1
|
Brown G, Somani BK. Atlas of 35 patient reported outcome measures (PROMs) in andrology: a comprehensive overview of literature. World J Urol 2023; 41:371-404. [PMID: 36534155 DOI: 10.1007/s00345-022-04246-2] [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: 08/09/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Disorders of male sexual health and functioning are complex and can have significant deleterious effects on patients psychological wellbeing and interpersonal relationships. It is well recognised that clinicians have an overall poor understanding of the true effect that disease has on their patients and self-reported patient-reported outcome measures (PROMs) aim to better communicate these issues. PROMs are generally welcomed by patients and their use in this highly sensitive area of clinical practice is well recognised. An atlas of available PROMs for key conditions in andrology is presented in this article. METHODS A comprehensive search of world literature was conducted from the inception of databases to June 2022, to identify male-specific PROMs relevant to four key andrological disorders: hypogonadism, erectile dysfunction, penile curvature and disorders of ejaculation. Each tool was evaluated in narrative format. RESULTS 35 PROMs were identified. 6 were designed for the assessment of hypogonadism, 18 for erectile dysfunction, one for penile curvature and 10 for ejaculatory disorders. In general, PROMs were brief, self-administered and user-friendly. There was sufficient scope and variety in all categories (apart from penile curvature) to give the clinician flexibility in tool selection and find an appropriate tool for different scenarios. CONCLUSION A number of PROMs exist within andrology that can be utilised in both research and clinical settings. PROMs enable subjective evaluation of difficult-to-assess aspects of the patient experience.
Collapse
Affiliation(s)
- G Brown
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK
| | - B K Somani
- Department of Urology, University Hospital Southampton NHS Trust, Southampton, UK.
| |
Collapse
|
2
|
Kaufman JM. Diagnosis of hypogonadism in ageing men. Rev Endocr Metab Disord 2022; 23:1139-1150. [PMID: 36355322 DOI: 10.1007/s11154-022-09763-4] [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] [Accepted: 10/10/2022] [Indexed: 11/11/2022]
Abstract
To make the diagnosis of hypogonadism in an ageing man, in absence of rare organic cause often referred to as functional or late onset hypogonadism (LOH), he should present with a clinical syndrome suggestive of androgen deficiency and have consistently low serum testosterone (T) levels. This does not differ from the diagnosis of any other form of hypogonadism. Particular to LOH diagnostic are uncertainties surrounding this entity: signs and symptoms of androgen deficiency (including sexual symptoms) are nonspecific in older men; clinical significance of only moderately low T levels is uncertain; comorbidity plays a substantial role with potential for reversibility; the place of T therapy in these men is debatable. This context demands for a pragmatic, but appropriately conservative approach to diagnosis. Evaluation should be stepwise with clinical evaluation, if suggestive for androgen deficiency, followed by measurement of a fasting morning serum T, if unequivocally low to be confirmed in a separate morning sample by a second low T or, if initial T borderline low or in presence of factors known to affect SHBG, by a low calculated free T level. All other (free) T results make hypogonadism an unlikely cause of the patient's symptoms. In the absence of consensus cut-off levels for total and free T in the published clinical guidelines for diagnosis of hypogonadism, it seems appropriate in the context of LOH to use stringent criteria indicating a convincingly low serum T. The approach to the diagnosis of LOH is not fundamentally different from that of other forms of hypogonadism but should put extra weight on prioritizing the shunning of overdiagnosis above the risk of underdiagnosis.
Collapse
Affiliation(s)
- Jean-Marc Kaufman
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium.
| |
Collapse
|
3
|
Akehi Y, Tanabe M, Yano H, Takashi Y, Kawanami D, Nomiyama T, Yanase T. A simple questionnaire for the detection of testosterone deficiency in men with late-onset hypogonadism. Endocr J 2022; 69:1303-1312. [PMID: 35831124 DOI: 10.1507/endocrj.ej22-0073] [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] [Indexed: 11/23/2022] Open
Abstract
The Aging Males' Symptoms (AMS) score, developed to screen for late-onset hypogonadism (LOH), contains 17 questions regarding mental, physical, and sexual parameters. In the Japanese guidelines, a free testosterone (FT) <8.5 pg/mL is recommended for testosterone treatment. However, previous studies have shown no correlation between total AMS scores and testosterone concentration. We aimed to develop a better questionnaire for the detection of testosterone deficiency in men, for the diagnosis of LOH. In 234 Japanese men, aged 40-64 years, we analyzed the relationships of AMS with serum total testosterone (TT), FT, calculated FT (cFT), and calculated bioavailable testosterone (cBT), and identified useful questions for the detection of testosterone deficiency. Four scores, a decrease in muscular strength, a decrease in ability to perform sexually or the frequency, a decrease in the number of morning erections, and a decrease in sexual desire/libido, were negatively associated with two or more of the above four testosterone parameters, and the sum of these four scores (named the selective score) correlated with TT and cFT, independent of age. Statistical analysis revealed an association between insulin resistance and testosterone deficiency, and a higher selective score in smokers than non-smokers. Cubic function model analysis and logistic regression analysis revealed that selective scores ≥10 corresponded with the testosterone concentrations recommended for the diagnosis of LOH, including FT <8.5 pg/mL, independent of age, insulin resistance, and smoking. Thus, the selective score represents a simple and useful means for screening of testosterone deficiency in Japanese men, as an indicator of LOH.
Collapse
Affiliation(s)
- Yuko Akehi
- Diabetes Therapeutics and Research Center, Institute of Advanced Medical Sciences, Tokushima University, Tokushima 770-8503, Japan
- Department of Endocrinology and Diabetes Mellitus, Faculty of Medicine, Fukuoka University, Fukuoka 814-0180, Japan
| | - Makito Tanabe
- Department of Endocrinology and Diabetes Mellitus, Faculty of Medicine, Fukuoka University, Fukuoka 814-0180, Japan
| | - Hiromi Yano
- Department of Preventive Medicine, Iizuka Hospital, Iizuka 820-8505, Japan
| | - Yuichi Takashi
- Department of Endocrinology and Diabetes Mellitus, Faculty of Medicine, Fukuoka University, Fukuoka 814-0180, Japan
| | - Daiji Kawanami
- Department of Endocrinology and Diabetes Mellitus, Faculty of Medicine, Fukuoka University, Fukuoka 814-0180, Japan
| | - Takashi Nomiyama
- Department of Endocrinology and Diabetes Mellitus, Faculty of Medicine, Fukuoka University, Fukuoka 814-0180, Japan
- Department of Diabetes, Metabolism and Endocrinology, International University of Health and Welfare Ichikawa Hospital, Ichikawa 272-0827, Japan
| | - Toshihiko Yanase
- Department of Endocrinology and Diabetes Mellitus, Faculty of Medicine, Fukuoka University, Fukuoka 814-0180, Japan
- Muta Hospital, Fukuoka 814-0163, Japan
| |
Collapse
|
4
|
Huhtaniemi IT, Wu FCW. Ageing male (part I): Pathophysiology and diagnosis of functional hypogonadism. Best Pract Res Clin Endocrinol Metab 2022; 36:101622. [PMID: 35210191 DOI: 10.1016/j.beem.2022.101622] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This narrative review summarizes key points of the pathogenesis and diagnosis of the ageing-related decline of testosterone (T) in men. The condition is commonly termed late-onset hypogonadism (LOH), but because it is more often caused by other factors than chronological ageing (obesity and other comorbidities), a more appropriate term is functional hypogonadism (FH). Unlike the classical organic hypogonadism, no anatomical or genetic aberrations are found in FH, and the suppression of T is milder. Moreover, FH can be reversible if the underlying cause (e.g. obesity, chronic disease) is removed/treated. Low serum total T in connection with more specific hypogonadism-associated symptoms (primarily sexual) form the basis of the diagnosis of FH. When T concentrations are borderline, the accuracy of diagnosis can be improved by assessment of free or calculated free T, especially when suppressed SHBG levels (usually related to obesity) are likely. Current data indicate that FH (low T and sexual symptoms) is not a common condition, and it is detectable in about 2% of community-dwelling men aged 40-80 years.
Collapse
Affiliation(s)
- Ilpo T Huhtaniemi
- Department of Digestion, Metabolism and Reproduction, Institute of Reproductive and Developmental Biology, Hammersmith Campus, Imperial College London, London W12 0NN, UK.
| | - 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
| |
Collapse
|
5
|
Bhasin S, Ozimek N. Optimizing the Diagnostic Accuracy and Treatment Decisions in Men with Testosterone Deficiency. Endocr Pract 2021; 27:1252-1259. [PMID: 34390882 DOI: 10.1016/j.eprac.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This narrative review offers a guideline-based approach to optimizing the diagnostic evaluation and treatment decision-making in men being evaluated for testosterone deficiency. METHODS A narrative review RESULTS: Testosterone deficiency is a clinical syndrome that results from the inability of the testes to produce normal amounts of testosterone, and is characterized by a constellation of symptoms and signs associated with consistently low testosterone concentrations. The diagnosis of testosterone deficiency is made by ascertainment of symptoms and signs; measurement of total and, if indicated, free testosterone levels, in early morning fasting samples on 2 or more days; measurement of LH and FSH to distinguish primary from secondary hypogonadism; and additional evaluation to ascertain the cause of testosterone deficiency. Non-specificity of symptoms and signs; variations in testosterone levels over time; inaccuracy in the measurement of total and free testosterone levels; variations in binding protein concentrations; and the suboptimal reference ranges contribute to diagnostic inaccuracy. Testosterone treatment is indicated for men with symptomatic testosterone deficiency. Testosterone treatment should be avoided in men with prostate or breast cancer, erythrocytosis, thrombophilia, increased risk of prostate cancer or severe lower urinary tract symptoms without prior urological evaluation, recent major adverse cardiovascular event, uncontrolled heart failure or severe untreated sleep apnea. Testosterone replacement therapy should be accompanied by a standardized monitoring plan. CONCLUSION The shared decision to treat should be guided by consideration of the burden of symptoms, potential benefits and risks, patient's values, and the cost and burden of long-term treatment and monitoring.
Collapse
Affiliation(s)
- Shalender Bhasin
- Harvard Medical School, Research Program in Men's Health: Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Noelle Ozimek
- Harvard Medical School, Research Program in Men's Health: Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
6
|
Hirokawa K, Fujii Y, Taniguchi T, Takaki J, Tsutsumi A. Andropause symptoms and sickness absence in Japanese male workers: a prospective study. Aging Male 2020; 23:1545-1552. [PMID: 33346726 DOI: 10.1080/13685538.2020.1862078] [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: 10/22/2022] Open
Abstract
OBJECTIVE The purpose of the study was to investigate the association between andropause symptoms and sickness absence in Japanese male workers over 2 years. METHODS A baseline survey asking about andropause symptoms, along with blood sampling for testosterone level, was conducted in June 2009. A total of 418 men (mean age = 52.4 years, SD = 8.6) participated and were followed through 2011. Hazard ratios (HRs) and 95% confidence intervals (CIs) for sickness absence were calculated using Cox proportional hazard models. RESULTS During the follow-up period, 31 of 35 participants who took sickness absences had physical illnesses. A higher andropause symptom score was associated with an increased risk of sickness absence. Testosterone deficiency (<350 ng/dL) was not associated with sickness absence. Among the subscales of andropause symptoms, the somatic symptom score was positively associated with sickness absence, whereas testosterone deficiency combined with high sexual symptoms was not associated with sickness absence. Results were similar when limited to sickness absence because of physical illness. No significant interaction between andropause symptoms and testosterone deficiency was found. CONCLUSIONS Non-specific andropause symptoms unrelated to testosterone deficiency were positively associated with sickness absence.
Collapse
Affiliation(s)
- Kumi Hirokawa
- Department of Nursing, Baika Women's University, Osaka, Japan
| | - Yasuhito Fujii
- Department of Welfare System and Health Science, Okayama Prefectural University, Soja, Japan
| | | | - Jiro Takaki
- Department of Public Health, Graduate School of Nursing, Sanyo Gakuen University, Okayama, Japan
| | - Akizumi Tsutsumi
- Department of Public Health, Kitasato University School of Medicine, Sagamihara, Japan
| |
Collapse
|
7
|
Afsharnia E, Pakgohar M, Haghani H, Sarani A, Khosravi S. The severity of hypogonadism symptoms and its risk factors among male employees of Tehran University of Medical Sciences. Aging Male 2020; 23:489-495. [PMID: 30651006 DOI: 10.1080/13685538.2018.1534095] [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: 10/27/2022] Open
Abstract
OBJECTIVES The current study was conducted to examine the severity of hypogonadism symptoms and their risk factors among the male employees of Tehran University of Medical Sciences (TUMS). METHODS This cross-sectional study was conducted on 80 male employees aged 40-60 years, with hypogonadism, at TUMS. The participants were selected through census sampling. The data collection tools included the demographic questionnaire and the Aging Male Symptoms (AMS) questionnaire. The participants first completed the demographic questionnaire and then the AMS questionnaire. SPSS statistical software version 22 (Chicago, IL) was used to analyze the data, and one-way ANOVA tests, Pearson's correlation coefficient, and stepwise multivariate logistic regression were applied. RESULTS Based on our findings, the mean overall score of hypogonadism symptoms was 41.71 ± 9.20. Based on Pearson's correlation coefficient results, there was a statistically significant association between the severity of hypogonadism symptoms and age (p < .001). Furthermore, there were significant associations between the economic status, cigarette consumption and hours of sleep and the severity of hypogonadism symptoms (p < .001). CONCLUSIONS The current study's results showed that certain factors can affect hypogonadism in males. Thus, it is important to reduce the severity of hypogonadism symptoms and to modify the factors related to this phenomenon.
Collapse
Affiliation(s)
- Elahe Afsharnia
- School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Reproductive Medicine and Geriatric Health, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Minoo Pakgohar
- Department of Biostatistics, School of Health, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Haghani
- School of Medicine, Islamic Azad University of Zahedan, Zahedan, Iran
| | - Asma Sarani
- Department of Community Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahla Khosravi
- Department of Community Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
8
|
Naz S, Mandhan N, Shankar P, Raj K, Memon S. Sensitivity, Specificity and Accuracy of Androgen Deficiency in Ageing Male (ADAM) Questionnaire for the Clinical Detection of Androgen Deficiency in the Male Population in Pakistan. Cureus 2020; 12:e11788. [PMID: 33409035 PMCID: PMC7779182 DOI: 10.7759/cureus.11788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Androgen deficiency in relation to the increasing age is quite prevalent worldwide. However, diagnosing it in low-income countries is quite a challenge due to cost concerns. Through this study, we plan to measure the sensitivity and specificity of the Androgen Deficiency in Ageing Male (ADAM) questionnaire in the Pakistani population. METHODS A cross-sectional survey study was conducted from September 2019 to November 2019 in a Pakistani tertiary care hospital. Two hundred and fifty-five participants belonging to ages 30-69 years completed the ADAM Questionnaire in the out-patient department. Venous blood samples were taken to check serum total testosterone levels. RESULTS The ADAM questionnaire revealed 90.12% sensitivity, 41.3% specificity, 45.34% positive predictive value, 90.80% negative predictive value, and 61.29% accuracy in the Pakistani population. CONCLUSION Low specificity and positive predictive value have been shown by the ADAM questionnaire. Hence, it cannot be used as a diagnostic tool to detect androgen deficiency, replacing the blood sample.
Collapse
Affiliation(s)
- Sidra Naz
- Internal Medicine, University of Health Sciences, Lahore, PAK
| | - Nikeeta Mandhan
- Internal Medicine, Dr. Ruth K. M. Pfau Civil Hospital, Karachi, PAK
| | - Prem Shankar
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Kuldeep Raj
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Sidra Memon
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| |
Collapse
|
9
|
Age-Related Male Hypogonadism and Cognitive Impairment in the Elderly: Focus on the Effects of Testosterone Replacement Therapy on Cognition. Geriatrics (Basel) 2020; 5:geriatrics5040076. [PMID: 33081371 PMCID: PMC7709679 DOI: 10.3390/geriatrics5040076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/09/2020] [Accepted: 10/13/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Epidemiological data report that male hypogonadism may play a role in cognitive impairment in elderly. However, the effect of testosterone replacement therapy (TRT) on cognitive abilities in this cluster of patients has not been well established. Methods. PubMed/MEDLINE, Google Scholar, Cochrane Library, and Web of Science were searched by using free text words and medical subject headings terms related with "male hypogonadism", "late-onset hypogonadism", elderly, cognition, "mild cognitive impairment", memory, "testosterone replacement therapy" used in various combinations according to the specific clinical questions. Original articles, reviews, and randomized controlled trials written in English were selected. Results. A long-term TRT could improve specific cognitive functions, such as verbal and spatial memory, cognitive flexibility, and physical vitality. However, randomized controlled trials do not provide positive results, and in most of the cases TRT might not induce beneficial effects on cognitive function in elderly men. Discussion and conclusions. Since the lengthening of life expectancy, the prevalence rate of cognitive decline in elderly men is expected to increase remarkably over the next decade with considerable healthcare and economical concerns. Therefore, this remains a relevant clinical topic and further investigations are needed for clarifying the role of TRT especially in elderly men with hypogonadism.
Collapse
|
10
|
Giagulli VA, Castellana M, Lisco G, Triggiani V. Critical evaluation of different available guidelines for late‐onset hypogonadism. Andrology 2020; 8:1628-1641. [DOI: 10.1111/andr.12850] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/19/2020] [Accepted: 06/22/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Vito Angelo Giagulli
- Interdisciplinary Department of Medicine‐Section of Internal Medicine Geriatrics, Endocrinology and Rare Diseases School of Medicine University of Bari “Aldo Moro” Bari Italy
- Outpatients Clinic of Endocrinology and Metabolic Disease Conversano Hospital Bari Italy
| | - Marco Castellana
- National Institute of Gastroenterology "Saverio de Bellis" Research Hospital Bari Italy
| | - Giuseppe Lisco
- Hospital Unit of Endocrinology Perrino Hospital Brindisi Italy
| | - Vincenzo Triggiani
- Interdisciplinary Department of Medicine‐Section of Internal Medicine Geriatrics, Endocrinology and Rare Diseases School of Medicine University of Bari “Aldo Moro” Bari Italy
| |
Collapse
|
11
|
García-Cruz E, Alcaraz A. Testosterone deficiency syndrome: Diagnosis and treatment. Actas Urol Esp 2020; 44:294-300. [PMID: 32423612 DOI: 10.1016/j.acuro.2019.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 10/28/2019] [Indexed: 11/18/2022]
Abstract
The testosterone deficiency syndrome (TDS) is a very common clinical and biochemical condition that affects approximately 2-5% men over the age of 40. From a clinical point of view, it is usually associated with decreased sexual desire and activity, erectile dysfunction, low energy and mood swings, along with T<8-12 nmol/l levels. Questionnaires are not useful in screening but may be useful for diagnosis and follow-up. Its diagnosis requires the presentation of multiple hypogonadism symptoms together with two morning T tests below the acceptable limits. LH and SHBG levels can be useful to determine the cause and the free T level, respectively. Contraindications for treatment are active prostate cancer, stage IV heart failure, breast cancer, desired fertility and hematocrit values over 54%. Treatment is based on the cause of TDS, if any, along with testosterone supplementation. The objective is to achieve normal testosterone levels. Follow-up includes clinical history, analysis (PSA, T+SHBG, hematocrit, glucose and lipid profile) and rectal examination, 3, 6 and 12 months after beginning treatment.
Collapse
Affiliation(s)
- Eduard García-Cruz
- Servicio de Urología, Hospital Clínic de Barcelona, Barcelona, España; Vigora, Barcelona, España.
| | - Antonio Alcaraz
- Servicio de Urología, Hospital Clínic de Barcelona, Barcelona, España
| |
Collapse
|
12
|
Pfaff D, Saad F. Sexual motivation: problem solved and new problems introduced. Horm Mol Biol Clin Investig 2020; 41:hmbci-2019-0055. [PMID: 31926079 DOI: 10.1515/hmbci-2019-0055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/17/2019] [Indexed: 11/15/2022]
Abstract
Background During the past 50 years, motivational studies have evolved from the logical inference of logically required "intervening variables" to explain behavioral change, to electrophysiological and molecular analyses of the mechanisms causing such changes. Aim The purpose of this review article is two-fold: first to describe the logic of sexual motivation in a way that applies to laboratory animals as well as humans, and the second is to address some of the problems of sexual motivation experienced by men. Results When problems of motivational mechanisms are stripped down to their essentials, as performed in the laboratory animal models and are available for reductionistic studies, then the problems can be solved with certainty, as illustrated in the first part of this review. However, with respect to human sexual motivation, the various determinants which include so many behavioral routes and so many brain states come into play, that definite conclusions are harder to come by, as illustrated in the second part of this review. Conclusions This review highlights a number of key questions that merit further investigation. These include (a) What mechanisms do cultural and experiential influences interact with androgenic hormone influences on human sexual motivation? (b) How would epigenetic effects in the human brain related to changes in motivation be investigated? (c) What are the effects of unpredictable traumatic and stressful human experiences on sexual motivation; (d) How such mechanisms are activated upon unpredictable traumatic and stressful insults? (e) What are the outstanding differences between sexual motivational drive and motivations driven by homeostatic systems such as hunger and thirst?
Collapse
Affiliation(s)
- Donald Pfaff
- Laboratory of Neurobiology and Behavior, The Rockefeller University, New York, NY, USA
| | - Farid Saad
- Consultant to Medical Affairs Men's Health/Andrology, Bayer AG, Berlin, Muellerstr. 178, 13353 Berlin, Germany
| |
Collapse
|
13
|
Kaufman JM, Lapauw B, Mahmoud A, T'Sjoen G, Huhtaniemi IT. Aging and the Male Reproductive System. Endocr Rev 2019; 40:906-972. [PMID: 30888401 DOI: 10.1210/er.2018-00178] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 12/27/2018] [Indexed: 12/21/2022]
Abstract
This narrative review presents an overview of current knowledge on fertility and reproductive hormone changes in aging men, the factors driving and modulating these changes, their clinical consequences, and the benefits and risks of testosterone (T) therapy. Aging is accompanied by moderate decline of gamete quality and fertility. Population mean levels show a mild total T decline, an SHBG increase, a steeper free T decline, and a moderate LH increase with important contribution of comorbidities (e.g., obesity) to these changes. Sexual symptoms and lower hematocrit are associated with low T and are partly responsive to T therapy. The relationship of serum T with body composition and metabolic health is bidirectional; limited beneficial effects of T therapy on body composition have only marginal effects on metabolic health and physical function. Skeletal changes are associated primarily with estradiol and SHBG. Cognitive decline is not consistently linked to low T and is not improved by T therapy. Although limited evidence links moderate androgen decline with depressive symptoms, T therapy has small beneficial effects on mood, depressive symptoms, and vitality in elderly patients with low T. Suboptimal T (and/or DHT) has been associated with increased risk of stroke, but not of ischemic heart disease, whereas an association with mortality probably reflects that low T is a marker of poor health. Globally, neither severity of clinical consequences attributable to low T nor the nature and magnitude of beneficial treatment effects justify the concept of some broadly applied "T replacement therapy" in older men with low T. Moreover, long-term safety of T therapy is not established.
Collapse
Affiliation(s)
- Jean-Marc Kaufman
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Bruno Lapauw
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Ahmed Mahmoud
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Guy T'Sjoen
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Ilpo Tapani Huhtaniemi
- Department of Surgery and Cancer, Institute of Reproductive and Developmental Biology, Imperial College London, London, United Kingdom.,Department of Physiology, Institute of Biomedicine, University of Turku, Turku, Finland
| |
Collapse
|
14
|
Evolution of Guidelines for Testosterone Replacement Therapy. J Clin Med 2019; 8:jcm8030410. [PMID: 30934591 PMCID: PMC6462962 DOI: 10.3390/jcm8030410] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 03/20/2019] [Indexed: 12/22/2022] Open
Abstract
Testosterone is an essential hormone required for the developmental growth and maintenance of the male phenotype during the whole life. With the increasing male life expectancy worldwide and development of adequate testosterone preparations, the prescription of testosterone has increased tremendously. Testosterone replacement should be based on low serum testosterone and related clinical symptoms. In the last two decades, with the accumulation of data, official recommendations have evolved in terms of definition, diagnosis, treatment, and follow-up. In practice, it is better for physicians to follow the Institutional Official Recommendations or Clinical Practice Guideline for an adequate diagnosis and treatment of testosterone deficiency. Currently, four official recommendations are available for diagnosis and treatment of patients with testosterone deficiency. The inconsistencies in the guidelines merely create confusion among the physicians instead of providing clear information. Furthermore, there is no definite method to assess serum testosterone and clinical symptoms. In the era of active testosterone replacement therapy (TRT), physicians’ practice patterns should be consistent with the clinical practice guidelines to avoid the misuse of testosterone. In this review, the author introduces the evolution of clinical guidelines to provide a comprehensive understanding of the differences and controversies with respect to TRT.
Collapse
|
15
|
Bhasin S, Brito JP, Cunningham GR, Hayes FJ, Hodis HN, Matsumoto AM, Snyder PJ, Swerdloff RS, Wu FC, Yialamas MA. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:1715-1744. [PMID: 29562364 DOI: 10.1210/jc.2018-00229] [Citation(s) in RCA: 819] [Impact Index Per Article: 136.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 01/26/2018] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To update the "Testosterone Therapy in Men With Androgen Deficiency Syndromes" guideline published in 2010. PARTICIPANTS The participants include an Endocrine Society-appointed task force of 10 medical content experts and a clinical practice guideline methodologist. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. CONSENSUS PROCESS One group meeting, several conference calls, and e-mail communications facilitated consensus development. Endocrine Society committees and members and the cosponsoring organization were invited to review and comment on preliminary drafts of the guideline. CONCLUSIONS We recommend making a diagnosis of hypogonadism only in men with symptoms and signs consistent with testosterone (T) deficiency and unequivocally and consistently low serum T concentrations. We recommend measuring fasting morning total T concentrations using an accurate and reliable assay as the initial diagnostic test. We recommend confirming the diagnosis by repeating the measurement of morning fasting total T concentrations. In men whose total T is near the lower limit of normal or who have a condition that alters sex hormone-binding globulin, we recommend obtaining a free T concentration using either equilibrium dialysis or estimating it using an accurate formula. In men determined to have androgen deficiency, we recommend additional diagnostic evaluation to ascertain the cause of androgen deficiency. We recommend T therapy for men with symptomatic T deficiency to induce and maintain secondary sex characteristics and correct symptoms of hypogonadism after discussing the potential benefits and risks of therapy and of monitoring therapy and involving the patient in decision making. We recommend against starting T therapy in patients who are planning fertility in the near term or have any of the following conditions: breast or prostate cancer, a palpable prostate nodule or induration, prostate-specific antigen level > 4 ng/mL, prostate-specific antigen > 3 ng/mL in men at increased risk of prostate cancer (e.g., African Americans and men with a first-degree relative with diagnosed prostate cancer) without further urological evaluation, elevated hematocrit, untreated severe obstructive sleep apnea, severe lower urinary tract symptoms, uncontrolled heart failure, myocardial infarction or stroke within the last 6 months, or thrombophilia. We suggest that when clinicians institute T therapy, they aim at achieving T concentrations in the mid-normal range during treatment with any of the approved formulations, taking into consideration patient preference, pharmacokinetics, formulation-specific adverse effects, treatment burden, and cost. Clinicians should monitor men receiving T therapy using a standardized plan that includes: evaluating symptoms, adverse effects, and compliance; measuring serum T and hematocrit concentrations; and evaluating prostate cancer risk during the first year after initiating T therapy.
Collapse
Affiliation(s)
| | | | | | | | - Howard N Hodis
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Alvin M Matsumoto
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Peter J Snyder
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | |
Collapse
|
16
|
Bandari J, Ayyash OM, Emery SL, Wessel CB, Davies BJ. Marketing and Testosterone Treatment in the USA: A Systematic Review. Eur Urol Focus 2017; 3:395-402. [PMID: 29174614 DOI: 10.1016/j.euf.2017.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 10/21/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT Testosterone replacement therapy (TRT) is currently approved by the Food and Drug Administration only for classic hypogonadism, although off-label indications have resulted in a dramatic expansion in prescriptions in the USA. Marketing may significantly affect prescriber behavior. OBJECTIVE To systematically review all available evidence on marketing and TRT in the USA. EVIDENCE ACQUISITION PubMed, Embase, and Scopus were searched up to July 2017 for all relevant publications reporting on assessments of the TRT market size, economic costs associated with hypogonadism, trends in TRT prescriptions, drug discontinuation rates, and advertising and sales efforts in the USA. EVIDENCE SYNTHESIS Twenty retrospective studies were included in the final analysis. The market size for hypogonadism constitutes 5.6-76.8% of men in the USA, with the lower end of the range representing the strictest criteria for diagnosis. Men with a diagnosis of hypogonadism consume $14 118 in direct and indirect costs to the payer. Over the last 2 decades, TRT prescriptions have increased between 1.8- and 4-fold. After 1 yr, 80-85% of men discontinue TRT. There is an association between direct-to-consumer advertising and testosterone testing, TRT prescriptions, and TRT without testosterone testing. There is a high prevalence of misinformation on Internet advertising. CONCLUSIONS Off-label indications have driven the dramatic expansion of TRT prescriptions over the last 2 decades. Direct-to-consumer advertising poses a unique challenge in the USA. Overtreatment can be avoided by applying strict diagnostic criteria for hypogonadism, which limits the addressable market for TRT. PATIENT SUMMARY In this report, we reviewed the relationship between marketing and testosterone therapy in the USA. We found that many patients are prescribed testosterone without an appropriate diagnosis of hypogonadism, which may be related to the marketing efforts for off-label prescribing.
Collapse
Affiliation(s)
- Jathin Bandari
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Omar M Ayyash
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Charles B Wessel
- University of Pittsburgh Health Sciences Library System, Pittsburgh, PA, USA
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
17
|
Presence of Androgen Receptor Variant in Neuronal Lipid Rafts. eNeuro 2017; 4:eN-NWR-0109-17. [PMID: 28856243 PMCID: PMC5575139 DOI: 10.1523/eneuro.0109-17.2017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 08/03/2017] [Accepted: 08/14/2017] [Indexed: 11/21/2022] Open
Abstract
Fast, nongenomic androgen actions have been described in various cell types, including neurons. However, the receptor mediating this cell membrane–initiated rapid signaling remains unknown. This study found a putative androgen receptor splice variant in a dopaminergic N27 cell line and in several brain regions (substantia nigra pars compacta, entorhinal cortex, and hippocampus) from gonadally intact and gonadectomized (young and middle-aged) male rats. This putative splice variant protein has a molecular weight of 45 kDa and lacks an N-terminal domain, indicating it is homologous to the human AR45 splice variant. Interestingly, AR45 was highly expressed in all brain regions examined. In dopaminergic neurons, AR45 is localized to plasma membrane lipid rafts, a microdomain involved in cellular signaling. Further, AR45 protein interacts with membrane-associated G proteins Gαq and Gαo. Neither age nor hormone levels altered AR45 expression in dopaminergic neurons. These results provide the first evidence of AR45 protein expression in the brain, specifically plasma membrane lipid rafts. AR45 presence in lipid rafts indicates that it may function as a membrane androgen receptor to mediate fast, nongenomic androgen actions.
Collapse
|
18
|
Khera M, Adaikan G, Buvat J, Carrier S, El-Meliegy A, Hatzimouratidis K, McCullough A, Morgentaler A, Torres LO, Salonia A. Diagnosis and Treatment of Testosterone Deficiency: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2017; 13:1787-1804. [PMID: 27914560 DOI: 10.1016/j.jsxm.2016.10.009] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 10/19/2016] [Accepted: 10/21/2016] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Testosterone deficiency (TD), also known as hypogonadism, is a condition affecting a substantial proportion of men as they age. The diagnosis and management of TD can be challenging and clinicians should be aware of the current literature on this condition. AIM To review the available literature concerning the diagnosis and management of TD and to provide clinically relevant recommendations from the Fourth International Consultation for Sexual Medicine (ICSM) meeting. METHODS A literature search was performed using the PubMed database for English-language original and review articles published or e-published up to January 2016. MAIN OUTCOME MEASURES Levels of evidence (LoEs) and grades of recommendations are provided based on a thorough analysis of the literature and committee consensus. RESULTS Recommendations were given for 12 categories of TD: definition, clinical diagnosis, routine measurement, screening questionnaires, laboratory diagnosis, threshold levels for the biochemical diagnosis of TD, prostate cancer, cardiovascular disease, fertility, testosterone (T) formulations, alternatives to T therapy, and adverse events and monitoring. A total of 42 recommendations were made: of these, 16 were unchanged from the Third ICSM and 26 new recommendations were made during this Fourth ICSM. Most of these recommendations were supported by LoEs 2 and 3. Several key new recommendations include the following: (i) the clinical manifestations of TD occur as a result of decreased serum androgen concentrations or activity, regardless of whether there is an identified underlying etiology [LoE = 1, Grade = A]; (ii) symptomatic men with total T levels lower than 12 nmol/L or 350 ng/dL should be treated with T therapy [LoE = 1, Grade = C]; (iii) a trial of T therapy in symptomatic men with total T levels higher than 12 nmol/L or 350 ng/dL can be considered based on clinical presentation [LoE = 3, Grade = C]; (iv) there is no compelling evidence that T treatment increases the risk of developing prostate cancer or that its use is associated with prostate cancer progression [LoE = 1, Grade = C]; and (v) the weight of evidence indicates that T therapy is not associated with increased cardiovascular risk [LoE = 2, Grade = B]. CONCLUSION TD is an important condition that can profoundly affect the sexual health of men. We provide guidance regarding its diagnosis and management. Men with TD who receive treatment often experience resolution or improvement in their sexual symptoms and non-sexual health benefits.
Collapse
Affiliation(s)
- Mohit Khera
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.
| | - Ganesh Adaikan
- Section of Sexual Medicine, Obstetrics and Gynaecology, National University Hospital, National University of Singapore, Singapore
| | - Jacques Buvat
- CETPARP (Centre d'études et de traitement de la pathologie de l'appareil reproducteur), Lille, France
| | - Serge Carrier
- Department of Urology, McGill University, Montreal, QC, Canada
| | - Amr El-Meliegy
- Department of Andrology, Dr Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Kostas Hatzimouratidis
- Second Department of Urology, Aristotle University of Thessaloniki, Pefka Thessaloniki, Greece
| | | | | | | | | |
Collapse
|
19
|
Liu Z, Liu J, Shi X, Wang L, Yang Y, Tao M, Fu Q. Comparing calculated free testosterone with total testosterone for screening and diagnosing late-onset hypogonadism in aged males: A cross-sectional study. J Clin Lab Anal 2016; 31. [PMID: 27714896 DOI: 10.1002/jcla.22073] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 09/06/2016] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE The aim of this study is to compare calculated free testosterone (cFT) and total testosterone (T) in predicting late-onset hypogonadism (LOH) in middle-aged and elderly males. METHODS We surveyed a random sample of 608 males between the ages of 45 and 87 years from Shanghai, China. The Aging Male Symptoms (AMS) questionnaire and the Androgen Deficiency in Aging Male (ADAM) questionnaire were completed by the subjects. Testosterone (T), sex hormone-binding globulin (SHBG), albumin, and other blood biochemical indexes were measured in 332 males. The corresponding cFT was obtained using the Vermeulen formula and the correlations between T and cFT were analyzed by SPSS statistical software. RESULTS Among the 332 males who underwent biochemical evaluation, 289 males (87.0%) was positively screened by the ADAM questionnaire and 232 males (69.9%) by the AMS questionnaire. As suggested by linear regression, cFT exhibited a negative correlation with age in both ADAM+ and AMS+ group, whereas T did not appear to have significant correlation with age. Besides, there were statistically significant differences in cFT (P<.001) in the AMS questionnaire. CONCLUSIONS Calculated free testosterone levels are more reliable than T levels for diagnosing LOH in middle-aged and elderly males.
Collapse
Affiliation(s)
- Zhangshun Liu
- Department of Reproductive Medicine Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jie Liu
- Department of Reproductive Medicine Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiaohong Shi
- Department of Reproductive Medicine Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Lihong Wang
- Department of Reproductive Medicine Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yan Yang
- Department of Reproductive Medicine Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Minfang Tao
- Department of Reproductive Medicine Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qiang Fu
- Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| |
Collapse
|
20
|
Trost LW, Mulhall JP. Challenges in Testosterone Measurement, Data Interpretation, and Methodological Appraisal of Interventional Trials. J Sex Med 2016; 13:1029-46. [PMID: 27209182 PMCID: PMC5516925 DOI: 10.1016/j.jsxm.2016.04.068] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/14/2016] [Accepted: 04/17/2016] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Male hypogonadism is a common condition, with an increasing body of literature on diagnosis, implications, and management. Given the significant variability in testosterone (T) from a physiologic and assay perspective, a thorough understanding of factors affecting T values and study methodology is essential to interpret reported study outcomes appropriately. However, despite the large number of publications on T, there are no reference materials consolidating all relevant and potentially confounding factors necessary to interpret T studies appropriately. AIMS To create a resource document that reviews sources of T variability, free vs total T, assay techniques and questionnaires, and study methodology relevant to interpreting outcomes. METHODS A PubMed search was performed of all the T literature published on T variability, assay techniques, and T-specific questionnaires. Results were summarized in the context of their impact on interpreting T literature outcomes and methodology. MAIN OUTCOME MEASURES Effect of various factors on T variability and their relevance to study methodology and outcomes. RESULTS Several factors affect measured T levels, including aging, circadian rhythms, geography, genetics, lifestyle choices, comorbid conditions, and intraindividual daily variability. The utility of free T over total T is debatable and must be compared using appropriate threshold levels. Among various assay techniques, mass spectrometry and equilibrium dialysis are gold standards. Calculated empirical estimates of free T also are commonly used and accepted. Hypogonadism-specific questionnaires have limited utility in screening for hypogonadism, and their role as objective end points for quantifying symptoms remains unclear. Numerous aspects of study methodology can directly or indirectly affect reported outcomes, including design (randomized, prospective, retrospective), duration, populations studied (age, comorbid conditions), low T threshold, therapeutic agent used, objective measurements and end points selected, and statistical interpretation. CONCLUSION Critical appraisal of the T literature requires an understanding of numerous factors resulting in T variability, study design and methodology, and limitations of assay techniques and objective measurement scales.
Collapse
Affiliation(s)
- Landon W Trost
- Department of Urology, Mayo Clinic, Rochester, MN, USA; Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - John P Mulhall
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
21
|
Holmes S, Singh M, Su C, Cunningham RL. Effects of Oxidative Stress and Testosterone on Pro-Inflammatory Signaling in a Female Rat Dopaminergic Neuronal Cell Line. Endocrinology 2016; 157:2824-35. [PMID: 27167771 PMCID: PMC4929547 DOI: 10.1210/en.2015-1738] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Parkinson's disease, a progressive neurodegenerative disorder, is associated with oxidative stress and neuroinflammation. These pathological markers can contribute to the loss of dopamine neurons in the midbrain. Interestingly, men have a 2-fold increased incidence for Parkinson's disease than women. Although the mechanisms underlying this sex difference remain elusive, we propose that the primary male sex hormone, testosterone, is involved. Our previous studies show that testosterone, through a putative membrane androgen receptor, can increase oxidative stress-induced neurotoxicity in dopamine neurons. Based on these results, this study examines the role of nuclear factor κ B (NF-κB), cyclooxygenase-2 (COX2), and apoptosis in the deleterious effects of androgens in an oxidative stress environment. We hypothesize, under oxidative stress environment, testosterone via a putative membrane androgen receptor will exacerbate oxidative stress-induced NF-κB/COX2 signaling in N27 dopaminergic neurons, leading to apoptosis. Our data show that testosterone increased the expression of COX2 and apoptosis in dopamine neurons. Inhibiting the NF-κB and COX2 pathway with CAPE and ibuprofen, respectively, blocked testosterone's negative effects on cell viability, indicating that NF-κB/COX2 cascade plays a role in the negative interaction between testosterone and oxidative stress on neuroinflammation. These data further support the role of testosterone mediating the loss of dopamine neurons under oxidative stress conditions, which may be a key mechanism contributing to the increased incidence of Parkinson's disease in men compared with women.
Collapse
Affiliation(s)
- Shaletha Holmes
- Department of Pharmacology and Neuroscience, Institute for Aging and Alzheimer's Disease Research, University of North Texas Health Science Center, Fort Worth, Texas 76107
| | - Meharvan Singh
- Department of Pharmacology and Neuroscience, Institute for Aging and Alzheimer's Disease Research, University of North Texas Health Science Center, Fort Worth, Texas 76107
| | - Chang Su
- Department of Pharmacology and Neuroscience, Institute for Aging and Alzheimer's Disease Research, University of North Texas Health Science Center, Fort Worth, Texas 76107
| | - Rebecca L Cunningham
- Department of Pharmacology and Neuroscience, Institute for Aging and Alzheimer's Disease Research, University of North Texas Health Science Center, Fort Worth, Texas 76107
| |
Collapse
|
22
|
Millar AC, Lau ANC, Tomlinson G, Kraguljac A, Simel DL, Detsky AS, Lipscombe LL. Predicting low testosterone in aging men: a systematic review. CMAJ 2016; 188:E321-E330. [PMID: 27325129 DOI: 10.1503/cmaj.150262] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2016] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Physicians diagnose and treat suspected hypogonadism in older men by extrapolating from the defined clinical entity of hypogonadism found in younger men. We conducted a systematic review to estimate the accuracy of clinical symptoms and signs for predicting low testosterone among aging men. METHODS We searched the MEDLINE and Embase databases (January 1966 to July 2014) for studies that compared clinical features with a measurement of serum testosterone in men. Three of the authors independently reviewed articles for inclusion, assessed quality and extracted data. RESULTS Among 6053 articles identified, 40 met the inclusion criteria. The prevalence of low testosterone ranged between 2% and 77%. Threshold testosterone levels used for reference standards also varied substantially. The summary likelihood ratio associated with decreased libido was 1.6 (95% confidence interval [CI] 1.3-1.9), and the likelihood ratio for absence of this finding was 0.72 (95% CI 0.58-0.85). The likelihood ratio associated with the presence of erectile dysfunction was 1.5 (95% CI 1.3-1.8) and with absence of erectile dysfunction was 0.83 (95% CI 0.76-0.91). Of the multiple-item instruments, the ANDROTEST showed both the most favourable positive likelihood ratio (range 1.9-2.2) and the most favourable negative likelihood ratio (range 0.37-0.49). INTERPRETATION We found weak correlation between signs, symptoms and testosterone levels, uncertainty about what threshold testosterone levels should be considered low for aging men and wide variation in estimated prevalence of the condition. It is therefore difficult to extrapolate the method of diagnosing pathologic hypogonadism in younger men to clinical decisions regarding age-related testosterone decline in aging men.
Collapse
Affiliation(s)
- Adam C Millar
- Department of Medicine (Millar, Tomlinson, Detsky, Lipscombe) and Institute of Health Policy, Management and Evaluation (Tomlinson, Detsky, Lipscombe), University of Toronto, Toronto, Ont.; Department of Medicine (Millar, Lau, Tomlinson, Kraguljac, Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Durham Veterans Affairs Medical Center (Simel), Durham, NC; Department of Medicine (Simel), Duke University, Durham, NC; Department of Medicine (Lipscombe), Women's College Research Institute of Women's College Hospital, Toronto, Ont
| | - Adrian N C Lau
- Department of Medicine (Millar, Tomlinson, Detsky, Lipscombe) and Institute of Health Policy, Management and Evaluation (Tomlinson, Detsky, Lipscombe), University of Toronto, Toronto, Ont.; Department of Medicine (Millar, Lau, Tomlinson, Kraguljac, Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Durham Veterans Affairs Medical Center (Simel), Durham, NC; Department of Medicine (Simel), Duke University, Durham, NC; Department of Medicine (Lipscombe), Women's College Research Institute of Women's College Hospital, Toronto, Ont
| | - George Tomlinson
- Department of Medicine (Millar, Tomlinson, Detsky, Lipscombe) and Institute of Health Policy, Management and Evaluation (Tomlinson, Detsky, Lipscombe), University of Toronto, Toronto, Ont.; Department of Medicine (Millar, Lau, Tomlinson, Kraguljac, Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Durham Veterans Affairs Medical Center (Simel), Durham, NC; Department of Medicine (Simel), Duke University, Durham, NC; Department of Medicine (Lipscombe), Women's College Research Institute of Women's College Hospital, Toronto, Ont
| | - Alan Kraguljac
- Department of Medicine (Millar, Tomlinson, Detsky, Lipscombe) and Institute of Health Policy, Management and Evaluation (Tomlinson, Detsky, Lipscombe), University of Toronto, Toronto, Ont.; Department of Medicine (Millar, Lau, Tomlinson, Kraguljac, Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Durham Veterans Affairs Medical Center (Simel), Durham, NC; Department of Medicine (Simel), Duke University, Durham, NC; Department of Medicine (Lipscombe), Women's College Research Institute of Women's College Hospital, Toronto, Ont
| | - David L Simel
- Department of Medicine (Millar, Tomlinson, Detsky, Lipscombe) and Institute of Health Policy, Management and Evaluation (Tomlinson, Detsky, Lipscombe), University of Toronto, Toronto, Ont.; Department of Medicine (Millar, Lau, Tomlinson, Kraguljac, Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Durham Veterans Affairs Medical Center (Simel), Durham, NC; Department of Medicine (Simel), Duke University, Durham, NC; Department of Medicine (Lipscombe), Women's College Research Institute of Women's College Hospital, Toronto, Ont
| | - Allan S Detsky
- Department of Medicine (Millar, Tomlinson, Detsky, Lipscombe) and Institute of Health Policy, Management and Evaluation (Tomlinson, Detsky, Lipscombe), University of Toronto, Toronto, Ont.; Department of Medicine (Millar, Lau, Tomlinson, Kraguljac, Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Durham Veterans Affairs Medical Center (Simel), Durham, NC; Department of Medicine (Simel), Duke University, Durham, NC; Department of Medicine (Lipscombe), Women's College Research Institute of Women's College Hospital, Toronto, Ont.
| | - Lorraine L Lipscombe
- Department of Medicine (Millar, Tomlinson, Detsky, Lipscombe) and Institute of Health Policy, Management and Evaluation (Tomlinson, Detsky, Lipscombe), University of Toronto, Toronto, Ont.; Department of Medicine (Millar, Lau, Tomlinson, Kraguljac, Detsky), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Durham Veterans Affairs Medical Center (Simel), Durham, NC; Department of Medicine (Simel), Duke University, Durham, NC; Department of Medicine (Lipscombe), Women's College Research Institute of Women's College Hospital, Toronto, Ont
| |
Collapse
|
23
|
|
24
|
Rastrelli G, Corona G, Tarocchi M, Mannucci E, Maggi M. How to define hypogonadism? Results from a population of men consulting for sexual dysfunction. J Endocrinol Invest 2016; 39:473-84. [PMID: 26733213 DOI: 10.1007/s40618-015-0425-1] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/16/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE The thresholds for testost erone (T) and the symptoms required for defining late onset hypogonadism (LOH) are under debate. The aims of the study are: (1) to verify the association between total and calculated free T (cfT) and sexual symptoms and (2) to identify thresholds for total and calculated free T to discriminate symptomatic from asymptomatic men. METHODS A consecutive series of 4890 men attending the outpatient clinic for sexual dysfunction was retrospectively studied. Biochemical parameters were collected. The relationships between symptoms and total or calculated free T were evaluated as LOESS curves. RESULTS Severe impairment in morning erections, low libido and ED were reported by 14.6, 2.7 and 60.2 %, respectively. Simultaneous presence of severe ED and impaired morning erections or low desire was reported by 12.7 and 1.9 %, respectively. Severely reduced desire and morning erections were complained of by 1.0 %. The simultaneous presence of the three severe sexual symptoms was reported by 0.8 %. Receiver operating characteristic (ROC) curve analysis showed that the highest accuracy for total T and cfT in detecting subjects with two symptoms was observed for reduced morning erections and desire (area under the ROC curve [AUC] = 0.670 ± 0.04 and 0.747 ± 0.04, for total T and cfT, respectively, both p < 0.0001). The addition of the third symptom, ED, further improved the accuracy (AUC = 0.681 ± 0.05 and 0.784 ± 0.04, for total T and cfT, respectively, both p < 0.0001). The assessment of the Youden index showed that the best thresholds for detecting men with androgen deficiency-related symptoms are 10.4 nmol/L for total T and ranges 225-260 pmol/L for cfT. CONCLUSIONS The simultaneous presence of reduced morning erections and desire is the cluster of symptoms that, along with total T < 10.4 nmol/L or cfT <225 pmol/L, defines LOH in a specific, evidence-based manner.
Collapse
Affiliation(s)
- G Rastrelli
- Sexual Medicine and Andrology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - G Corona
- Sexual Medicine and Andrology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
- Endocrinology Section, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - M Tarocchi
- Gastroenterology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - E Mannucci
- Diabetes Section Geriatric Unit, Department of Critical Care, University of Florence, Via delle Oblate 1, 50139, Florence, Italy
| | - M Maggi
- Sexual Medicine and Andrology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy.
| |
Collapse
|
25
|
Gelhorn HL, Vernon MK, Stewart KD, Miller MG, Brod M, Althof SE, DeRogatis LR, Dobs A, Seftel AD, Revicki DA. Content Validity of the Hypogonadism Impact of Symptoms Questionnaire (HIS-Q): A Patient-Reported Outcome Measure to Evaluate Symptoms of Hypogonadism. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2015; 9:181-90. [DOI: 10.1007/s40271-015-0138-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
26
|
Abstract
In primary care practice, it is not unusual to encounter male patients in their 50s or older who report having loss of libido, erectile dysfunction, fatigue, and depression. Such signs and symptoms may signal an age-related decline in androgen levels, which commonly begins after age 40. However, psychologic problems and medical illness often confound the diagnosis. Drs Tan and Pu, who are currently conducting research on androgen deficiency, discuss the diagnostic difficulties of the physiologic phenomenon of andropause and offer a comprehensive approach to clinical assessment and laboratory evaluation.
Collapse
Affiliation(s)
- Robert S Tan
- Department of Family Practice and Community Medicine, University of Texas Medical School at Houston, Garden Terrace Alzheimer's Center, Houston, TX, USA.
| | | |
Collapse
|
27
|
Sterling J, Bernie AM, Ramasamy R. Hypogonadism: Easy to define, hard to diagnose, and controversial to treat. Can Urol Assoc J 2015; 9:65-8. [PMID: 25737761 DOI: 10.5489/cuaj.2416] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
| | - Aaron M Bernie
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY
| | | |
Collapse
|
28
|
Bernie AM, Scovell JM, Ramasamy R. Comparison of questionnaires used for screening and symptom identification in hypogonadal men. Aging Male 2014; 17:195-8. [PMID: 25247629 DOI: 10.3109/13685538.2014.963041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Late-onset hypogonadism (LOH) is typically defined as the cluster of symptoms appearing in aging men and accompanied by a decrease in serum testosterone levels. The identification of a simple screening tool with a high level of sensitivity and specificity to predict LOH has remained a challenge. To identify men with LOH, a variety of self-administered questionnaires have been developed including The Saint Louis University Androgen Deficiency in the Aging Male (ADAM) Questionnaire, The Quantitative ADAM (qADAM) Questionnaire, The Aging Male Symptoms (AMS) rating scale, The Massachusetts Male Aging Study (MMAS) questionnaire and The New England Research Institutes (NERI) hypogonadism questionnaire. The applicability of these questionnaires in the clinical setting is debated because some of the symptoms associated with LOH could be attributed to the natural process of aging and comorbidities. The goal of this review is to compare the utility and the validity of the different LOH questionnaires.
Collapse
Affiliation(s)
- Aaron M Bernie
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medical College , New York, NY , USA and
| | | | | |
Collapse
|
29
|
Huhtaniemi I. Late-onset hypogonadism: current concepts and controversies of pathogenesis, diagnosis and treatment. Asian J Androl 2014; 16:192-202. [PMID: 24407185 PMCID: PMC3955328 DOI: 10.4103/1008-682x.122336] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Although suppressed serum testosterone (T) is common in ageing men, only a small proportion of them develop the genuine syndrome of low T associated with diffuse sexual (e.g., erectile dysfunction), physical (e.g. loss of vigor and frailty) and psychological (e.g., depression) symptoms. This syndrome carries many names, including male menopause or climacterium, andropause and partial androgen deficiency of the ageing male (PADAM). Late-onset hypogonadism (LOH) describes it best and is therefore generally preferred. The decrease of T in LOH is often marginal, and hypogonadism can be either due to primary testicular failure (low T, high luteinizing hormone (LH)) or secondary to a hypothalamic-pituitary failure (low T, low or inappropriately normal LH). The latter form is more common and it is usually associated with overweight/obesity or chronic diseases (e.g., type 2 diabetes mellitus, the metabolic syndrome, cardiovascular and chronic obstructive pulmonary disease, and frailty). A problem with the diagnosis of LOH is that often the symptoms (in 20%–40% of unselected men) and low circulating T (in 20% of men >70 years of age) do not coincide in the same individual. The European Male Ageing Study (EMAS) has recently defined the strict diagnostic criteria for LOH to include the simultaneous presence of reproducibly low serum T (total T <11 nmol l−1 and free T <220 pmol l−1) and three sexual symptoms (erectile dysfunction, and reduced frequency of sexual thoughts and morning erections). By these criteria, only 2% of 40- to 80-year-old men have LOH. In particular obesity, but also impaired general health, are more common causes of low T than chronological age per se. Evidence-based information whether, and how, LOH should be treated is sparse. The most logical approach is lifestyle modification, weight reduction and good treatment of comorbid diseases. T replacement is widely used for the treatment, but evidence-based information about its real benefits and short- and long-term risks, is not yet available. In this review, we will summarize the current concepts and controversies in the pathogenesis, diagnosis and treatment of LOH.
Collapse
Affiliation(s)
- Ilpo Huhtaniemi
- Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmth Campus, London, UK; Department of Physiology, University of Turku, Kiinamyllynkatu, Turku, Finland,
| |
Collapse
|
30
|
Zarotsky V, Huang MY, Carman W, Morgentaler A, Singhal PK, Coffin D, Jones TH. Systematic literature review of the risk factors, comorbidities, and consequences of hypogonadism in men. Andrology 2014; 2:819-34. [PMID: 25269643 DOI: 10.1111/andr.274] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 08/05/2014] [Accepted: 08/12/2014] [Indexed: 12/16/2022]
Affiliation(s)
- V. Zarotsky
- Product Value Strategy Consulting; Optum; Eden Prairie MN USA
| | - M.-Y. Huang
- Global Health Outcomes; Merck & Co. Inc.; West Point PA USA
- School of Pharmacy; Temple University; Philadelphia PA USA
| | - W. Carman
- Epidemiology; Optum; Ann Arbor MI USA
| | - A. Morgentaler
- Men's Health Boston; Brookline MA USA
- Harvard Medical School; Boston MA USA
| | - P. K. Singhal
- Global Health Outcomes; Merck & Co. Inc.; West Point PA USA
| | - D. Coffin
- Boolean Research Consulting; Westmount QC Canada
| | - T. H. Jones
- Robert Hague Centre for Diabetes and Endocrinology; Barnsley Hospital NHS Foundation Trust; Barnsley UK
- Department of Human Metabolism; School of Medicine and Biomedical Sciences; University of Sheffield; Sheffield UK
| |
Collapse
|
31
|
Cabral RD, Busin L, Rosito TE, Koff WJ. Performance of Massachusetts Male Aging Study (MMAS) and androgen deficiency in the aging male (ADAM) questionnaires in the prediction of free testosterone in patients aged 40 years or older treated in outpatient regimen. Aging Male 2014; 17:147-54. [PMID: 24739016 DOI: 10.3109/13685538.2014.908460] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE At present, calculated free testosterone assessment is considered as the gold standard in diagnosing male hypogonadism. However, this assessment is not available for all the individuals diagnosed with decreased testicular function. The investigators of this study were, thus, prompted to evaluate whether the androgen deficiency in the aging male (ADAM) and the Massachusetts Male Ageing Study (MMAS) questionnaires could be used to replace biochemical parameters in the diagnosis for hypogonadism in men aged 40 years and above. METHODS We evaluated 460 men, aged 40 years and above, all volunteers of a screening program for prostate cancer based at the Hospital de Clínicas of Porto Alegre. In this study, we assessed the efficiency of the ADAM and MMAS questionnaires in diagnosing Brazilian men with low levels of total, calculated free and bioavailable testosterone. RESULTS The sensitivity of the ADAM questionnaire in diagnosing the calculated free testosterone was 73.6%, whereas specificity was 31.9%. ADAM could be used to properly classify our cohort into normal or hypogonadal individuals in 52.75% of the cases. The sensitivity of the MMAS questionnaire was 59.9%, whereas the specificity was 42.9%, resulting in a successful classification of 51.4% of the patients. CONCLUSION The ADAM and MMAS questionnaires showed adequate sensitivity in diagnosing male patients with low levels of free testosterone. However, because of the lack of specificity, these tools cannot replace calculated free testosterone assessments in men aged 40 years and above.
Collapse
Affiliation(s)
- Renan Desimon Cabral
- Urology Department, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul , Porto Algre , Brazil
| | | | | | | |
Collapse
|
32
|
García‐Cruz E, Leibar‐Tamayo A, Romero‐Otero J, Asiaín I, Carrión A, Castañeda R, Mateu L, Luque P, Cardeñosa O, Alcaraz A. Marked Testosterone Deficiency‐Related Symptoms May be Associated to Higher Metabolic Risk in Men with Low Testosterone Levels. J Sex Med 2014; 11:2292-301. [DOI: 10.1111/jsm.12615] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
33
|
Martits AM, Costa EMF, Nardi AC, Nardozza Jr A, Faria G, Facio Jr FN, Bernardo WM. Late-onset hypogonadism or ADAM: diagnosis. Rev Assoc Med Bras (1992) 2014; 60:286-94. [DOI: 10.1590/1806-9282.60.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Indexed: 11/22/2022] Open
|
34
|
Alidjanov J, Wolf J, Schuppe HC, Weidner W, Diemer T, Linn T, Halefeldt I, Wagenlehner F, Wiltink J, Pilatz A. Validation of the German version of the ‘Hypogonadism Related Symptom Scale’ (HRS) in andrological patients with infertility, HIV infection and metabolic syndrome. Andrologia 2014; 46:1189-97. [DOI: 10.1111/and.12215] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2013] [Indexed: 01/20/2023] Open
Affiliation(s)
- J. Alidjanov
- Department of Urology, Pediatric Urology and Andrology; Justus Liebig University; Giessen Germany
- Outpatient Department; The Republican Specialized Center of Urology; Tashkent Uzbekistan
| | - J. Wolf
- Department of Urology, Pediatric Urology and Andrology; Justus Liebig University; Giessen Germany
| | - H.-C. Schuppe
- Department of Urology, Pediatric Urology and Andrology; Justus Liebig University; Giessen Germany
| | - W. Weidner
- Department of Urology, Pediatric Urology and Andrology; Justus Liebig University; Giessen Germany
| | - T. Diemer
- Department of Urology, Pediatric Urology and Andrology; Justus Liebig University; Giessen Germany
| | - T. Linn
- Clinical Research Unit; 3rd Medical Clinic and Policlinic; Justus Liebig University; Giessen Germany
| | - I. Halefeldt
- Department of Urology, Pediatric Urology and Andrology; Justus Liebig University; Giessen Germany
| | - F. Wagenlehner
- Department of Urology, Pediatric Urology and Andrology; Justus Liebig University; Giessen Germany
| | - J. Wiltink
- Department of Psychosomatic Medicine and Psychotherapy; University Medical Center of the Johannes Gutenberg University; Mainz Germany
| | - A. Pilatz
- Department of Urology, Pediatric Urology and Andrology; Justus Liebig University; Giessen Germany
| |
Collapse
|
35
|
Holmes S, Abbassi B, Su C, Singh M, Cunningham RL. Oxidative stress defines the neuroprotective or neurotoxic properties of androgens in immortalized female rat dopaminergic neuronal cells. Endocrinology 2013; 154:4281-92. [PMID: 23959938 PMCID: PMC3800758 DOI: 10.1210/en.2013-1242] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Males have a higher risk for developing Parkinson's disease and parkinsonism after ischemic stroke than females. Although estrogens have been shown to play a neuroprotective role in Parkinson's disease, there is little information on androgens' actions on dopamine neurons. In this study, we examined the effects of androgens under conditions of oxidative stress to determine whether androgens play a neuroprotective or neurotoxic role in dopamine neuronal function. Mitochondrial function, cell viability, intracellular calcium levels, and mitochondrial calcium influx were examined in response to androgens under both nonoxidative and oxidative stress conditions. Briefly, N27 dopaminergic cells were exposed to the oxidative stressor, hydrogen peroxide, and physiologically relevant levels of testosterone or dihydrotestosterone, applied either before or after oxidative stress exposure. Androgens, alone, increased mitochondrial function via a calcium-dependent mechanism. Androgen pretreatment protected cells from oxidative stress-induced cell death. However, treatment with androgens after the oxidative insult increased cell death, and these effects were, in part, mediated by calcium influx into the mitochondria. Interestingly, the negative effects of androgens were not blocked by either androgen or estrogen receptor antagonists. Instead, a putative membrane-associated androgen receptor was implicated. Overall, our results indicate that androgens are neuroprotective when oxidative stress levels are minimal, but when oxidative stress levels are elevated, androgens exacerbate oxidative stress damage.
Collapse
Affiliation(s)
- Shaletha Holmes
- PhD, Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, 3400 Camp Bowie Boulevard, Fort Worth, Texas 76107-2699.
| | | | | | | | | |
Collapse
|
36
|
Chen W, Liu ZY, Wang LH, Zeng QS, Wang HQ, Sun YH. Are the Aging Male's Symptoms (AMS) scale and the Androgen Deficiency in the Aging Male (ADAM) questionnaire suitable for the screening of late-onset hypogonadism in aging Chinese men? Aging Male 2013; 16:92-6. [PMID: 23862578 DOI: 10.3109/13685538.2013.805319] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The Aging Male's Symptoms (AMS) scale and the Androgen Deficiency in the Aging Male (ADAM) questionnaire have been widely used for screening men suspected of late-onset hypogonadism (LOH). We evaluated the consistency of the two questionnaires with sex hormone levels. A total of 985 men completed the two questionnaires, as well as an analysis of the serum levels of total testosterone (TT), bioavailable testosterone (BT), luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol (E2), prolactin (PRL) and sex hormone-binding globulin (SHBG). No correlation was observed between any hormone level and the psychological or somatic section of the AMS score, whereas the sexual section was correlated with the levels of FT, LH, FSH, SHBG and BT. Significant correlations were observed between the result of the two questionnaires and these hormone levels. When LOH was defined as TT < 300 ng/dl and FT < 5 ng/dl, the sensitivity and specificity of the AMS scale were 54.0% and 41.2% compared with 78.7% and 14.8% for the ADAM questionnaire. Several sex hormone levels correlated with the two questionnaires, but neither of these questionnaires had sufficient sensitivity and specificity. It is necessary to provide a new questionnaire applicable to the Chinese population to screening LOH.
Collapse
Affiliation(s)
- Wei Chen
- The Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | | | | | | | | | | |
Collapse
|
37
|
Abstract
Aging in men is associated with a decrease in serum testosterone levels due to attrition in testicular Leydig cells and slowing of the hypothalamic GnRH pulse generator. The practicing endocrinologist is frequently consulted for consideration of testosterone therapy in older men with late-onset hypogonadism (LOH), a condition that many clinicians fail to distinguish from organic hypogonadism. Recent data using syndromic definition show that only 2% of 40-80-year-old men have LOH. Co-morbidities and obesity strongly contribute to LOH, suggesting that testosterone is a biomarker of health. Hence, prevention and treatment of these co-morbidities might attenuate age-related decline in androgen levels.
Collapse
Affiliation(s)
- Shehzad Basaria
- Section of Men's Health, Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| |
Collapse
|
38
|
Rodriguez-Tolrà J, Torremadé J, di Gregorio S, del Rio L, Franco E. Effects of testosterone treatment on bone mineral density in men with testosterone deficiency syndrome. Andrology 2013; 1:570-5. [DOI: 10.1111/j.2047-2927.2013.00090.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 02/11/2013] [Accepted: 03/24/2013] [Indexed: 11/27/2022]
Affiliation(s)
- J. Rodriguez-Tolrà
- Department of Urology; Hospital Universitari de Bellvitge; L'Hospitalet; Spain
| | - J. Torremadé
- Department of Urology; Hospital Universitari de Bellvitge; L'Hospitalet; Spain
| | | | | | - E. Franco
- Department of Urology; Hospital Universitari de Bellvitge; L'Hospitalet; Spain
| |
Collapse
|
39
|
Hirokawa K, Taniguchi T, Fujii Y, Takaki J, Tsutsumi A. Job demands as a potential modifier of the association between testosterone deficiency and andropause symptoms in Japanese middle-aged workers: A cross-sectional study. Maturitas 2012; 73:225-9. [DOI: 10.1016/j.maturitas.2012.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 07/05/2012] [Accepted: 07/11/2012] [Indexed: 10/28/2022]
|
40
|
Investigation on psychological symptoms improves ANDROTEST accuracy in predicting hypogonadism in subjects with sexual dysfunction. Int J Impot Res 2012; 25:34-9. [DOI: 10.1038/ijir.2012.33] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
41
|
Abstract
UNLABELLED Symptoms of testosterone deficiency and concentrations of testosterone (T) and bioavailable testosterone (BT) were studied in 35- and 45-year-old men. METHODS A questionnaire, was sent to all 35- and 45-year-old men in Linköping, Sweden (n=1998). The questionnaire has earlier been used for 55- to 75-year-old men and included demographic data, medical history, different symptoms possibly of T deficiency and the 10 questions from the "ADAM-questionnaire". Totally 200 men randomly selected among the men who answered the questionnaire were asked to give blood samples for analysis of T- and BT-concentrations. RESULTS A total of 38.7% of the questionnaires were returned and analysed, and 43.5% of the 200 randomly selected men gave blood samples. The older age group reported more symptoms that may be connected to low B and BT and had lower T- and BT-concentrations. Less strong erections and higher alcohol consumption were associated with lower concentrations of BT in 45-year-old men. CONCLUSIONS The burden of symptoms possibly related to low T concentrations were higher in 45-year-old men, and BT and T were lower. However, due to the low answer frequency and number of blood samples analyzed no general conclusions can be drawn.
Collapse
Affiliation(s)
- Anna-Clara E Spetz Holm
- Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden.
| | | | | |
Collapse
|
42
|
Giannoulis MG, Martin FC, Nair KS, Umpleby AM, Sonksen P. Hormone replacement therapy and physical function in healthy older men. Time to talk hormones? Endocr Rev 2012; 33:314-77. [PMID: 22433122 PMCID: PMC5393154 DOI: 10.1210/er.2012-1002] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Improving physical function and mobility in a continuously expanding elderly population emerges as a high priority of medicine today. Muscle mass, strength/power, and maximal exercise capacity are major determinants of physical function, and all decline with aging. This contributes to the incidence of frailty and disability observed in older men. Furthermore, it facilitates the accumulation of body fat and development of insulin resistance. Muscle adaptation to exercise is strongly influenced by anabolic endocrine hormones and local load-sensitive autocrine/paracrine growth factors. GH, IGF-I, and testosterone (T) are directly involved in muscle adaptation to exercise because they promote muscle protein synthesis, whereas T and locally expressed IGF-I have been reported to activate muscle stem cells. Although exercise programs improve physical function, in the long-term most older men fail to comply. The GH/IGF-I axis and T levels decline markedly with aging, whereas accumulating evidence supports their indispensable role in maintaining physical function integrity. Several studies have reported that the administration of T improves lean body mass and maximal voluntary strength in healthy older men. On the other hand, most studies have shown that administration of GH alone failed to improve muscle strength despite amelioration of the detrimental somatic changes of aging. Both GH and T are anabolic agents that promote muscle protein synthesis and hypertrophy but work through separate mechanisms, and the combined administration of GH and T, albeit in only a few studies, has resulted in greater efficacy than either hormone alone. Although it is clear that this combined approach is effective, this review concludes that further studies are needed to assess the long-term efficacy and safety of combined hormone replacement therapy in older men before the medical rationale of prescribing hormone replacement therapy for combating the sarcopenia of aging can be established.
Collapse
Affiliation(s)
| | - Finbarr C. Martin
- Guy's and St. Thomas' National Health Service Foundation Trust (F.C.M.), and Institute of Gerontology (F.C.M.), King's College, London WC2R 2LS, United Kingdom
| | | | - A. Margot Umpleby
- Department of Human Metabolism, Diabetes, and Metabolic Medicine (A.M.U.), Postgraduate Medical School, University of Surrey, Guildford GU2 7WG, United Kingdom
| | - Peter Sonksen
- St. Thomas' Hospital and King's College (P.S.), London SE1 7EW, United Kingdom; and Southampton University (P.S.), SO17 1BJ, Southampton, United Kingdom
| |
Collapse
|
43
|
Liu CC, Lee YC, Wang CJ, Yeh HC, Li WM, Wu WJ, Huang CN, Bao BY, Huang CH, Huang SP. The impact of androgen receptor CAG repeat polymorphism on andropausal symptoms in different serum testosterone levels. J Sex Med 2012; 9:2429-37. [PMID: 22429282 DOI: 10.1111/j.1743-6109.2012.02672.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION In addition to a depletion of androgen, attenuated action of androgen receptor (AR) might also contribute to andropausal symptoms. AIM To evaluate the interaction of AR cytosine adenine guanine (CAG) repeat polymorphism and serum testosterone levels and their effect on andropausal symptoms in aging Taiwanese men. METHODS From August 2007 to April 2008, a free health screening for men older than 40 years was conducted by a medical center in Kaohsiung City, Taiwan. All participants received physical examination, answered questionnaires to collect their demographic information and medical histories, completed the Androgen Deficiency in the Aging Male (ADAM) questionnaire, and provided 20-cm(3) whole blood samples for biochemical and genetic evaluation. MAIN OUTCOME MEASURES The ADAM questionnaire was used to evaluate andropausal symptoms. Serum albumin, total testosterone (TT), and sex hormone-binding globulin levels were measured. Free testosterone level was calculated. AR gene CAG repeat polymorphism was determined by direct sequencing. RESULTS Seven hundred two men with the mean age of 57.2 ± 6.5 years were included. There was no significant association between TT levels and the distribution of AR CAG repeat polymorphism. When TT levels were above 340 ng/dL, subjects with AR CAG repeat lengths ~25 showed significantly higher risk of developing andropausal symptoms, as compared with those with AR CAG repeat lengths ~22 (P = 0.006), but this was not observed when TT levels were 340 ng/dL or below. Age and number of comorbidities were also independent risk factors for andropausal symptoms. CONCLUSION In subjects with normal TT concentration, those with longer AR CAG repeat lengths have a higher risk of developing andropausal symptoms. Age and number of comorbidities can also influence the appearance of andropausal symptoms. In clinical practice, a multifactorial approach to evaluate andropausal symptoms and the interactions between those risk factors is suggested.
Collapse
Affiliation(s)
- Chia-Chu Liu
- Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Corona G, Rastrelli G, Vignozzi L, Mannucci E, Maggi M. How to recognize late-onset hypogonadism in men with sexual dysfunction. Asian J Androl 2012; 14:251-9. [PMID: 22286862 PMCID: PMC3735094 DOI: 10.1038/aja.2011.138] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 07/31/2011] [Accepted: 08/11/2011] [Indexed: 11/09/2022] Open
Abstract
Late-onset hypogonadism (LOH) has been considered the most common form of male hypogonadism with a prevalence of approximately 1 in 100 men. Diagnosis of LOH should be made in symptomatic men with unequivocally low serum testosterone (T) levels. However, its clinical presentation is often insidious and difficult to recognize because it is characterized by nonspecific symptoms that make differential diagnosis with physiological ageing problematic. Sexual dysfunction is the most important determinant for medical consultation and the most specific symptom associated with low T. We therefore analysed a consecutive series of 1734 subjects who attended our unit for sexual dysfunction to investigate the associations between low T (different thresholds), sexual parameters, medical history data (delayed puberty, pituitary disease or cryptorchidism) and their physical exam results. Metabolic parameters, in particular waist circumference, display the greatest accuracy in detecting low T. We found that only the association of several symptoms and signs could significantly raise the clinical suspicion of low T. Structured inventories, which cluster together symptoms and signs of hypogonadism, can help clinicians suspect androgen deficiency. In particular, structured interviews, such as ANDROTEST, have been demonstrated to have a greater accuracy when compared to self reported questionnaires in detecting low T levels.
Collapse
Affiliation(s)
- Giovanni Corona
- Sexual Medicine and Andrology Unit, Department of Clinical Physiopathology, University of Florence, Florence 50139, Italy
| | | | | | | | | |
Collapse
|
45
|
Chiu YW, Chu CL, Chen Y, Jiang JR, Chau YL, Hsu SC, Hsieh ML, Chen CL, Chen CY. Complaint of insomnia as a predictor of aging symptoms in males at a men's health clinic. Aging Male 2012; 15:7-13. [PMID: 22044340 DOI: 10.3109/13685538.2011.605185] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Issues of men's health have been greatly researched by scholars in recent decades. At men's health clinics, many patients complain of both insomnia and aging males' symptoms (AMS). These symptoms might be influenced by biological, psychological or even social factors. The aim of this study was to investigate different aspects of the relationship between insomnia and aging symptoms. METHODS This cross-sectional study included 231 males from a men's health clinic. Participants completed a set of general data and screening assessments, including the AMS rating scale, insomnia severity index (ISI), Beck depression inventory-II (BDI-II) and Beck anxiety inventory Chinese version (BAI), to investigate the severity of aging symptoms, insomnia, depression and anxiety. RESULTS The ISI correlated significantly with the AMS scale, both with (partial correlation coefficient = 0.470) and without (r = 0.580) controlled variances of depression and anxiety. Using linear regression, aging symptoms were statistically predicted by the severity of the ISI, and a substantial proportion of the variance was explained (adjusted R(2) = 0.410). When all variables were included, this proportion rose to 55.3% (adjusted R(2) = 0.553). CONCLUSION We suggest that insomnia is a good predictor of aging symptoms across all age groups of men.
Collapse
Affiliation(s)
- Yu-Wen Chiu
- Men's Health Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Abstract
There is a higher prevalence of low testosterone levels in males with type 2 diabetes compared to those without. Additionally, there is evidence that low testosterone levels may predict the development of type 2 diabetes. Symptoms of hypogonadism include decreased libido, decreased bone mineral density (BMD), and decreased lean muscle mass. The majority of the published cases in men with diabetes were attributed to age-related idiopathic hypogonadotropic hypogonadism. This paper reviews the link between type 2 diabetes and age-related hypogonadism and the treatment options for hypogonadism. Pharmacists who provide care for males with diabetes should be aware of the increased incidence of hypogonadism, know how to screen for it, and be able to recommend appropriate therapy.
Collapse
Affiliation(s)
- Gina J. Ryan
- Department of Pharmacy, Mercer University, Atlanta, GA, USA
| | - Lynetta J. Jobe
- University of Maryland Eastern Shore, School of Pharmacy and Health Professions, Hazel Hall, Princess Anne, MD, USA
| |
Collapse
|
47
|
Abstract
The endocrinology of the aging male is complex, with multiple hormones along the hypothalamic-pituitary-testicular (HPT) axis interacting with one another in feedback. As men age, there is a small and progressive (not precipitous, as in women) decline in several sex hormones, in particular testosterone and dehydroepiandrosterone, and related increases in luteinizing hormone, follicle-stimulating hormone, and sex hormone-binding globulin. The importance of these changes is wide-ranging because of the ubiquitous role of sex hormones in male physiology. This chapter discusses the endocrinology of the aging male. We provide an overview of the regulation of the HPT axis with an emphasis on the changes that occur with aging and the measurement of gonadal steroids, including hormone pulsatility, within-subject and circadian variations. The difficulties of assessing the symptoms of late-onset hypogonadism are highlighted. There is a comprehensive discussion of the epidemiology of sex hormone changes, including their age associations, prevalence of symptomatic hypogonadism, secular changes, risk factors, and the association of sex hormones with outcomes.
Collapse
Affiliation(s)
- Andre B. Araujo
- Director, Epidemiology, New England Research Institutes, Inc., 9 Galen Street, Watertown, MA 02472, Tel: 617.923.7747 x452, Fax: 617.673.9509,
| | - Gary A. Wittert
- Head, Discipline of Medicine, The University of Adelaide, Principal Research Scientist, New England Research Institutes, Inc., Phone: +61 882225502, Fax: +61 882233870,
| |
Collapse
|
48
|
Ridderskamp D, Zellner M. [Clinical symptoms of hypogonadism after radical prostatectomy]. Urologe A 2011; 50:445-51. [PMID: 21424426 DOI: 10.1007/s00120-010-2479-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study checked whether the prevalence of hypogonadal symptoms [measured using the Aging Males' Symptoms Scale (AMSS)] after radical prostatectomy can give information about the prevalence of hypogonadism in this group of patients. Distribution of the level of complaints (no, mild, moderate or severe) on the AMSS after radical prostatectomy (n=576) was analyzed in all patients (G) and stratified by the point in time of data collection [surgery to AMSS less (K1) and more than 1 year (K2)].The total score shows more patients with mild and moderate symptoms in G, K1, and K2 compared with the control (G 57.6 and 23.4%, K1 59.1 and 22.4%, K2 40 and 35.6% vs 36.5 and 11.2%). In the somatic score G and K1 show 2.4% (G) and 1.7% (K1) less patients with no and 1.5% (G) and 0.9% (K1) less patients with little complaints compared with the control; 2.6% (G) and 1.8% (K1) more patients state moderate and 1.2% (G) and 0.8% (K1) more severe complaints. K2 shows fewer patients with no and mild (22.2 and 31.1% vs 33.3 and 39.3%) and more with moderate and severe complaints (33.3 and 13.3% vs 21.0 and 6.4%) compared with the control. In the psychological score patients in G and K1 state less mild complaints (G 33.9%, K1 32.8% vs 41.8%), more patients state no complaints (G 45.8%, K1 47.3% vs 43.6%) as well as moderate and severe complaints (G 12.8%, K1 12.8% vs 10.9% and G 7.5%, K1 7.2% vs 3.7 %) compared with the control. K2 shows more complaints of all levels compared with the control (mild 46.7 vs 41.8%, moderate 13.3 vs 10.9%, and severe 11.1 vs 3.7%). In the sexual score all groups of patients show significantly more severe complaints (G 89.6%, K1 89.5%, K2 91.1% vs 6.1%).Multiple factors influenced by surgery and diagnosis of cancer which are independent of hormonal effects make distribution of hypogonadal symptoms on the AMSS not suitable to give information about the prevalence of hypogonadism after radical prostatectomy. An analysis of serum testosterone seems to be essential.
Collapse
Affiliation(s)
- D Ridderskamp
- Urologische Abteilung, Johannesbad-Fachklinik, Johannesstraße 2, 94072 Bad Füssing, Deutschland.
| | | |
Collapse
|
49
|
Trinick TR, Feneley MR, Welford H, Carruthers M. International web survey shows high prevalence of symptomatic testosterone deficiency in men. Aging Male 2011; 14:10-5. [PMID: 20828244 PMCID: PMC3038589 DOI: 10.3109/13685538.2010.511325] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Though the clinical significance of testosterone deficiency is becoming increasingly apparent, its prevalence in the general population remains unrecognised. A large web-based survey was undertaken over 3 years to study the scale of this missed diagnosis. METHODS An online questionnaire giving the symptoms characterising testosterone deficiency syndrome (Aging Male Symptoms-AMS-scale) was set up on three web sites, together with questions about possible contributory factors. RESULTS Of over 10,000 men, mainly from the UK and USA, who responded, 80% had moderate or severe scores likely to benefit from testosterone replacement therapy (TRT). The average age was 52, but with many in their 40s when the diagnosis of 'late onset hypogonadism' is not generally considered. Other possible contributory factors to the high testosterone deficiency scores reported were obesity (29%), alcohol (17.3%), testicular problems such as mumps orchitis (11.4%), prostate problems (5.6%), urinary infection (5.2%) and diabetes 5.7%. CONCLUSIONS In this self-selected large international sample of men, there was a very high prevalence of scores which if clinically relevant would warrant a therapeutic trial of testosterone treatment. This study suggests that there are large numbers of men in the community whose testosterone deficiency is neither being diagnosed nor treated.
Collapse
Affiliation(s)
- Tom R Trinick
- Department of Chemical Pathology, The Ulster Hospital, Belfast, United Kingdom
| | | | | | | |
Collapse
|
50
|
Corona G, Rastrelli G, Forti G, Maggi M. Update in Testosterone Therapy for Men (CME). J Sex Med 2011; 8:639-54; quiz 655. [DOI: 10.1111/j.1743-6109.2010.02200.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|