Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels

Commentary: Who is a candidate for testosterone therapy? A synthesis of international expert opinions

INTRODUCTION

Despite increasing use of testosterone therapy (TTh) for men with testosterone deficiency (TD), there remains uncertainty determining who is a candidate for treatment.

AIM

The aim if this study was to report the opinions of international experts on TTh, as initially presented at the meeting of the World Meeting on Sexual Medicine in Chicago, United States in August 2012.

METHODS

Expert responses to questions regarding the diagnosis of TD based on their own clinical and research experience.

RESULTS

All experts emphasized the primacy of symptoms for the diagnosis of TD. Total testosterone (T) thresholds used to identify TD ranged from 350 ng/dL to 400 ng/dL (12-14 nmol/L); however, experts emphasized the diagnostic limitations of this test. Free T was obtained by all, with some valuing this test more than total T for clinical decision making. Only one expert routinely used a screening questionnaire. None used age-adjusted values. Bioavailable T and the free androgen index were not used. Luteinizing hormone (LH) and sex hormone-binding globulin levels were routinely obtained at evaluation. Additional supportive evidence for TD diagnosis included small testicular volume, high androgen receptor CAG repeats, elevated LH, and presence of diabetes or metabolic syndrome. Two T tests were generally obtained but not always required. Some experts did not require morning testing in men 50 years and older. All monitored prostate-specific antigen and hematocrit after initiation of TTh. All but one expert would consider a trial of TTh to a symptomatic man with total T within the normal range. Recent studies suggesting increased cardiovascular risk with T therapy were not found to be credible.

CONCLUSIONS

Determining who is a candidate for TTh requires clinical assessment based on symptoms and signs, with confirmatory laboratory evaluation. These expert opinions differed from some published guidelines by the emphasis on symptoms as paramount, recognition of the limitations of total T as a diagnostic test, and the potential utility of a therapeutic trial in symptomatic cases with normal total T concentrations.

Hypogonadism and Testosterone Therapy: Associations With Cardiovascular Risk

Testosterone replacement therapy (TRT) use is increasing, primarily in men with symptomatic hypogonadism. There are many benefits associated with TRT use, including improved sexual function, improved bone mineral density, and increased free fat mass and strength. As TRT use increases, its role on cardiovascular health must be explored. While previous evidence identified no adverse cardiovascular risks associated with TRT use, more recent studies suggest that there may be an associated risk, especially in elderly men and younger men with cardiac disease. Care must be taken with TRT use in these groups of men by careful monitoring for cardiac dysfunction. While testosterone therapy has many benefits and may generally be well tolerated, those prescribing the therapy must be cognizant of the potential adverse cardiovascular risks and advise men on the potential risks versus benefits.

Induction of androgen formation in the male by a TAT-VDAC1 fusion peptide blocking 14-3-3ɛ protein adaptor and mitochondrial VDAC1 interactions

Low testosterone (T), a major cause of male hypogonadism and infertility, is linked to mood changes, fatigue, osteoporosis, reduced bone-mass index, and aging. The treatment of choice, T replacement therapy, has been linked with increased risk for prostate cancer and luteinizing hormone (LH) suppression, and shown to lead to infertility, cardiovascular diseases, and obesity. Alternate methods to induce T with lower side effects are desirable. In search of the mechanisms regulating T synthesis in the testes, we identified the 14-3-3ɛ protein adaptor as a negative regulator of steroidogenesis. Steroidogenesis begins in mitochondria. 14-3-3ɛ interacts with the outer mitochondrial membrane voltage-dependent anion channel (VDAC1) protein, forming a scaffold that limits the availability of cholesterol for steroidogenesis. We report the development of a tool able to induce endogenous T formation. Peptides able to penetrate testes conjugated to 14-3-3ɛ site of interaction with VDAC1 blocked 14-3-3ɛ-VDAC1 interactions while at the same time increased VDAC1-translocator protein (18 kDa) interactions that induced steroid formation in rat testes, leading to increased serum T levels. These peptides rescued intratesticular and serum T formation in adult male rats treated with gonadotropin-releasing hormone antagonist, which dampened LH and T production.

Modulation of neointimal lesion formation by endogenous androgens is independent of vascular androgen receptor

Aims

Low androgen levels have been linked with an increased risk of cardiovascular disease in men. Previous studies have suggested that androgens directly inhibit atherosclerotic lesion formation although the underlying mechanisms for this remain unclear. This study addressed the hypothesis that endogenous androgens inhibit arterial remodelling by a direct action on the androgen receptor (AR) in the vascular wall.

Methods and results

We studied a series of novel mouse lines with cell-specific deletion of the AR in either the endothelium or in smooth muscle cells or both cell types. Findings were compared with a model of global androgen deficiency in wild-type mice (castrated). We characterized the cardiovascular phenotype, vascular pharmacology and histology, and assessed neointimal lesion formation following vascular injury to the femoral artery. Cell-specific AR deletion did not alter body weight, circulating testosterone levels or seminal vesicle weight, but caused limited alterations in arterial contractility and blood pressure. Neointimal lesion formation was unaltered by selective deletion of AR from the vascular endothelium, smooth muscle, or both cell types. Castration in wild-type mice increased neointimal lesion volume (Sham vs. Castration: 2.4 × 10⁷ ± 4.5 × 10⁶ vs. 3.9 × 10⁷ ± 4.9 × 10⁶ µm³, P = 0.04, n = 9–10).

Conclusion

Vascular cell-specific AR deletion had no effect on neointimal lesion formation, while low systemic androgen levels adversely affect neointimal lesion size. These findings suggest that the cardio-protective effects of androgens are mediated either by AR outside the vasculature or by AR-independent mechanisms.

Neurologic complications of nondiabetic endocrine disorders

PURPOSE OF REVIEW

This article provides an overview of the neurologic complications found in the various endocrine disorders affecting adult patients. Specifically, disorders in pituitary hormones (prolactin, growth hormone, vasopressin, and oxytocin), thyroid hormones, adrenal hormones (glucocorticoids), and sex hormones (estrogen and testosterone) will be covered, with an emphasis on identifying the signs and symptoms in addition to diagnosing and managing these disorders.

RECENT FINDINGS

Hyperthyroidism in the young was found to increase the risk for ischemic stroke in a recent prospective case-cohort study. The cognitive effects of hormonal therapy in postmenopausal women remain controversial, but a recent study found no benefit or risk in cognitive function when treating younger (50 to 55 years of age) postmenopausal women with hormonal therapy.

SUMMARY

Endocrine disorders can cause various neurologic complications, from insidious myopathy to acute encephalopathy. Diagnosing the endocrine disorder as the cause of the neurologic impairment is essential, as treating the underlying hormonal dysfunction will often rapidly reverse the neurologic symptoms. Ongoing research is needed to further clarify the role of hormonal dysfunction in neurologic disorders.

Testosterone, aging and survival: biomarker or deficiency

PURPOSE OF REVIEW

The purpose of this study is to review recent studies that examined the association of endogenous and exogenous testosterone and mortality in older men.

RECENT FINDINGS

Over the past several years, there has been a steep rise in testosterone prescriptions. The increased use of testosterone occurred in the context of several studies that reported an association between low serum testosterone and increased cardiovascular events and mortality. In contrast, recent studies have reported an association between testosterone treatment and adverse events. A testosterone treatment trial of mobility-impaired elderly men with prevalent cardiovascular disease was stopped due to increased cardiovascular events in the T-treated men and a meta-analysis reported increased cardiovascular events in T-treated men. In two recent large observational studies, testosterone treatment was associated with an increased risk for serious adverse cardiovascular events.

SUMMARY

Low testosterone is associated with mortality in multiple cohort studies; however, it is unclear if this is a causal association or due to low testosterone being a biomarker of poor health. Given recent reports of adverse outcomes associated with testosterone treatment, a conservative use of testosterone is warranted in men with cardiovascular disease who may be at greater risk for adverse outcomes.

Testosterone and cardiovascular disease

PURPOSE OF REVIEW

Use of testosterone among men is increasing rapidly. Low serum testosterone is positively associated with cardiovascular disease and its risk factors. No large randomized controlled trial (RCT) has assessed the effects of testosterone on cardiovascular outcomes. Here recent evidence accumulating from other sources - pharmacoepidemiology, Mendelian randomization studies and meta-analysis of small RCTs - is reviewed to inform current testosterone usage.

RECENT FINDINGS

In a large, well conducted pharmacoepidemiology study specifically testosterone prescription was associated with myocardial infarction. Two Mendelian randomization studies did not corroborate beneficial effects of higher endogenous testosterone on cardiovascular risk factors, but suggested higher endogenous testosterone raised LDL cholesterol and lowered HDL cholesterol. A comprehensive meta-analysis of RCTs summarizing 27 trials including 2994 men found increased risk of cardiovascular-related events on testosterone (odds ratio 1.54, 95% confidence interval 1.09-2.18).

SUMMARY

Contrary to expectations from observational studies, current indications suggest testosterone causes ischemic cardiovascular disease with corresponding implications for practice. A large RCT would undoubtedly settle the issue definitively. Given mounting evidence of harm and the urgency of the situation assembling all the evidence from completed RCTs of testosterone or androgen deprivation therapy and use of Mendelian randomization might generate a definitive answer most quickly.

The putative mechanisms underlying testosterone and cardiovascular risk

The use of testosterone supplementation therapy (TST) is increasing primarily in men with symptomatic hypogonadism. While TST has been shown to have numerous benefits, as its use increases, the role on cardiovascular health must be explored. Previous evidence showed no adverse cardiovascular risks associated with TST use; however, more recent studies suggest that there may be an associated risk. The exact mechanism by which TST may contribute to cardiovascular risk has not been elucidated. Numerous mechanisms have been proposed which include testosterone's effect on thromboxane A2 receptors, vascular adhesion molecule 1 receptors, erythropoiesis, and obstructive sleep apnea, all of which can ultimately lead to atherogenesis and increased cardiovascular risk.

Testosterone, cardiovascular risk, and hormonophobia

INTRODUCTION

A public outcry against testosterone (T) therapy has suddenly occurred based on two reports suggesting treatment was associated with increased cardiovascular (CV) risks.

AIM

To analyze scientific and social bases for concerns regarding T therapy.

METHODS

Analysis of recent articles regarding CV risks with T and comparison with events surrounding publication of results of the Women's Health Initiative in 2002.

RESULTS

In the first study, the percentage of individuals with an adverse event was lower by half in men who received T compared with untreated men (10.1% vs. 21.2%). However, an opposite conclusion was reached via complex statistics. The second study reported minor increased rate of nonfatal myocardial infarction (MI) up to 90 days after receiving a T prescription compared with the prior 12 months. However, there was no control group, so it is unknown whether this MI rate was increased, reduced, or unchanged compared with untreated men. Neither study provided substantive evidence of risk, yet these were lauded as proof of dangers, despite a substantial literature to the contrary. Similar events followed the publication of the Women's Health Initiative in 2002 when a media frenzy over increased risks with female hormone replacement therapy obscured the fact that the reported excess risk was clinically meaningless, at two events per 1,000 person-years. Stakeholders driving concerns regarding hormone risks are unlikely to be clinicians with real-world patient experience.

CONCLUSIONS

The use of weak studies as proof of danger indicates that cultural (i.e., nonscientific) forces are at play. Negative media stories touting T's risks appear fueled by antipharma sentiment, anger against aggressive marketing, and antisexuality. This stance is best described as "hormonophobia." As history shows, evidence alone may be insufficient to alter a public narrative. The true outrage is that social forces and hysteria have combined to deprive men of a useful treatment without regard for medical science.

Osteoporosis in men: a review

Osteoporosis and consequent fracture are not limited to postmenopausal women. There is increasing attention being paid to osteoporosis in older men. Men suffer osteoporotic fractures about 10 years later in life than women, but life expectancy is increasing faster in men than women. Thus, men are living long enough to fracture, and when they do the consequences are greater than in women, with men having about twice the 1-year fatality rate after hip fracture, compared to women. Men at high risk for fracture include those men who have already had a fragility fracture, men on oral glucocorticoids or those men being treated for prostate cancer with androgen deprivation therapy. Beyond these high risk men, there are many other risk factors and secondary causes of osteoporosis in men. Evaluation includes careful history and physical examination to reveal potential secondary causes, including many medications, a short list of laboratory tests, and bone mineral density testing by dual energy X-ray absorptiometry (DXA) of spine and hip. Recently, international organizations have advocated a single normative database for interpreting DXA testing in men and women. The consequences of this change need to be determined. There are several choices of therapy for osteoporosis in men, with most fracture reduction estimation based on studies in women.

Characteristics of compensated hypogonadism in patients with sexual dysfunction

INTRODUCTION

In the last few years, a view that subclinical endocrine disorders represent milder forms of the clinically overt disease has emerged. Accordingly, it has been proposed that compensated hypogonadism represents a genuine clinical subset of late-onset hypogonadism.

AIM

The aim of the present study is to investigate the associations of compensated hypogonadism with particular clinical and psychological characteristics of male subjects complaining of sexual dysfunction.

METHODS

After excluding documented genetic causes of hypogonadism, an unselected consecutive series of 4,173 patients consulting our unit for sexual dysfunction was studied. Compensated hypogonadism was identified according to the European Male Ageing study criteria: total testosterone ≥10.5 nmol/L and luteinizing hormone >9.4 U/L.

MAIN OUTCOME MEASURES

Several hormonal, biochemical, and instrumental (penile Doppler ultrasound) parameters were studied, along with results of the Structured Interview on Erectile Dysfunction (SIEDY) and ANDROTEST.

RESULTS

One hundred seventy (4.1%) subjects had compensated hypogonadism, whereas 827 (19.8%) had overt hypogonadism. After adjustment for confounding factors, no specific sexual symptoms were associated with compensated hypogonadism. However, compensated hypogonadism individuals more often reported psychiatric symptoms, as detected by Middlesex Hospital Questionnaire score, when compared with both eugonadal and overt hypogonadal subjects (adjusted odds ratios = 1.018 [1.005;1.031] and 1.014 [1.001;1.028], respectively; both P < 0.005). In addition, subjects with compensated or overt hypogonadism had an increased predicted risk of cardiovascular events (as assessed by Progetto Cuore risk algorithm) when compared with eugonadal individuals. Accordingly, mortality related to major adverse cardiovascular events (MACEs), but not MACE incidence, was significantly higher in subjects with both compensated and overt hypogonadism when compared with eugonadal subjects.

CONCLUSIONS

The present data do not support the concept that compensated (subclinical) hypogonadism represents a new clinical entity. The possibility that subclinical hypogonadism could be a normal response of the hypothalamus-pituitary-testis axis to somatic illness should be considered. Further studies are urgently needed to clarify this latter point.

Androgen deficiency and type 2 diabetes mellitus

The rising incidence of T2DM is well recognised and associated with trends in obesity and ageing. It is estimated that 2.8% of the world population had a diagnosis of diabetes mellitus in 2000, which is projected to rise to 4.3% by 2030. Diabetes, obesity and ageing are also associated with an increased risk of isolated male hypogonadotropic hypogonadism, often labelled 'late onset hypogonadism' (LOH) to distinguish it from hypogonadism secondary to distinct hypothalamopituitary pathology. Whether the incidence of hypogonadism is increasing is open to question; the past decade, however, has witnessed a marked increase in the prescription of testosterone replacement therapy. Testosterone deficiency appears to be particularly common in type 2 diabetes with a prevalence of 33% observed in one cohort of 103 men (mean age 54.7). However, the diagnosis of androgen deficiency states is not necessarily straightforward, depending amongst other factors, upon whether a biochemical threshold or a syndromic approach (mandating the presence of certain key clinical features) is employed. The pathogenic mechanisms underlying obesity and diabetes related hypogonadism remain unclear with several competing theories, most of which are not mutually exclusive. Whilst a large body of epidemiological evidence associates testosterone deficiency with increased risk of cardiovascular disease and mortality, little evidence exists to support a protective effect of testosterone replacement. The benefits of androgen replacement in younger men with pituitary disease are well established, however, the potential benefits and safety of androgen replacement in older men is much less well developed. At present, replacement therapy in older men is advocated principally for the amelioration of sexual symptoms. This review will seek to explore issues around the pathogenesis, diagnosis, clinical consequences and management of male hypogonadism as it relates to T2DM.

An update on male hypogonadism therapy

INTRODUCTION

Men who have symptoms associated with persistently low serum total testosterone level should be assessed for testosterone replacement therapy.

AREAS COVERED

Acute and chronic illnesses are associated with low serum testosterone and these should be recognized and treated. Once the diagnosis of male hypogonadism is made, the benefits of testosterone treatment usually outweigh the risks. Without contraindications, the patient should be offered testosterone replacement therapy. The options of testosterone delivery systems (injections, transdermal patches/gels, buccal tablets, capsules and implants) have increased in the last decade. Testosterone improves symptoms and signs of hypogonadism such as sexual function and energy, increases bone density and lean mass and decreases visceral adiposity. In men who desire fertility and who have secondary hypogonadism, testosterone can be withdrawn and the patients can be placed on gonadotropins. New modified designer androgens and selective androgen receptor modulators have been in preclinical and clinical trials for some time. None of these have been assessed for the treatment of male hypogonadism.

EXPERT OPINION

Despite the lack of prospective long-term data from randomized, controlled clinical trials of testosterone treatment on prostate health and cardiovascular disease risk, the available evidence suggests that testosterone therapy should be offered to symptomatic hypogonadal men.

Androgen deprivation therapy and cardiovascular risk in chinese patients with nonmetastatic carcinoma of prostate

Background. Androgen deprivation therapy (ADT) in nonmetastatic prostate cancer is unclear. Recent data suggests possible increase in the cardiovascular risks receiving ADT. The aim of the study was to investigate the cardiovascular outcomes in a cohort of Chinese nonmetastatic prostate cancer patients with no previously documented cardiovascular disease. Methods and Results. 745 patients with no previously documented cardiovascular disease and/or diabetes mellitus diagnosed to have nonmetastatic prostate cancer were recruited. Of these, 517 patients received ADT and the remaining 228 did not. After a mean follow-up of 5.3 years, 60 patients developed primary composite endpoint including (1) coronary artery disease, (2) congestive heart failure, and (3) ischemic stroke. Higher proportion of patients on ADT (51 patients, 9.9%) developed composite endpoint compared with those not on ADT (9 patients, 3.9%) with hazard ratio (HR) of 2.06 (95% confidence interval (CI): 1.03–3.24, P = 0.04). Furthermore, Cox regression analysis revealed that only the use of ADT (HR: 2.1, 95% CI: 1.03–4.25, P = 0.04) and hypertension (HR: 2.0, 95% CI: 1.21–3.33, P < 0.01) were independent predictors for primary composite endpoint. Conclusion. ADT in Chinese patients with nonmetastatic prostate cancer with no previously documented cardiovascular disease was associated with subsequent development of cardiovascular events.

The putative mechanisms underlying testosterone and cardiovascular risk

The use of testosterone supplementation therapy (TST) is increasing primarily in men with symptomatic hypogonadism. While TST has been shown to have numerous benefits, as its use increases, the role on cardiovascular health must be explored. Previous evidence showed no adverse cardiovascular risks associated with TST use; however, more recent studies suggest that there may be an associated risk. The exact mechanism by which TST may contribute to cardiovascular risk has not been elucidated. Numerous mechanisms have been proposed which include testosterone’s effect on thromboxane A2 receptors, vascular adhesion molecule 1 receptors, erythropoiesis, and obstructive sleep apnea, all of which can ultimately lead to atherogenesis and increased cardiovascular risk.

Endogenous sex hormones, metabolic syndrome, and diabetes in men and women

Endogenous sex hormones predict impairments of glucose regulation. Cross-sectional studies suggest that lower levels of testosterone in men and higher levels in women increase risk of metabolic syndrome and diabetes, whereas lower levels of sex hormone binding globulin in both men and women increase risk of metabolic syndrome and diabetes. In a systematic review, we summarize existing longitudinal studies, which suggest similar patterns. However, these studies are often limited to a single sex steroid measure. Whether these associations are primarily a marker of adiposity, and whether these associations differ between younger eugonadal vs older hypogonadal adults is also uncertain. The impact of exogenous sex steroid therapy may not reflect relationships between sex hormones and impaired glucose regulation that occur without supplementation. Therefore, examination of endogenous sex steroid trajectories and obesity trajectories within individuals might aid our understanding of how sex steroids contribute to glucose regulation.

Effects of testosterone undecanoate replacement and withdrawal on cardio-metabolic, hormonal and body composition outcomes in severely obese hypogonadal men: a pilot study

PURPOSE

Modifications of cardiovascular and metabolic parameters during testosterone (T) replacement and withdrawal have never been investigated in severely obese hypogonadal men.

METHODS

Twenty-four severely obese (mean BMI 42; mean age 54.5) hypogonadal men (mean T = 245 ± 52 ng/dL) were enrolled in an observational, parallel-arm, open-label, 54-week study of hypocaloric diet plus physical activity (DPE; n = 12) or DPE plus T injections (DPE + T; n = 12), followed by 24 weeks of DPE alone. Primary endpoints were variations from baseline of cardiovascular (cardiac performance, blood pressure, endothelial function, carotid intima-media thickness, CIMT; epicardial fat thickness, EF) and body composition (fat/lean mass) parameters. Secondary endpoints were variations from baseline of hormonal (T and GH) and metabolic (oral glucose tolerance test, lipids, fibrinogen) parameters.

RESULTS

At 54 weeks, DPE + T showed improvements in EF, ejection fraction, diastolic function, CIMT and endothelial function (p < 0.01 vs. controls). Also, hormonal (T, p < 0.0001; GH, p < 0.01), metabolic (HOMA, p < 0.01; microalbuminuria, p < 0.01), lipid (total cholesterol, p < 0.05) and inflammatory (fibrinogen, p < 0.05) parameters improved. After 24 weeks from T withdrawal, all cardiac and hormonal parameters returned to baseline, while fat but not lean mass and blood pressure ameliorations were maintained. An inverse relationship either between EF vs. endothelial function and EF vs. T levels was found (r (2) = -0.46, p < 0.001 and r (2) = -0.56, p < 0.0005, respectively) while direct relationship between T vs. endothelial function occurred (r (2) = 0.43, p < 0.005) in DPE + T. A 33 % dropout rate was reported in DPE without serious adverse events.

CONCLUSIONS

In middle-aged hypogonadal obese men, 1-year T treatment was safe and improved cardio-metabolic and hormonal parameters. We firstly demonstrated that T withdrawal determines a return back to hypogonadism within 6 months, with loss of cardiovascular and some body composition improvements attained.

Low testosterone at time of transplantation is independently associated with poor patient and graft survival in male renal transplant recipients

PURPOSE

Low testosterone is common in men with renal disease and it increases the risk of death in those on dialysis. We studied serum testosterone at transplantation and correlated it with patient and graft outcomes.

MATERIALS AND METHODS

We identified serum samples collected and frozen at the time of transplantation in male recipients of primary kidney transplants done more than 6 years ago at our institution. In 197 recipients there was sufficient serum to determine total testosterone. We analyzed contingency outcomes by the Fisher exact test, continuous values by the Student t-test and survival by the Gehan-Breslow-Wilcoxon test.

RESULTS

Mean patient age was 48.9 years (range 14 to 75). There were 100 living and 97 cadaveric donors, and 53 recipients (27%) had diabetes. Mean ± SD serum testosterone was 477 ± 251.3 ng/dl (range 48 to 2,013). Testosterone was low (less than 220 ng/dl) in 24 patients. Age did not correlate with testosterone. Low testosterone recipients had worse 1-year patient survival (75% vs 95%, p = 0.003), 3-year patient survival (62.5% vs 86.1%, p = 0.008), 1-year graft survival (62.5% vs 92.4%) and 3-year graft survival (50% vs 76.3%, p = 0.01). Survival curves showed significantly worse patient survival (p = 0.004) and graft survival (p = 0.02) for low testosterone. On multivariable analysis low testosterone was independently associated with patient death (HR 2.27, 95% CI 1.19-4.32) and graft loss (HR 2.05, 95% CI 1.16-3.62).

CONCLUSIONS

Low testosterone at transplantation is associated with patient death and graft loss. If due to causality, testosterone therapy may impact survival. Without causality low testosterone may still be a marker for posttransplant risk.

Erectile dysfunction in the elderly: an old widespread issue with novel treatment perspectives

Erectile dysfunction (ED) is one of the most common chronic diseases affecting men and its prevalence increases with aging. It is also the most frequently diagnosed sexual dysfunction in the older male population. A number of different diseases potentially worsening sexual function may occur in elderly people, together with polypharmacy. Related causes of ED are variable and can include arterial, neurogenic, hormonal, cavernosal, iatrogenic, and psychogenic causes. The aim of the present review was to examine the main aspects of erectile dysfunction going through epidemiology and pathophysiology and revise most of ED in elderly disabled men and in those affected with psychiatric disorders. Lastly we tried to focus on the main aspects of nonpharmacological and pharmacological treatments of ED and the recreational use in the elderly. Phosphodiesterase-5 inhibitors (PDE5-I) are commonly used for on-demand or chronic treatment of ED. It is widely known that PDE5-I have lower response rates in older men than in younger patients, but they have the advantages of ease of use and excellent safety profile, also in the elderly. The old and new PDE5-I as well as the alternative treatments for ED are extensively discussed.

Association of sex hormones, aging, and atrial fibrillation in men: the Framingham Heart Study

BACKGROUND

Endogenous sex hormones have been related to cardiovascular outcomes and mortality. We hypothesized that sex hormones are related to atrial fibrillation (AF) in a community-based cohort of middle-aged to older men.

METHODS AND RESULTS

We examined testosterone, estradiol, and dehydroepiandrosterone sulfate in relation to incident AF in men participating in the Framingham Heart Study. We assessed the 10-year risk of AF in multivariable-adjusted hazard models. The cohort consisted of 1251 men (age, 68.0±8.2 years), of whom 275 developed incident AF. We identified a significant interaction between age and testosterone and, therefore, stratified men into age 55 to 69 years (n=786), 70 to 79 years (n=351), and ≥80 years (n=114). In men aged 55 to 69 years, each 1 SD decrease in testosterone was associated with hazard ratio (HR) 1.30 (95% confidence interval [CI], 1.07-1.59) for incident AF. The association between testosterone and 10-year incident AF in men 70 to 79 years did not reach statistical significance. In men≥80 years, a 1 SD decrease in testosterone was associated with HR 3.53 (95% CI, 1.96-6.37) for AF risk. Estradiol was associated with incident AF (HR, 1.12; 95% CI, 1.01-1.26). Dehydroepiandrosterone sulfate had a borderline association with risk of AF that was not statistically significant (HR, 1.12; 95% CI, 0.99-1.28).

CONCLUSIONS

Testosterone and estradiol are associated with incident AF in a cohort of older men. Testosterone deficiency in men≥80 years is strongly associated with AF risk. The clinical and electrophysiological mechanisms underlying the associations between sex hormones and AF in older men merit continued investigation.

Testosterone lab testing and initiation in the United Kingdom and the United States, 2000 to 2011

CONTEXT

New formulations, increased marketing, and wider recognition of declining testosterone levels in older age may have contributed to wider testosterone testing and supplementation in many countries.

OBJECTIVE

Our objective was to describe testosterone testing and testosterone treatment in men in the United Kingdom and United States.

DESIGN

This was a retrospective incident user cohort.

SETTING

We evaluated commercial and Medicare insurance claims from the United States and general practitioner healthcare records from the United Kingdom for the years 2000 through 2011.

PARTICIPANTS

We identified 410,019 US men and 6858 UK men who initiated a testosterone formulation as well as 1,114,329 US men and 66,140 UK men with a new testosterone laboratory measurement.

MAIN OUTCOME MEASURES

Outcome measures included initiation of any injected testosterone, implanted testosterone pellets, or prescribed transdermal or oral testosterone formulation.

RESULTS

Testosterone testing and supplementation have increased pronouncedly in the United States. Increased testing in the United Kingdom has identified more men with low levels, yet US testing has increased among men with normal levels. Men in the United States tend to initiate at normal levels more often than in the United Kingdom, and many men initiate testosterone without recent testing. Gels have become the most common initial treatment in both countries.

CONCLUSIONS

Testosterone testing and use has increased over the past decade, particularly in the United States, with dramatic shifts from injections to gels. Substantial use is seen in men without recent testing and in US men with normal levels. Given widening use despite safety and efficacy questions, prescribers must consider the medical necessity of testosterone before initiation.

Testosterone and glucose metabolism in men: current concepts and controversies

A wealth of observational studies show that low testosterone is associated with insulin resistance and with an increased risk of diabetes and the metabolic syndrome. Experimental studies have identified potential mechanisms by which low testosterone may lead to insulin resistance. Visceral adipose tissue is an important intermediate in this relationship. Actions of testosterone or its metabolite oestradiol on other tissues such as muscle, liver, bone or the brain, and body composition-independent effects may also play a role. However, definitive evidence from randomised controlled trials (RCTs) to clarify whether the association of low testosterone with disordered glucose metabolism is causative is currently lacking. It therefore remains possible that this association is due to reverse causation, or simply originates by association with common health and lifestyle factors. RCTs of testosterone therapy in men with or without diabetes consistently show modest metabolically favourable changes in body composition. Despite this, testosterone effects on glucose metabolism have been inconsistent. Recent evidence suggests that the hypothalamic-pituitary-testicular axis suppression in the majority of obese men with metabolic disorders is functional, and may be, at least in part, reversible with weight loss. Until further evidence is available, lifestyle measures with emphasis on weight reduction, treatment of comorbidities and optimisation of diabetic control should remain the first-line treatment in these men. Such measures, if successful, may be sufficient to normalise testosterone levels in men with metabolic disorders, who typically have only modest reductions in circulating testosterone levels.

The Effect of Testosterone on Cardiovascular Disease

Cardiovascular disease is the leading cause of death in the United States. Testosterone is the principal male sex hormone and plays an important role in men’s health and well-being. Historically, testosterone was believed to adversely affect cardiovascular function. However, contemporary literature has refuted this traditional thinking; testosterone has been suggested to have a protective effect on cardiovascular function through its effects on the vascular system. Data from modern research indicate that hypogonadism is closely related to the development of various cardiovascular risk factors, including hyperlipidemia and insulin resistance. Several studies have demonstrated beneficial effects of testosterone supplementation therapy on reversing symptoms of hypogonadism and improving cardiovascular disease risk profiles. In this review, we perform a critical analysis on the association between testosterone and cardiovascular disease.

Increased risk of non-fatal myocardial infarction following testosterone therapy prescription in men

BACKGROUND

An association between testosterone therapy (TT) and cardiovascular disease has been reported and TT use is increasing rapidly.

METHODS

We conducted a cohort study of the risk of acute non-fatal myocardial infarction (MI) following an initial TT prescription (N = 55,593) in a large health-care database. We compared the incidence rate of MI in the 90 days following the initial prescription (post-prescription interval) with the rate in the one year prior to the initial prescription (pre-prescription interval) (post/pre). We also compared post/pre rates in a cohort of men prescribed phosphodiesterase type 5 inhibitors (PDE5I; sildenafil or tadalafil, N = 167,279), and compared TT prescription post/pre rates with the PDE5I post/pre rates, adjusting for potential confounders using doubly robust estimation.

RESULTS

In all subjects, the post/pre-prescription rate ratio (RR) for TT prescription was 1.36 (1.03, 1.81). In men aged 65 years and older, the RR was 2.19 (1.27, 3.77) for TT prescription and 1.15 (0.83, 1.59) for PDE5I, and the ratio of the rate ratios (RRR) for TT prescription relative to PDE5I was 1.90 (1.04, 3.49). The RR for TT prescription increased with age from 0.95 (0.54, 1.67) for men under age 55 years to 3.43 (1.54, 7.56) for those aged ≥ 75 years (p trend = 0.03), while no trend was seen for PDE5I (p trend = 0.18). In men under age 65 years, excess risk was confined to those with a prior history of heart disease, with RRs of 2.90 (1.49, 5.62) for TT prescription and 1.40 (0.91, 2.14) for PDE5I, and a RRR of 2.07 (1.05, 4.11).

DISCUSSION

In older men, and in younger men with pre-existing diagnosed heart disease, the risk of MI following initiation of TT prescription is substantially increased.

Increased risk of non-fatal myocardial infarction following testosterone therapy prescription in men

Background

An association between testosterone therapy (TT) and cardiovascular disease has been reported and TT use is increasing rapidly.

Methods

We conducted a cohort study of the risk of acute non-fatal myocardial infarction (MI) following an initial TT prescription (N = 55,593) in a large health-care database. We compared the incidence rate of MI in the 90 days following the initial prescription (post-prescription interval) with the rate in the one year prior to the initial prescription (pre-prescription interval) (post/pre). We also compared post/pre rates in a cohort of men prescribed phosphodiesterase type 5 inhibitors (PDE5I; sildenafil or tadalafil, N = 167,279), and compared TT prescription post/pre rates with the PDE5I post/pre rates, adjusting for potential confounders using doubly robust estimation.

Results

In all subjects, the post/pre-prescription rate ratio (RR) for TT prescription was 1.36 (1.03, 1.81). In men aged 65 years and older, the RR was 2.19 (1.27, 3.77) for TT prescription and 1.15 (0.83, 1.59) for PDE5I, and the ratio of the rate ratios (RRR) for TT prescription relative to PDE5I was 1.90 (1.04, 3.49). The RR for TT prescription increased with age from 0.95 (0.54, 1.67) for men under age 55 years to 3.43 (1.54, 7.56) for those aged ≥75 years (p_trend = 0.03), while no trend was seen for PDE5I (p_trend = 0.18). In men under age 65 years, excess risk was confined to those with a prior history of heart disease, with RRs of 2.90 (1.49, 5.62) for TT prescription and 1.40 (0.91, 2.14) for PDE5I, and a RRR of 2.07 (1.05, 4.11).

Discussion

In older men, and in younger men with pre-existing diagnosed heart disease, the risk of MI following initiation of TT prescription is substantially increased.

Testosterone deficiency: a determinant of aortic stiffness in men

OBJECTIVE

Low testosterone levels and increased aortic stiffness are predictors of cardiovascular events. The influence of androgen level on the age- and blood pressure-related increase in aortic stiffness is unknown.

METHODS

From January 2007 to June 2011 we enrolled 455 consecutive men with no evidence of cardiovascular disease from a large cohort followed in our Department for arterial function studies. Their total testosterone (TT) levels were measured and carotid-femoral pulse wave velocity (PWVc-f) was measured as an index of aortic stiffness.

RESULTS

In multivariable analysis, PWVc-f values were inversely correlated to TT after adjustment for confounders (β = -0.365, P < 0.001). In younger age categories (<50 yrs and 50-59 yrs), patients with testosterone deficiency (TD) had higher blood pressure-adjusted PWVc-f (P < 0.001 and P = 0.005, respectively) compared to subjects with normal TT, indicating an "aging effect" of 10 years, whereas in older age categories such a difference was not observed. Furthermore, in men with a higher mean pressure (102-108 mmHg and >108 mmHg), patients with TD had higher age-adjusted PWVc-f (P < 0.001) compared to subjects with normal TT, indicating a synergistic unfavorable effect of testosterone deficiency and blood pressure on aortic stiffness.

CONCLUSIONS

TT levels are independently associated with aortic stiffening. The effect of low testosterone concentration on aortic stiffness is more prominent in young men and in subjects with higher blood pressure levels. These findings identify testosterone as a marker of arterial damage with special emphasis on young and hypertensive individuals and support its role as predictor of events.

Risks of testosterone therapy in elderly men

Testosterone supplementation therapy (TST) is a widely used treatment for men with late onset hypogonadism. The benefits seen with TST, such as improved libido and energy level, beneficial effects on bone density have been well documented. Although hypogonadism remains an independent risk factor for mortality, recent studies have examined the association between testosterone therapy and cardiovascular risk.

Beyond stage I germ cell tumors: current status regarding treatment and long-term toxicities

Approximately 20% to 40% of patients with germ-cell tumors (GCT) will need advanced medical treatment because of relapse or initial metastatic disease. The survival and recommended treatment for men with metastatic disease varies according to histology, primary and metastatic sites, and the level of prechemotherapy tumor markers. For patients with a good prognosis, three cycles of bleomycin, etoposide, and cisplatin (BEP) or four cycles of etoposide, and cisplatin are recommended. For patients with intermediate- and poor prognosis, four cycles of bleomycin, etoposide, and cisplatin remains the preferred treatment option, although a switch to a more intensive regimen can be considered a new alternative. A major advance in salvage therapy for GCT in the last 5 years was the development of a new risk classification system. Initial salvage treatment includes both high-dose chemotherapy and standard-dose chemotherapy. There is clear consensus that patients with residual masses larger than 1 cm should undergo postchemotherapy retroperitoneal lymph node dissection (PC-RPLND); however, the role of PC-RPLND in patients with serologic and radiographic complete response to first-line chemotherapy is controversial. The rationale for PC-RPLND in patients with small residual masses is discussed, and only a small minority of advanced nonseminoma GCT (NSGCT) patients are suitable candidates for observation after first-line chemotherapy. Post-treatment long-term toxicity has emerged as an important issue for GCT survivors. Examples of late effects are secondary nongerm-cell cancers and cardiovascular disease, which represent the most severe and potentially life-threatening effects of cancer treatment. Follow-up of cancer survivors should include recommendations for maintaining a healthy lifestyle to reduce the risk of serious long-term and late effects of treatment.

Testosterone deficiency, cardiac health, and older men

Low levels of testosterone are manifested by erectile dysfunction, reduced sexual desire, and loss of morning erections with increasing numbers of men are being diagnosed and require treatment. The prevalence rates of testosterone deficiency vary according to different studies but may be as high as 40% in populations of patients with type 2 diabetes. There is increasing evidence that testosterone deficiency is associated with increased cardiovascular and all-cause mortality. Screening for low testosterone is recommended in a number of high risk groups including those with type 2 diabetes and metabolic syndrome. There are recent data to suggest that testosterone replacement therapy may reduce cardiovascular mortality as well as improving multiple surrogate markers for cardiovascular events. Specific clinical trials of testosterone replacement therapy are needed in selected populations but in the meantime we must treat patients based on the best current evidence.

Testosterone Supplementation Improves Carbohydrate and Lipid Metabolism in Some Older Men with Abdominal Obesity

Background/Objectives

The effects of testosterone supplementation on carbohydrate and lipid metabolism in obese older men are uncertain. We conducted a single-arm open-label prospective pilot study to investigate the effects of testosterone supplementation on central and peripheral insulin sensitivity in older men with upper body obesity and insulin resistance.

Subjects/Methods

Twenty men (62–78 years-old) with morning testosterone levels <13.9 nmol/L (400 ng/dL), waist circumference ≥ 102 cm, and HOMA-IR ≥ 4.0 or HgbA1C 5.7–6.4% applied transdermal testosterone (10 mg) daily for 20 weeks. Insulin sensitivity (Si) was determined by a 2-stage glucose clamp, liver and intramyocellular lipid by ¹H-MR spectroscopy and body composition by DEXA.

Results

Testosterone supplementation significantly reduced total fat (−.9 ± 2.4 kg, p=0.002), trunk fat (−1.3 ± 1.4 kg, p=0.0007) and extremity fat (−0.7 ± 1.1 kg, p=0.01), and increased extremity lean tissue (+1.3 ± 1.4 kg, p=0.0006). Whole body (WB) Si improved by 21% (0.76 ± 1.57 dL/min per µU/mL, p=0.04) and insulin-stimulated glucose uptake (Rd) by 24% (0.91 ± 1.74 dL/min per µU/mL, p=0.03). Improvements in glucose kinetics were limited to men with reductions in trunk and extremity fat greater than median declines for the entire group. Reductions in intramyocellular lipid were associated with improvements in WB Si (p=0.04) and Rd (p=0.03). Change in Rd accounted for 90% of the change in WB Si. Hepatic glucose output and liver lipid/H₂O were unchanged (p>0.05). Multivariable analyses revealed that reductions in extremity fat, trunk fat, and FFA levels during the clamp accounted for 45% (p=0.004), 31% (p=0.002) and 8% (p=0.04) of respective changes in Rd. Triglycerides decreased by −0.40 ± 0.67mmol/L (p=0.02), LDL-C by-0.35 ± 0.57 mmol/L (p=0.02), and HDL-C by −0.14 ± 0.19 mmol/L (p=0.004).

Conclusions

Testosterone supplementation that resulted in greater reductions in regional adiposity was associated with improved insulin sensitivity, lower LDL-C and fasting triglycerides, but lower HDL-C. Placebo controlled trials need to further examine the potential cardiometabolic risks/benefits of androgen supplementation for older men with low testosterone levels, central obesity, and insulin resistance.