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Kanakis GA, Pofi R, Goulis DG, Isidori AM, Armeni E, Erel CT, Fistonić I, Hillard T, Hirschberg AL, Meczekalski B, Mendoza N, Mueck AO, Simoncini T, Stute P, van Dijken D, Rees M, Lambrinoudaki I. EMAS position statement: Testosterone replacement therapy in older men. Maturitas 2023; 178:107854. [PMID: 37845136 DOI: 10.1016/j.maturitas.2023.107854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Late-onset hypogonadism is the clinical entity characterised by low testosterone concentrations associated with clinical symptoms in the absence of organic disease in ageing men. It has been associated with metabolic syndrome, reduced bone mineral density, and increased cardiovascular morbidity and mortality risk. Although testosterone replacement therapy (TRT) reverses most of these conditions in young hypogonadal men, the risk/benefit ratio of TRT in older men is debatable. AIM To update the 2015 EMAS statement on TRT in older men with new research on late-onset hypogonadism and TRT. MATERIALS AND METHODS Literature review and consensus of expert opinion. SUMMARY RECOMMENDATIONS TRT should be offered only to symptomatic older men with confirmed low testosterone concentrations after explaining the uncertainties regarding the long-term safety of this treatment. TRT may be offered to men with severe hypogonadism and erectile dysfunction to improve sexual desire, erectile, and orgasmic function. It should also be considered in hypogonadal men with severe insulin resistance or pre-diabetes mellitus. TRT may also be considered, in combination with proven treatment strategies, for osteoporosis, or for selected patients with persistent mild depressive symptoms and/or low self-perceived quality of life, combined with standard medical care for each condition. TRT is contraindicated in hypogonadal men actively seeking fertility treatment. Due to a lack of data, TRT should not be routinely used in older men to improve exercise capacity/physical function, improve cognitive function, or prevent cognitive decline. TRT must be avoided in older, frail men with known breast cancer or untreated prostate cancer and all men who have had myocardial infarction or stroke within the last four months, and those with severe or decompensated heart failure. The quality of evidence regarding patients with previous prostate cancer or cardiovascular disease is too low to draw definitive conclusions. Any limits on duration of use are arbitrary, and treatment should continue for as long as the man feels the benefits outweigh the risks for him, and decisions must be made on an individual basis. Withdrawal should be considered when hypogonadism is reversed after the resolution of underlying disorder. Short-acting transdermal preparations should be preferred for TRT initiation in older men, but injectable forms may be considered subsequently. Older men on TRT should be monitored at 3, 6, and 12 months after initiation and at least yearly thereafter, or earlier and more frequently if indicated. Evaluation should include assessment of the clinical response, and measurement of total testosterone, haematocrit, and prostate-specific antigen (PSA) concentrations. Bone density and/or quality should also be assessed. Obese and overweight patients should be encouraged to undergo lifestyle modifications, including exercise and weight loss, to increase endogenous testosterone.
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Affiliation(s)
- George A Kanakis
- Department of Endocrinology & IVF Unit, Athens Naval and Veteran Affairs Hospital, Athens, Greece.
| | - Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Greece
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Eleni Armeni
- Second Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Greece; Royal Free Hospital, London, UK
| | - C Tamer Erel
- İstanbul-Cerrahpaşa University, Cerrahpaşa School of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
| | - Ivan Fistonić
- Faculty for Health Studies, University of Rijeka, Rijeka, Croatia
| | - Timothy Hillard
- Department of Obstetrics & Gynaecology, University Hospitals Dorset, Poole, UK
| | - Angelica-Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Blazej Meczekalski
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, Poznan, Poland
| | - Nicolás Mendoza
- Department of Obstetrics and Gynecology, University of Granada, Spain
| | - Alfred O Mueck
- Department of Women's Health, University Hospital Tuebingen, Germany; Beijing OB/GYN Hospital, Capital Medical University, China
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56100 Pisa, Italy
| | - Petra Stute
- Department of Obstetrics and Gynecology, University Clinic Inselspital, Bern, Switzerland
| | - Dorenda van Dijken
- Department of Obstetrics and Gynecology, OLVG Hospital, Amsterdam, the Netherlands
| | - Margaret Rees
- Women's Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Irene Lambrinoudaki
- Second Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Greece
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Foran D, Chen R, Jayasena CN, Minhas S, Tharakan T. The use of hormone stimulation in male infertility. Curr Opin Pharmacol 2023; 68:102333. [PMID: 36580771 DOI: 10.1016/j.coph.2022.102333] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/22/2022] [Indexed: 12/28/2022]
Abstract
Infertility affects 15% of couples worldwide and in approximately 50% of cases the cause is secondary to an abnormality of the sperm. However, treatment options for male infertility are limited and empirical use of hormone stimulation has been utilised. We review the contemporary data regarding the application of hormone stimulation to treat male infertility. There is strong evidence supporting the use of hormone stimulation in hypogonadotropic hypogonadism but there is inadequate evidence for all other indications.
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Affiliation(s)
- Daniel Foran
- Department of Metabolism, Digestion, and Reproduction, Imperial College London, London, United Kingdom.
| | - Runzhi Chen
- Department of Metabolism, Digestion, and Reproduction, Imperial College London, London, United Kingdom
| | - Channa N Jayasena
- Department of Metabolism, Digestion, and Reproduction, Imperial College London, London, United Kingdom
| | - Suks Minhas
- Department of Urology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, United Kingdom
| | - Tharu Tharakan
- Department of Metabolism, Digestion, and Reproduction, Imperial College London, London, United Kingdom; Department of Urology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, United Kingdom
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Ayele HT, Brunetti VC, Renoux C, Tagalakis V, Filion KB. Testosterone replacement therapy and the risk of venous thromboembolism: A systematic review and meta-analysis of randomized controlled trials. Thromb Res 2021; 199:123-131. [PMID: 33486321 DOI: 10.1016/j.thromres.2020.12.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 01/20/2023]
Abstract
INTRODUCTION The cardiovascular safety of testosterone replacement therapy (TRT) is controversial. While several studies have investigated the association between TRT and the risk of arterial thrombosis, limited information is available regarding its risk of venous thromboembolism (VTE). We aimed to compare the risk of VTE in men randomized to TRT versus placebo or active-comparator in a systematic review. METHODS We searched Medline, EMBASE, CINAHL, CENTRAL, and clinical trial registries to identify randomized controlled trials (RCTs) comparing TRT to placebo in men aged ≥18 years. We assessed study quality using the Cochrane Risk of Bias assessment tool and the overall quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Data were pooled across RCTs using random-effects models. RESULTS A total of 13 RCTs (n = 5050) were included in our meta-analysis. In all, 2636 men were randomized to testosterone, and 2414 men to placebo. Sample sizes ranged from 101 to 790 men, and TRT duration from 3 to 36 months. Five studies had a high risk of bias, largely driven by unclear randomization and outcome assessment. When data were pooled across RCTs, testosterone therapy was not associated with VTE compared with placebo (RR: 1.03, 95% CI: 0.49-2.14; I2: 0%; low-quality evidence). Similar estimates were obtained for deep vein thrombosis and pulmonary embolism outcomes. CONCLUSIONS Our systematic review suggests that TRT is not associated with an increased risk of VTE. However, estimates were accompanied by a wide 95% CIs, and a clinically important increased risk cannot be ruled out.
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Affiliation(s)
- Henok Tadesse Ayele
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, H3T 1E2, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada.
| | - Vanessa C Brunetti
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, H3T 1E2, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada.
| | - Christel Renoux
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, H3T 1E2, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada.
| | - Vicky Tagalakis
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, H3T 1E2, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada; Division of General Internal Medicine, Department of Medicine, Jewish General Hospital, McGill University, Montreal, Quebec, H3T 1E2, Canada.
| | - Kristian B Filion
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, H3T 1E2, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada; Department of Medicine, McGill University, Montreal, Quebec, Canada.
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Tharakan T, Salonia A, Corona G, Dhillo W, Minhas S, Jayasena C. The Role of Hormone Stimulation in Men With Nonobstructive Azoospermia Undergoing Surgical Sperm Retrieval. J Clin Endocrinol Metab 2020; 105:5893978. [PMID: 32810280 DOI: 10.1210/clinem/dgaa556] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/13/2020] [Indexed: 02/07/2023]
Abstract
Nonobstructive azoospermia, (NOA) is the most common cause of azoospermia. NOA is characterized by hypergonadotropic hypogonadism, testicular failure, and impaired spermatogenesis. The recent development of surgical sperm retrieval techniques such as microsurgical testicular sperm extraction (mTESE) has, for the first time, allowed some men with NOA to father biological children. It is common practice for endocrine stimulation therapies such as gonadotropins, selective estrogen receptor modulators (SERMs), and aromatase inhibitors to be used prior to mTESE to increase intratesticular testosterone synthesis with the aim of improving sperm retrieval rates; however, there is currently a paucity of data underpinning their safety and efficacy. We present 2 cases of men with NOA undergoing endocrine stimulation therapy and mTESE. We also discuss the current evidence and controversies associated with the use of hormonal stimulation therapy in couples affected by this severe form of male infertility.
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Affiliation(s)
- Tharu Tharakan
- Section of Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
- Department of Urology, Imperial Healthcare NHS Trust, Charing Cross Hospital, London, United Kingdom
| | - Andrea Salonia
- Division of Experimental Oncology/Unite of Urology, URI, IRCCS Ospedale, San Raffaele, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Giovanni Corona
- Andrology Unit, Department of Clinical Physiopathology, University of Florence, Florence, Italy
| | - Waljit Dhillo
- Section of Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Suks Minhas
- Department of Urology, Imperial Healthcare NHS Trust, Charing Cross Hospital, London, United Kingdom
| | - Channa Jayasena
- Section of Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
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Corona G, Dicuio M, Rastrelli G, Maseroli E, Lotti F, Sforza A, Maggi M. Testosterone treatment and cardiovascular and venous thromboembolism risk: what is 'new'? J Investig Med 2017; 65:964-973. [PMID: 28495861 DOI: 10.1136/jim-2017-000411] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2017] [Indexed: 12/21/2022]
Abstract
In men, testosterone (T) production declines as a function of ageing. Late-onset hypogonadism (LOH) is the most commonly used term to indicate this age-related condition. In LOH, the relative clinical significance and the potential benefit of testosterone treatment (TTh) are still the subject of strong criticisms in the scientific community. The debate is further complicated by the recent position statement of the US Food and Drug Administration (FDA) emphasizing that, in LOH, the benefits and safety of TTh have not been fully established. Hence, the FDA required a labeling change to inform patients about a possible increased cardiovascular (CV) risk of TTh. Similar considerations were previously released by the FDA and by Health Canada concerning a TTh-related venous thromboembolism (VTE) risk. In this review, we will summarize the available evidence concerning a possible link among TTh and CV and VTE risks. For this purpose, data derived from epidemiological studies analyzing relationships between the aforementioned risks and endogenous T levels will be analyzed. In addition, evidence deriving from interventional studies including pharmacoepidemiological and placebo-controlled randomized controlled trials (RCTs) will be examined. Our analysis shows that available data do not support an increased CV risk related to TTh. Similar considerations can be drawn for the relationship between TTh and VTE. The previously reported cases of TTh-related VTE were frequently related to a previously undiagnosed thrombophilia-hypofibrinolysis status. Hence, an anamnestic screening for thrombophilia before starting TTh is recommended, just as it is for the use of oral contraceptives.
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Affiliation(s)
- G Corona
- Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Azienda-Usl Bologna, Bologna, Italy
| | - M Dicuio
- Urology Unit, Maggiore Hospital, Bologna, Italy.,Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - G Rastrelli
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - E Maseroli
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - F Lotti
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - A Sforza
- Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Azienda-Usl Bologna, Bologna, Italy
| | - M Maggi
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
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Glueck CJ, Jetty V, Goldenberg N, Shah P, Wang P. Thrombophilia in Klinefelter Syndrome With Deep Venous Thrombosis, Pulmonary Embolism, and Mesenteric Artery Thrombosis on Testosterone Therapy: A Pilot Study. Clin Appl Thromb Hemost 2016; 23:973-979. [PMID: 27582022 DOI: 10.1177/1076029616665923] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
We compared thrombophilia and hypofibrinolysis in 6 men with Klinefelter syndrome (KS), without previously known familial thrombophilia, who had sustained deep venous thrombosis (DVT)-pulmonary emboli (PE) or mesenteric artery thrombosis on testosterone replacement therapy (TRT). After the diagnosis of KS, TRT had been started in the 6 men at ages 11, 12, 13, 13, 19, and 48 years. After starting TRT, DVT-PE or mesenteric artery thrombosis was developed in 6 months, 1, 11, 11, 12, and 49 years. Of the 6 men, 4 had high (>150%) factor VIII (177%, 192%, 263%, and 293%), 3 had high (>150%) factor XI (165%, 181%, and 193%), 1 was heterozygous for the factor V Leiden mutation, and 1 was heterozygous for the G20210A prothrombin gene mutation. None of the 6 men had a precipitating event before their DVT-PE. We speculate that the previously known increased rate of DVT-PE and other thrombi in KS reflects an interaction between prothrombotic, long-term TRT with previously undiagnosed familial thrombophilia. Thrombophilia screening in men with KS before starting TRT would identify a cohort at increased risk for subsequent DVT-PE, providing an optimally informed estimate of the risk/benefit ratio of TRT.
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Affiliation(s)
- Charles J Glueck
- 1 The Jewish Hospital of Cincinnati, Dept. of Internal Medicine, Cincinnati, Ohio, USA.,2 The Cholesterol, Metabolism, and Thrombosis Center, Cincinnati, OH, USA
| | - Vybhav Jetty
- 1 The Jewish Hospital of Cincinnati, Dept. of Internal Medicine, Cincinnati, Ohio, USA.,2 The Cholesterol, Metabolism, and Thrombosis Center, Cincinnati, OH, USA
| | - Naila Goldenberg
- 1 The Jewish Hospital of Cincinnati, Dept. of Internal Medicine, Cincinnati, Ohio, USA.,2 The Cholesterol, Metabolism, and Thrombosis Center, Cincinnati, OH, USA
| | - Parth Shah
- 1 The Jewish Hospital of Cincinnati, Dept. of Internal Medicine, Cincinnati, Ohio, USA.,2 The Cholesterol, Metabolism, and Thrombosis Center, Cincinnati, OH, USA
| | - Ping Wang
- 2 The Cholesterol, Metabolism, and Thrombosis Center, Cincinnati, OH, USA
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Glueck CJ, Lee K, Prince M, Jetty V, Shah P, Wang P. Four Thrombotic Events Over 5 Years, Two Pulmonary Emboli and Two Deep Venous Thrombosis, When Testosterone-HCG Therapy Was Continued Despite Concurrent Anticoagulation in a 55-Year-Old Man With Lupus Anticoagulant. J Investig Med High Impact Case Rep 2016; 4:2324709616661833. [PMID: 27536705 PMCID: PMC4971595 DOI: 10.1177/2324709616661833] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 06/29/2016] [Accepted: 07/02/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND When exogenous testosterone or treatments to elevate testosterone (human chorionic gonadotropin [HCG] or Clomid) are prescribed for men who have antecedent thrombophilia, deep venous thrombosis and pulmonary embolism often occur and may recur despite adequate anticoagulation if testosterone therapy is continued. CASE PRESENTATION A 55-year-old white male was referred to us because of 4 thrombotic events, 3 despite adequate anticoagulation over a 5-year period. We assessed interactions between thrombophilia, exogenous testosterone therapy, and recurrent thrombosis. In 2009, despite low-normal serum testosterone 334 ng/dL (lower normal limit [LNL] 300 ng/dL), he was given testosterone (TT) cypionate (50 mg/week) and human chorionic gonadotropin (HCG; 500 units/week) for presumed hypogonadism. Ten months later, with supranormal serum T (1385 ng/dL, upper normal limit [UNL] 827 ng/dL) and estradiol (E2) 45 pg/mL (UNL 41 pg/mL), he had a pulmonary embolus (PE) and was then anticoagulated for 2 years (enoxaparin, then warfarin). Four years later, on TT-HCG, he had his first deep venous thrombosis (DVT). TT was stopped and HCG continued; he was anticoagulated (enoxaparin, then warfarin, then apixaban, then fondaparinux). One year after his first DVT, on HCG, still on fondaparinux, he had a second DVT (5/315), was anticoagulated (enoxaparin + warfarin), with a Greenfield filter placed, but 8 days later had a second PE. Thrombophilia testing revealed the lupus anticoagulant. After stopping HCG, and maintained on warfarin, he has been free of further DVT-PE for 9 months. CONCLUSION When DVT-PE occur on TT or HCG, in the presence of thrombophilia, TT-HCG should be stopped, lest DVT-PE reoccur despite concurrent anticoagulation.
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Affiliation(s)
| | - Kevin Lee
- Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | | | - Vybhav Jetty
- Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Parth Shah
- Jewish Hospital of Cincinnati, Cincinnati, OH, USA
| | - Ping Wang
- Jewish Hospital of Cincinnati, Cincinnati, OH, USA
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