTE). We aimed to compare the risk of VTE in men randomized to TRT versus placebo or active-comparator in a systematic review. METHODS We searched Medline, EMBASE, CINAHL, CENTRAL, and clinical trial registries to identify randomized controlled trials (RCTs) comparing TRT to placebo in men aged ≥18 years. We assessed study quality using the Cochrane Risk of Bias assessment tool and the overall quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Data were pooled across RCTs using random-effects models. RESULTS A total of 13 RCTs (n = 5050) were included in our meta-analysis. In all, 2636 men were randomized to testosterone, and 2414 men to placebo. Sample sizes ranged from 101 to 790 men, and TRT duration from 3 to 36 months. Five studies had a high risk of bias, largely driven by unclear randomization and outcome assessment. When data were pooled across RCTs, testosterone therapy was not associated with VTE compared with placebo (RR: 1.03, 95% CI: 0.49-2.14; I2: 0%; low-quality evidence). Similar estimates were obtained for deep vein thrombosis and pulmonary embolism outcomes. CONCLUSIONS Our systematic review suggests that TRT is not associated with an increased risk of VTE. However, estimates were accompanied by a wide 95% CIs, and a clinically important increased risk cannot be ruled out.
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Affiliation(s)
- Henok Tadesse Ayele
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, H3T 1E2, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada.
| | - Vanessa C Brunetti
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, H3T 1E2, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada.
| | - Christel Renoux
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, H3T 1E2, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada.
| | - Vicky Tagalakis
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, H3T 1E2, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada; Division of General Internal Medicine, Department of Medicine, Jewish General Hospital, McGill University, Montreal, Quebec, H3T 1E2, Canada.
| | - Kristian B Filion
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, H3T 1E2, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada; Department of Medicine, McGill University, Montreal, Quebec, Canada.
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49
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Symptoms of hormonal changes in Polish men and women in the second half of life. HEALTH PSYCHOLOGY REPORT 2021. [DOI: 10.5114/hpr.2021.102888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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50
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Handelsman DJ. The Illusory Case for Treatment of an Invented Disease. Front Endocrinol (Lausanne) 2021; 12:682620. [PMID: 35116001 PMCID: PMC8803734 DOI: 10.3389/fendo.2021.682620] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- David J. Handelsman
- ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia
- Andrology Department, Concord Hospital, Sydney, NSW, Australia
- *Correspondence: David J. Handelsman,
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