Association of specific symptoms and metabolic risks with serum testosterone in older men

Effects of androgen replacement therapy on cognitive function in patients with hypogonadism: A systematic review and meta‑analysis

Hypogonadism, characterized by low testosterone levels, is linked to cognitive decline, particularly in memory and executive function. Androgen replacement therapy (ART) aims to counter these deficits by restoring testosterone levels. In the present systematic review and meta-analysis, it was hypothesized that ART improves cognitive function in hypogonadal men, with domain-specific effects. A comprehensive literature search was conducted across databases up to October 2024, identifying 14 studies that met inclusion criteria. Cognitive outcomes were categorized into memory, attention, executive function and visuospatial abilities, and a meta-analysis was performed using a random-effects model. Study heterogeneity was evaluated using prediction interval statistics, and sensitivity analyses were conducted. Publication bias was assessed using Begg's and Egger's tests, with adjustments using the trim-and-fill method. The meta-analysis demonstrated statistically significant but domain-specific cognitive effects of ART. The pooled standardized mean difference (SMD) for overall cognition was 0.454 (95% CI: 0.341-0.566; P<0.001). Domain-specific analyses revealed that ART led to improvements in executive function (SMD=0.488; 95% CI: 0.372-0.604; P<0.001) and memory (SMD=0.457; 95% CI: 0.338-0.577; P<0.001), but smaller effects were observed in attention (SMD=0.217; 95% CI: 0.084-0.351; P=0.001) and visuospatial abilities (SMD=0.226; 95% CI: 0.146-0.306; P<0.001). Sensitivity analyses confirmed the stability of the findings. Despite the detection of publication bias (Kendall's tau = 0.265, P<0.001; Egger's intercept = 1.92, P<0.001), the adjusted effect size remained consistent after applying the trim-and-fill method. Study heterogeneity was moderate, likely reflecting variations in cognitive assessment tools and intervention protocols. ART significantly improves executive function and memory in hypogonadal men, while the impact on attention and visuospatial abilities is less pronounced. These findings underscore the domain-specific nature of ART's cognitive benefits and highlight the importance of considering study heterogeneity when interpreting results. Clinically, this suggests that ART may be more effective in targeting memory and executive function deficits. However, the modest effect sizes and presence of publication bias indicate a need for further research to refine protocols, including standardized cognitive assessments and exploration of long-term effects.

Does the hemodialysis program affect the testosterone serum level in patients with end-stage renal disease?

PURPOSE

This study aimed to evaluate the effect of high flux membrane hemodialysis on total serum testosterone (TST) levels in male patients with end-stage renal disease (ESRD).

METHODS

The study included 60 male ESRD patients with a mean age of 54.02 ± 13.40 years, undergoing a standard hemodialysis program et al. Najah National University Hospital. All patients underwent three weekly sessions of four hours each using high flux membrane hemodialysis. TST and hematocrit (Hct) levels were measured before and after hemodialysis. Patients with prostate cancer, liver insufficiency, prior prostate surgery, or those on androgen therapy were excluded. The study assessed changes in TST and Hct levels and their correlation.

RESULTS

Post-dialysis, there was a significant increase in serum testosterone levels from 3.13 ± 1.44 ng/ml to 4.17 ± 2.04 ng/ml (r = 0.78, p = 0.001). Hematocrit levels also rose significantly from 32.31% ± 3.90% to 35.27% ± 4.89% (r = 0.754, p = 0.001). The percentage change in TST and Hct levels was 35 ± 0.33% and 9 ± 0.1%, respectively, with a correlation between these changes (r = 0.277, p = 0.032).

CONCLUSION

High flux membrane dialysis did not filter testosterone molecules, and the significant increase in TST levels post-dialysis is likely due to hemoconcentration. Since many patients had low or borderline TST levels before dialysis, androgen supplementation may offer clinical benefits.

Late-onset hypogonadism: current methods of clinical diagnosis and treatment in Japan

ABSTRACT

Testosterone affects several organs in the body and is very important for male well-being. Aging men with late-onset hypogonadism (LOH) experience physiologic, psychiatric, and sexual symptoms related to a decline in the serum concentration of testosterone with age. However, it is well-known that the extent of the decline in testosterone concentration does not correlate with the severity of LOH-related symptoms. Therefore, it is difficult to diagnose and treat patients with LOH. In addition, the symptoms, response to testosterone replacement therapy (TRT), and medical insurance coverage differ among ethnicities and countries. The evaluation of testosterone is essential for the diagnosis and treatment of LOH. The effects of testosterone are determined not only by the serum testosterone concentration but also by the androgen receptor sensitivity. A low number of glutamine repeats is indicative of high androgenic activity, and the number shows ethnicity-related differences (fewer in African American than in Caucasian people and more in East Asian people). The diagnosis of LOH is typically made using subjective symptoms and the serum testosterone concentration. The Aging Male Symptoms scale is widely used to evaluate the symptoms. The normal range of total testosterone concentration varies around the world; therefore, clinicians should follow the guidelines of their regional academic society. The principal treatment for LOH is TRT. There are many types of TRT and other treatment strategies are also available. Thus, physicians should treat LOH according to each patient's situation, considering related disorders, such as diabetes, osteoporosis, metabolic syndrome, and depression.

Psychosocial Factors and Andropause Symptoms Among Japanese Men: An Internet-Based Cross-Sectional Study

This study aimed to investigate the relationship between psychosocial factors and andropause symptoms among Japanese men in an internet-based cross-sectional study. We conducted an internet-based cross-sectional study in 2024, named Japanese Men's health and Andropause Related Symptoms (J-MARS) study. Data on demographics, medical history, andropause symptoms, lifestyles (physical activity, insomnia, height, weight, and smoking and drinking habits), and psychological distress were collected from 1,489 men aged 20-69 years who participated in the J-MARS study. Andropause symptoms were measured using the Aging Males' Symptoms (AMS) rating scale, which was included in the analysis. We conducted a multivariate logistic regression analysis, and estimated odds ratios and 95% confidence intervals to examine the associated factors with severe andropause symptoms. Severe andropause symptoms according to the AMS score were noted in 125 men (8.4%). Severe andropause symptoms were associated with former smoking, current smoking, strength training (≥1.0 hr/day), probable insomnia, moderate psychological distress, and severe psychological distress. After excluding 289 participants with cardiovascular disease, cerebrovascular disease, cancer, or depression, severe andropause symptoms were associated with age, absence of a spouse, and suspected insomnia in addition to the above factors. Age, insomnia, and psychological distress were also significantly associated with all AMS subdomains (somatic, psychological, and sexual symptoms). Psychological stress, insomnia, and smoking habits are strongly associated with severe andropause symptoms. These findings may be useful for the prevention of andropause and for patient education.

[Testosterone-"Fuel" for old men?]

Testosterone is a natural hormone which is an essential factor to maintain the physical and emotional well-being in men, regardless of age. Male hypogonadism is an endocrinal condition of testosterone deficiency with the potential to cause multiple physical complaints and psychosocial problems. The condition can be of primary (due to testicular injury), secondary (due to diseases of the hypothalamus or pituitary gland) or functional nature (due to comorbidities, such as inflammatory diseases, obesity, type 2 diabetes mellitus). Testosterone deficiency causes problems of a sexual nature, promotes metabolic disequilibrium and can impair physical abilities (reduction in muscle mass, increase in fat mass). In addition, in the condition of hypogonadism depression, osteoporosis and/or anemia often develop. A testosterone replacement therapy should not be initiated in cases of a desire to have children, unclear processes of the prostate glands or mammary glands or an elevated hematocrit value. The diagnosis as well as treatment and monitoring of the treatment should follow the international guidelines and then a clear improvement in the abovenamed complaints can be expected. Particularly functional hypogonadism, which is mostly but not exclusively diagnosed in older men, always requires treatment of the underlying comorbidity prior to starting testosterone administration.

Seminal vesicles - an overlooked pair of accessory glands in male sexual dysfunction: a narrative review

The seminal vesicles (SVs) have long been recognized for their role in male fertility, yet their contribution to male sexual function is often underestimated. In recent decades, studies have gradually unveiled an association between SVs and various male sexual dysfunctions (SDs), including diminished libido, erectile dysfunction, premature ejaculation, delayed ejaculation, and orgasmic disorder. We conducted a comprehensive literature search of publications up until April 2024 in PubMed, Google Scholar, and CNKI, focusing on original studies, case reports, and reviews addressing the relationship between SVs and male SDs. The aim was to explore the pathophysiological mechanisms, clinical evaluation, and management of this relationship, providing urologists and andrologists with new insights into diagnosing and treating complex male SDs. Current research suggests that SVs may play a role in male sexual function, but the evidence remains limited. Future large-scale, rigorously designed studies are needed to further validate this relationship.

The Role of SHBG as a Marker in Male Patients with Metabolic-Associated Fatty Liver Disease: Insights into Metabolic and Hormonal Status

Background: Metabolic-associated fatty liver disease (MAFLD) is a spectrum of liver diseases linked to insulin resistance (IR), type 2 diabetes, and metabolic disorders. IR accelerates fat accumulation in the liver, worsening MAFLD. Regular physical activity and weight loss can improve liver function, reduce fat, and lower cardiovascular risk. This study examines the role of sex hormone-binding globulin (SHBG) in MAFLD, focusing on its potential as a biomarker and its relationship with insulin resistance. Methods: The study included 98 male patients (ages 30-55) with MAFLD, identified through systematic examinations, and 74 healthy male controls. All participants underwent abdominal ultrasound and blood tests after fasting, assessing markers such as glucose, liver enzymes (AST, ALT, γGT), lipids (cholesterol, triglycerides), insulin, SHBG, estradiol, and testosterone. SHBG levels were analyzed in relation to body mass index (BMI) and age. Results: A significant association was found between low SHBG levels and the presence of fatty liver. Individuals with MAFLD had lower SHBG levels compared to controls. BMI and age were key factors influencing SHBG, with higher BMI linked to lower SHBG in younger men, while SHBG remained stable in older individuals regardless of BMI. Conclusion: SHBG may serve as a valuable biomarker for early detection and risk assessment of MAFLD. The complex relationship between SHBG, BMI, and age highlights the importance of considering both hormonal and metabolic factors when assessing fatty liver risk. Our findings support the need for comprehensive metabolic evaluations in clinical practice.

Novel perspectives of testosterone therapy in men with functional hypogonadism: traversing the gaps of knowledge

INTRODUCTION

In the past decade, there has been a significant augmentation in the corpus of evidence pertaining to functional hypogonadism. Despite this, prevailing clinical guidelines continue to advise against the universal screening for hypogonadism in middle-aged and elderly males.

FINDINGS

Numerous randomized controlled trials have scrutinized the effects of testosterone therapy in males afflicted with type 2 diabetes and/or obesity. However, these guidelines uniformly assert that lifestyle modifications and weight reduction should be the primary intervention strategies in overweight and obese males, relegating testosterone therapy to a secondary, selective option. It is extensively documented that testosterone therapy can yield substantial improvements in various metabolic parameters as well as ameliorate symptoms of erectile dysfunction. Moreover, recent studies have demonstrated the potential of testosterone therapy in reversing type 2 diabetes in males with low-normal testosterone levels who are at elevated risk for this condition, in comparison to the outcomes achievable through lifestyle modifications alone.

CONCLUSION

This focused review article aims to present a comprehensive update on the latest data concerning the innovative aspects of testosterone therapy in males with functional hypogonadism, particularly in the context of type 2 diabetes and/or obesity. Additionally, it will delve into the cardiovascular safety of such interventions within this high-risk demographic, with a special emphasis on insights gleaned from the TRAVERSE trial.

Age-specific testosterone thresholds: reconsidering diagnostic criteria for hypogonadism across generations of Vietnamese men

The definition and diagnosis of functional hypogonadism (FH) remains challenging due to the nonspecific nature of symptoms and the inconsistency in normal testosterone thresholds. We conducted this single-center cross-sectional study on medical records of men aged 18 and above undergoing annual health check-ups to evaluate the correlation of age and metabolic components with testosterone. A total of 5,374 healthy men were included in the analysis. Total testosterone levels peaked at 18 years and gradually declined to age 40, followed by a mild increase. Based on the American Urology Association guideline, age-specific cutoffs for low testosterone were 14.61 nmol/l, 12.74 nmol/l, 12.70 nmol/l, and 13.98 nmol/l for those under 30, 30-40, 40-50, and over 50 years old respectively. Triglyceride - Glucose index showed a consistent negative correlation with testosterone across all age groups. In conclusion, testosterone levels demonstrated an age-related decline in early adulthood but a potential increase thereafter among healthy Vietnamese men. Metabolic components, rather than aging, had a consistent negative correlation with testosterone. Age-specific cutoffs for low testosterone may improve the detection of functional hypogonadism.

Preconceptional maternal hyperandrogenism and metabolic syndrome risk in male offspring: a long-term population-based study

PURPOSE

There is limited research on the effects of maternal hyperandrogenism (MHA) on cardiometabolic risk factors in male offspring. We aimed to compare the risk of metabolic syndrome (MetS) in sons of women with preconceptional hyperandrogenism (HA) to those of non-HA women in later life.

METHODS

Using data obtained from the Tehran Lipid and Glucose Cohort Study, with an average of 20 years follow-up, 1913 sons were divided into two groups based on their MHA status, sons with MHA (n = 523) and sons without MHA (controls n = 1390). The study groups were monitored from the baseline until either the incidence of events, censoring, or the end of the study period, depending on which occurred first. Age-scaled unadjusted and adjusted Cox regression models were utilized to evaluate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between MHA and MetS in their sons.

RESULTS

There was no significant association between MHA and HR of MetS in sons with MHA compared to controls, even after adjustment (unadjusted HR (95% CI) 0.94 (0.80-1.11), P = 0.5) and (adjusted HR (95% CI) 0.98 (0.81-1.18), P = 0.8). Sons with MHA showed a HR of 1.35 for developing high fasting blood sugar compared to controls (unadjusted HR (95% CI) 1.35 (1.01-1.81), P = 0.04), however, after adjustment this association did not remain significant (adjusted HR (95% CI) 1.25 (0.90-1.74), P = 0.1).

CONCLUSION

The results suggest that preconceptional MHA doesn't increase the risk of developing MetS in sons in later life. According to this suggestion, preconceptional MHA may not have long-term metabolic consequences in male offspring.

Standardising the biochemical confirmation of adult male hypogonadism: A joint position statement by the Society for Endocrinology and Association of Clinical Biochemistry and Laboratory Medicine

BACKGROUND

Inter-assay variation between different immunoassays and different mass spectrometry methods hampers the biochemical confirmation of male hypogonadism. Furthermore, some laboratories utilise assay manufacturer reference ranges that do not necessarily mirror assay performance characteristics, with the lower limit of normality ranging from 4.9 nmol/L to 11 nmol/L. The quality of the normative data underlying commercial immunoassay reference ranges is uncertain.

DESIGN

A working group reviewed published evidence and agreed upon standardised reporting guidance to augment total testosterone reports.

RESULTS

Evidence-based guidance on appropriate blood sampling, clinical action limits, and other major factors likely to affect the interpretation of results are provided.

CONCLUSIONS

This article aims to improve the quality of the interpretation of testosterone results by non-specialist clinicians. It also discusses approaches for assay harmonisation which have been successful in some but not all healthcare systems.

Changes in Testosterone Levels Following Surgical Sperm Retrieval in Men with Non-Obstructive Azoospermia: Systematic Review and Meta-Analysis

PURPOSE

Surgical sperm retrieval (SSR) is used to extract spermatozoa for use with intracytoplasmic sperm injection in men with obstructive and non-obstructive azoospermia (NOA). The procedure may lead to segmental devascularization, postoperative fibrosis, and atrophy with a subsequent decrease in testosterone. The aim of the study is to investigate the impact of SSR on serum levels of total testosterone (TT), follicle-stimulating hormone (FSH), luteinizing hormone (LH) testicular volume, and sexual function in infertile azoospermic men.

MATERIALS AND METHODS

In this systematic review and meta-analysis (SRMA), we searched articles in "PubMed" and "Scopus" exploring the impact of SSR on TT, FSH, LH, and testicular volume. The full-text articles were screened to assess eligibility before data extraction, quality assessment, and meta-analysis.

RESULTS

Seventeen studies meeting the inclusion criteria were finally analyzed and included 1,685 infertile, azoospermic men. Patients underwent SSR and were followed in the postoperative period (one week to 32 months). The analysis showed a significant reduction in TT (mean difference [MD] 3.81 nmol/L, 95% confidence interval [CI] 0.55:7.06; p=0.02) compared to pre-SSR values. We also observed insignificant differences in serum FSH (MD 5.08 IU/L, 95% CI -5.6:15.8; p=0.35), LH (MD -2.96 IU/L, 95% CI -6.31:0.39; p=0.08), and no change in testicular volume (MD 0.07 mL, 95% CI -1.92:2.07; p=0.94) after SSR. Sexual dysfunction was associated with hypogonadism, depression, and anxiety, especially in men with unsuccessful SSR and Klinefelter syndrome.

CONCLUSIONS

The results of this SRMA indicate a significant reduction in TT after SSR. Sexual dysfunction after testicular sperm extraction and the potential negative impact of future SSR repeat should be considered during preoperative counseling.

A case of 49,XXXYY followed-up from infancy to adulthood with review of literature

49,XXXYY is an extremely rare sex chromosomal aneuploidy (SCA), with only seven cases reported worldwide to date. Among these cases, only three have been documented into adulthood. Moreover, no cases of 49,XXXYY have been reported in Japan. This SCA has been identified in two scenarios: in vitro fertilization and abortion. Similar to 47,XXY, this aneuploidy is a type of Klinefelter syndrome. Aneuploidy of the X chromosome can lead to various progressive complications due to excess X chromosomes. Herein, we present the case of a Japanese man with 49,XXXYY. He exhibited developmental delays and external genitalia abnormalities since early infancy but was not closely monitored for these symptoms until the age of 3 years old. At that time, a chromosome test revealed his karyotype to be 49,XXXYY. Subsequent examinations were conducted due to various symptoms, including delayed motor development, intellectual disability, facial dysmorphisms, forearm deformities, hip dysplasia, cryptorchidism, micropenis, primary hypogonadism, and essential tremor. Since reaching puberty, he has undergone testosterone replacement therapy for primary hypogonadism, experiencing no complications related to androgen deficiency to date. He has maintained normal lipid and glucose metabolism, as well as bone density, for a prolonged period. There are no other reports on the long-term effects of testosterone treatment for the SCA. Appropriate testosterone replacement therapy is recommended for individuals with 49,XXXYY to prevent complications. This report will contribute to an enhanced understanding of the 49,XXXYY phenotype, aiding in the diagnosis, treatment, and genetic counseling of future cases.

Understanding the Meat-Masculinity Link: Traditional and Non-Traditional Masculine Norms Predicting Men's Meat Consumption

Conformity to masculinity ideology predicts men's meat consumption and willingness to reduce their meat intake, but it is unknown which specific masculine norms account for these relationships. This study investigated which traditional and non-traditional masculine norms predict meat consumption, red and processed meat consumption, and willingness to reduce meat consumption in 557 Australian and English males. Men who support the use of physical violence and place high importance on sex ate more meat. Willingness to reduce was highest among men with gender egalitarian views. Targeting these specific masculine norms may be important for mitigating men's overconsumption of meat.

Disturbed sex hormone milieu in males and females with major depressive disorder and low-grade inflammation

Sex hormones have biological effects on inflammation, and these might contribute to the sex-specific features of depression. C-reactive protein (CRP) is the most widely used inflammatory biomarker and consistent evidence shows a significant proportion (20-30 %) of patients with major depressive disorder (MDD) have CRP levels above 3 mg/L, a threshold indicating at least low-grade inflammation. Here, we investigate the interplay between sex hormones and CRP in the cross-sectional, observational Biomarkers in Depression Study. We measured serum high-sensitivity (hs-)CRP, in 64 healthy controls and 178 MDD patients, subdivided into those with hs-CRP below 3 mg/L (low-CRP; 53 males, 72 females) and with hs-CRP above 3 mg/L (high-CRP; 19 males, 34 females). We also measured interleukin-6, testosterone, 17-β-estradiol (E2), progesterone, sex-hormone binding globulin (SHBG), follicle-stimulating and luteinising hormones, and calculated testosterone-to-E2 ratio (T/E2), free androgen and estradiol indexes (FAI, FEI), and testosterone secretion index. In males, high-CRP patients had lower testosterone than controls (p = 0.001), and lower testosterone (p = 0.013), T/E2 (p < 0.001), and higher FEI (p = 0.015) than low-CRP patients. In females, high-CRP patients showed lower SHGB levels than controls (p = 0.033) and low-CRP patients (p = 0.034). The differences in testosterone, T/E2 ratio, and FEI levels in males survived the Benjamini-Hochberg FDR correction. In linear regression analyses, testosterone (β = -1.069 p = 0.033) predicted CRP concentrations (R2 = 0.252 p = 0.002) in male patients, and SHBG predicted CRP levels (β = -0.628 p = 0.009, R2 = 0.172 p = 0.003) in female patients. These findings may guide future research investigating interactions between gonadal and immune systems in depression, and the potential of hormonal therapies in MDD with inflammation.

Changes in post-transplant serum testosterone levels in men undergoing lung transplantation: a pilot study using the TriNetX Research Network

Hypogonadism is understudied in men requiring solid organ transplants, particularly among lung transplant recipients. Improvement in serum testosterone levels has been reported in kidney and liver transplantation. Using the TriNetX Research Network, we performed a retrospective cohort study to evaluate the incidence of peri-transplant hypogonadism and the natural course of serum testosterone following successful lung transplantation. Men aged ≥ 18 with a lung transplant and total testosterone drawn within one year pre- and post-transplant were included. Men with receipt of testosterone therapy were excluded. A low testosterone (<300 ng/dL) and normal testosterone (≥300 ng/dL) cohort was created before employing descriptive and analytic statistics to investigate the incidence of peri-transplant hypogonadism and the change in serum testosterone levels following lung transplantation. In our entire cohort, lung transplantation was not associated with a significant increase in post-transplant serum testosterone (329.86 ± 162.56 ng/dL pre-transplant and 355.13 ± 216.11 ng/dL post-transplant, p = 0.483). The number of men with low testosterone decreased by 9.8% following lung transplantation but was not significant, p = 0.404. In this pilot study, no significant change in the number of hypogonadal men nor serum testosterone levels was observed among men undergoing lung transplantation.

Longitudinal analysis of external quality assessment of immunoassay-based steroid hormone measurement indicates potential for improvement in standardization

As hormonal disorders are linked to several diseases, the accurate quantitation of steroid hormone levels in serum is crucial in order to provide patients with a reliable diagnosis. Mass spectrometry-based methods are regarded as having the highest level of specificity and sensitivity. However, immunoassays are more commonly used in routine diagnostics to measure steroid levels as they are more cost effective and straightforward to conduct. This study analyzes the external quality assessment results for the measurement of testosterone, progesterone and 17β-estradiol in serum using immunoassays between early 2020 and May 2022. As reference measurement procedures are available for the three steroid hormones, the manufacturer-specific biases were normalized to the reference measurement values. The manufacturer-specific coefficients of variation were predominantly inconspicuous, below 20% for the three hormones when outliers are disregarded, however there were large differences between the various manufacturer collectives. For some collectives, the median bias to the respective reference measurement value was repeatedly greater than ±35%, which is the acceptance limit defined by the German Medical Association. In the case of testosterone and progesterone determination, some collectives tended to consistently over- or underestimate analyte concentrations compared to the reference measurement value, however, for 17β-estradiol determination, both positive and negative biases were observed. This insufficient level of accuracy suggests that cross-reactivity continues to be a fundamental challenge when antibody detection is used to quantify steroids with a high structural similarity. Distinct improvements in standardization are required to provide accurate analysis and thus, reliable clinical interpretations. The increased accuracy of the AX immunoassay for testosterone measurement, as observed in the INSTAND EQAs between 2020 and 2022, could be the result of a recalibration of the assay and raises hope for further improvement of standardization of immunoassay-based steroid hormone analyses in the coming years.

Interactions among insulin resistance, epigenetics, and donor sex in gene expression regulation of iPSC-derived myoblasts

About 25% of people in the general population are insulin resistant, increasing the risk for type 2 diabetes (T2D) and metabolic disease. Transcriptomic analysis of induced pluripotent stem cells differentiated into myoblasts (iMyos) from insulin-resistant (I-Res) versus insulin-sensitive (I-Sen) nondiabetic individuals revealed that 306 genes increased and 271 genes decreased in expression in iMyos from I-Res donors with differences of 2-fold or more. Over 30 of the genes changed in I-Res iMyos were associated with T2D by SNPs and were functionally linked to insulin action and control of metabolism. Interestingly, we also identified more than 1,500 differences in gene expression that were dependent on the sex of the cell donor, some of which modified the insulin resistance effects. Many of these sex differences were associated with increased DNA methylation in cells from female donors and were reversed by 5-azacytidine. By contrast, the insulin sensitivity differences were not reversed and thus appear to reflect genetic or methylation-independent epigenetic effects.

Testosterone and aging male, a perspective from a developing country

PURPOSE

Hypogonadism is associated with a wide range of physical and psychological symptoms that can affect the overall health of men. However, in a developing country, there are several imposing challenges in the diagnosis and treatment of hypogonadism, including a lack of awareness and understanding of the condition among healthcare providers and patients, limited resources and the high cost of treatment. This review aimed to examine the potential benefits and risks of testosterone replacement therapy (TRT) and provides a perspective of a developing country on the topic.

MATERIALS AND METHODS

A comprehensive literature review was conducted to gather relevant information on the impact of testosterone deficiency on ageing males and the effectiveness of TRT for treating hypogonadism. Published peer-reviewed articles were analyzed to evaluate the benefits and risks of TRT. Additionally, the unique challenges faced in the diagnosis and treatment of hypogonadism in a developing country were considered.

RESULTS

Testosterone replacement therapy has been shown to be an effective treatment for hypogonadism, particularly in symptomatic men with low testosterone levels. It offers potential benefits such as improvements in symptoms and overall quality of life. However, there are associated risks and side effects that need to be considered. In a developing country, challenges such as limited awareness and understanding of hypogonadism, resource constraints, and high treatment costs pose additional barriers to accessing TRT and comprehensive care.

CONCLUSION

In conclusion, TRT holds promise as a treatment for hypogonadism, but its implementation and accessibility face significant challenges in a developing country. Addressing these challenges, including raising awareness, allocating resources, and finding cost-effective solutions, is crucial for ensuring that men with hypogonadism in such settings receive appropriate diagnosis and treatment. Further research and efforts are needed to improve the management of hypogonadism in developing countries and optimize the potential benefits of TRT for affected individuals.

An overview on androgen-mediated actions in skeletal muscle and adipose tissue

Androgens are a class of steroid hormones primarily associated with male sexual development and physiology, but exert pleiotropic effects in either sex. They have a crucial role in various physiological processes, including the regulation of skeletal muscle and adipose tissue homeostasis. The effects of androgens are mainly mediated through the androgen receptor (AR), a ligand-activated nuclear receptor expressed in both tissues. In skeletal muscle, androgens via AR exert a multitude of effects, ranging from increased muscle mass and strength, to the regulation of muscle fiber type composition, contraction and metabolic functions. In adipose tissue, androgens influence several processes including proliferation, fat distribution, and metabolism but they display depot-specific and organism-specific effects which differ in certain context. This review further explores the potential mechanisms underlying androgen-AR signaling in skeletal muscle and adipose tissue. Understanding the roles of androgens and their receptor in skeletal muscle and adipose tissue is essential for elucidating their contributions to physiological processes, disease conditions, and potential therapeutic interventions.

The British Society for Sexual Medicine Guidelines on Male Adult Testosterone Deficiency, with Statements for Practice

Testosterone deficiency (TD) is an increasingly common problem with significant health implications, but its diagnosis and management can be challenging. A multi-disciplinary panel from BSSM reviewed the available literature on TD and provide evidence-based statements for clinical practice. Evidence was derived from Medline, EMBASE and Cochrane searches on hypogonadism, testosterone therapy (T Therapy) and cardiovascular safety from May 2017 to September 2022. This revealed 1,714 articles, including 52 clinical trials and 32 placebo-controlled randomised controlled trials. A total of twenty-five statements are provided, relating to five key areas: screening, diagnosis, initiating T Therapy, benefits and risks of T Therapy, and follow-up. Seven statements are supported by level 1 evidence, eight by level 2, five by level 3, and five by level 4. Recent studies have demonstrated that low levels of testosterone in men are associated with increased risk of incident type 2 diabetes mellitus, worse outcomes in chronic kidney disease and COVID 19 infection with increased all-cause mortality, along with significant quality of life implications. These guidelines should help practitioners to effectively diagnose and manage primary and age-related TD.

Update on acquired hypogonadism in men living with HIV: pathogenesis, clinic, and treatment

Hypogonadism is a frequent finding among men living with HIV (MLWH) and it seems to occur earlier in comparison with the general male population. Although the prevalence of hypogonadism in MLWH has significantly lowered thanks to advancements in medical management, it remains high if compared with age-matched HIV-uninfected men, ranging from 13% to 40% in the age group of 20-60 years. Signs and symptoms of low serum testosterone (T) in MLWH are cause of concern since they are non-specific, of mild-to-moderate degree, and often overlapping with those of infection per se. For these reasons, hypogonadism can be underestimated in the absence of targeted laboratory blood examinations. With regard to the etiological factors involved in the T decrease, emerging evidence has suggested the functional nature of hypogonadism in MLWH, pointing out the mutual relationship between sex steroids, health status, comorbidities, and HIV-related factors. In agreement with this hypothesis, a therapeutic approach aiming at improving or reversing concomitant diseases through lifestyle changes (e.g. physical activity) rather than pharmacological T treatment should be theoretically considered. However, considering both patient's barriers to lifestyle changes to be maintained overtime and the lack of evidence-based data on the efficacy of lifestyle changes in normalizing serum T in MLWH, T therapy remains an option when other non-pharmacological interventions are ineffective as well as for all other functional forms of hypogonadism. From this perspective, the traditional therapeutic management of male hypogonadism in MLWH, especially the role of T supplementation, should be revised in the light of the probable functional nature of hypogonadism by considering a good balance between benefits and harmful. This narrative review presents an overview of current knowledge on hypogonadism in MLWH, deepening the factors driving and taking part in T decrease, providing advice for the clinical approach, and underlining the importance of individualized treatment aiming at optimizing non-gonadal comorbidities and thus avoiding over-, or even unnecessary, treatment with T.

Relationship between testosterone-estradiol ratio and some anthropometric and metabolic parameters among Nigerian men

Background

Alterations in sex hormone levels are implicated in the regulation of metabolic processes in men. In recent years, the prevalence of metabolic disorders, such as obesity, insulin resistance, and type 2 diabetes, has risen in Nigeria. In men, these disorders may be associated with the ratio of serum testosterone to estradiol levels. Therefore, we investigated the relationship between the testosterone-estradiol (T/E2) ratio, anthropometry, and metabolic parameters in Nigerian men.

Method

Eighty-five adult men were recruited for this study. Participants' data such as age, weight, height, BMI, and waist circumference were collected. Plasma total testosterone and estradiol levels, as well as metabolic parameters such as fasting blood sugar, creatinine, urea, HDL cholesterol, total cholesterol, and triglycerides levels, were determined. The data were analyzed using SPSS version 25 software.

Results

Anthropometric parameters such as weight, height, BMI, and waist circumference showed a negative correlation with plasma T/E2 (r = -0.265, -0.288, -0.106, -0.204; p = 0.007, 0.004, 0.167, 0.061 respectively). However, the T/E2 ratio showed a positive correlation with the metabolic parameters such as fasting blood sugar, HDL cholesterol levels, plasma creatinine, and urea (r = 0.219, 0.096, 0.992, 0.152; p = 0.022, 0.192, <0.001, 0.082 respectively), while there were negative correlations with total cholesterol and triglycerides levels (r = -0.200, -0.083; p = 0.034, 0.226 respectively).

Conclusion

These findings show that there are significant correlations between the T/E2 ratio and weight, height, fasting blood sugar, creatinine, and urea, while there are no significant correlations between T/E2 ratio and BMI, waist circumference, HDL-cholesterol, and triglycerides.

Does Testosterone Salvage PDE5i Non-Responders? A Scoping Review

Erectile physiology, in order to function normally, requires the complex coordination of endocrine, neurocognitive, neuromuscular and vascular mechanisms. Testosterone (T) influences male sexuality as well as penile erections at multiple levels, including a direct influence on the nitric oxide synthase (NOS)/cGMP/phosphodiesterase 5 pathway in the penis. However, the precise role of testosterone replacement (TRT) to “salvage” men with mixed ED failing phosphdiesterase-5 inhibitors (PDE5i) remains unclear. We conducted a scoping review identifying the rationale for TRT in ED failing PDE5i, and we critically discuss clinical trials that have examined TRT in the setting of PDE5i use. Overall, TRT replacement appears to be well tolerated and may enhance the response to PDE5i and quality of life, particularly for men with mixed ED, and particularly among men with very low levels of testosterone. However, most of the available literature examines concurrent TRT alone or simultaneous TRT + PDE5i usage, without necessarily selecting for PDE5i failure cases. The present studies are limited to heterogenous studies with small sample sizes, without an exact predominant etiologic factor causing ED. Furthermore, studies showing the most benefit are non-placebo-controlled trials; however, the correction of more profound hypogonadism may lead to an improved response to PDE5i. Stronger conclusions would require properly selected patient populations and larger placebo-controlled RCTs.

Summary of the clinical practice manual for late-onset hypogonadism

Testosterone plays an important role in maintaining both physical and mental function. Age-related testosterone depletion contributes to the development of angina, arteriosclerosis, obesity, metabolic syndrome, dementia, frailty, and a range of other conditions. A condition involving age-related testosterone depletion and the associated clinical symptoms is defined as late-onset hypogonadism (LOH). LOH is treated by testosterone replacement therapy. Indications for testosterone replacement therapy are determined by evaluating symptoms and signs.

Updates on androgen replacement therapy and lower urinary tract symptoms: a narrative review

Lower urinary tract symptoms (LUTS) are caused by higher tension at the bladder neck level (due to fibrosis or stiffness) or benign prostatic hyperplasia, which causes static obstruction of the bladder outlet. Both forms cause a group of symptoms such as hesitancy, intermittency, weak stream, nocturia, urine frequency, and urgency. Additionally, LUTS (obstructive or irritative symptoms) are common in elderly men with hypogonadism, identified as the reduced testes capability in producing sex steroids and sperm, and are categorized as testosterone deficiency. Even though the mode of action (MoA) of testosterone therapy (TTh) on hypogonadal men needs more researched and understanding, the effectiveness of TTh in the development of male genital organs has been reported in several studies. This review shows the latest updates of TTh in LUTS including potential adverse effects, advantages, and disadvantages.

Androgen dysfunction in non-alcoholic fatty liver disease: Role of sex hormone binding globulin

Non-alcoholic fatty liver disease (NAFLD) is the most common form of chronic liver disease in the world. It is linked mainly to insulin resistance and metabolic syndrome including obesity and dyslipidemia. In addition, various endocrine dysfunctions including polycystic ovary syndrome (PCOS) and hypogonadism are involved in the development and progression of NAFLD. We need to know the disease pathophysiology more accurately due to the heterogeneity of clinical presentation of fatty liver disease. The liver is the major metabolic organ with sexual dimorphism. Sexual dimorphism is associated not only with behavioral differences between men and women, but also with physiological differences reflected in liver metabolism. In men, normal androgen levels prevent hepatic fat accumulation, whereas androgen deficiency induce hepatic steatosis. In women, higher androgens can increase the risk of NAFLD in PCOS. Sex hormone binding globulin (SHBG) is involved in androgen regulation. Recently, SHBG may be reported as a surrogate marker for NAFLD. Therefore, this review will focus on the mechanism of androgen dysfunction in the regulation of hepatic metabolism, the risk of developing NAFLD, and the potential role of SHBG in the course of NAFLD.; Keywords: Non-alcoholic fatty liver disease, insulin resistance, sexual dimorphism, androgen, sex hormone binding globulin.

A Proposal of a New Nomogram to Predict the Need for Testosterone ReplACEment (TRACE): A Simple Tool for Everyday Clinical Practice

International guidelines suggest to use testosterone therapy (TTh) in hypogonadal men presenting symptoms of testosterone deficiency (TD), even if there is no fixed threshold level of T at which TTh should be started. We aimed to develop and validate a nomogram named TRACE (Testosterone ReplACEment) for predicting the need of TTh in patients with "low-normal" total testosterone levels. The following nomogram variables were used: serum T level; serum LH level; BMI; state of nocturnal erections; metabolic comorbidities; and IPSS total score. The nomogram has been tested by calculating concordance probabilities, as well as assaying the calibration of predicted probability of clinical testosterone deficiency and need for TTh, together with the clinical outcome of the TTh. A cohort of 141 patients was used for the development of the nomogram, while a cohort of 123 patients attending another institution was used to externally validate and calibrate it. Sixty-four patients (45.3%) received TTh. Among them, sixty patients (93.7%) reported a significant clinical improvement after TTh. The nomogram had a concordance index of 0.83 [area under the ROC curve 0.81 (95% CI 0.71-0.83)]. In conclusion, the TRACE nomogram accurately predicted the probability of clinical impairment related to TD, and resulted in a simple and reliable method to use to select hypogonadal patients with not clearly pathological testosterone values who will benefit from TTh.

Androgens and male sexual function

Sexual symptoms are the most specific determinants of low testosterone (T) observed during adulthood. In this narrative review, we summarize the most important evidence supporting the positive relationships between endogenous T levels and sexual activity in the adult male, by using preclinical and clinical observations. In addition, we also report an update of our previous meta-analysis evaluating the effects of T treatment (TRT) on sexual functioning in subjects with T deficiency. Available data indicate that TRT of symptomatic hypogonadal men can improve several aspects of sexual life, including erection. However, the effect is rather modest and lower in subjects with associated metabolic conditions. The specific observed effects are similar to those derived from lifestyle intervention. Since TRT might result in body composition improvement, it is reasonable to suppose that an initial treatment with T can improve the willingness of hypogonadal subjects to perform physical exercise and to adhere to a healthier behavior. Similar data were derived from animal models. However, it should be important to recognize that lifestyle modifications should be the first step to promote weigh reduction. TRT can be combined with lifestyle interventions only in symptomatic hypogonadal subjects especially in the presence of comorbid metabolic conditions.

Ageing male (part I): Pathophysiology and diagnosis of functional hypogonadism

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.

Novel protein markers of androgen activity in humans: proteomic study of plasma from young chemically castrated men

Background

Reliable biomarkers of androgen activity in humans are lacking. The aim of this study was, therefore, to identify new protein markers of biological androgen activity and test their predictive value in relation to low vs. normal testosterone values and some androgen deficiency linked pathologies.

Methods

Blood samples from 30 healthy GnRH-antagonist treated males were collected at three time points: a) before GnRH antagonist administration; b) 3 weeks later, just before testosterone undecanoate injection, and c) after additional 2 weeks. Subsequently they were analysed by mass spectrometry to identify potential protein biomarkers of testosterone activity. Levels of proteins most significantly associated with testosterone fluctuations were further tested in a cohort of 75 hypo- and eugonadal males suffering from infertility. Associations between levels of those markers and cardio-metabolic parameters, bone mineral density as well as androgen receptor CAG repeat lengths, were explored.

Results

Using ROC analysis, 4-hydroxyphenylpyruvate dioxygenase (4HPPD), insulin-like growth factor-binding protein 6 (IGFBP6) and fructose-bisphosphate aldolase (ALDOB), as well as a Multi Marker Algorithm, based on levels of 4HPPD and IGFBP6, were shown to be best predictors of low (< 8 nmol/L) vs. normal (> 12 nmol/L) testosterone. They were also more strongly associated with metabolic syndrome and diabetes than testosterone levels. Levels of ALDOB and 4HPPD levels also showed association with AR CAG-repeat lengths.

Conclusions

We identified potential new protein biomarkers of testosterone action. Further investigations to elucidate their clinical potential are warranted.

Funding

The work was supported by ReproUnion 2.0 (grant no 20201846), which is funded by the Interreg V EU program.

The dose-response relationship between sex hormones and hyperuricemia in different gender: NHANES 2013-2016

OBJECTIVES

To access the dose-response relationship between sex hormones and hyperuricemia (HUA), and to find the cut-off value in different gender.

METHODS

9,685 participants were derived from the database of National Health and Nutrition Examination Survey (NHANES). Restricted cubic spline (RCS) analysis were applied to explore the relationship between sex hormones and HUA after adjusting for confounding factors by propensity score match (PSM). Logistic regression was used to estimate the odds ratio (OR) and 95% CI.

RESULTS

The prevalence of HUA was 15.13% in female participants and 22.30% in male participants. Logistic regression analysis showed that estradiol (E2) was independently associated with HUA for a P value of 0.003 and 0.01in female and male participants, respectively. Testosterone (T) was only independently associated with HUA in male participants (P&lt;0.001) but not in female participants (P = 0.59). RCS analysis showed a dose-response relationship between sex hormones and HUA. The risk of HUA increased as E2 lower than 29.6pg/mL in female participants and T lower than 389.1ng/dL in male participants. E2 higher than 23.6pg/ml was an independent risk factor for HUA in male participants.

CONCLUSION

A dose-response relationship was found between sex hormones and HUA. The cut-off value of E2 in male and female participants was 29.6pg/mL and 23.6pg/mL, respectively, and the cut-off value of T in male participants was 389.1ng/dL. These results provide a reference for preventing HUA and hormone supplement therapy.

FSHB Genotype Identified as a Relevant Diagnostic Parameter Revealed by Cluster Analysis of Men With Idiopathic Infertility

Introduction and Objectives

About 30-75% of infertile men are diagnosed with idiopathic infertility, thereby lacking major causative factors to explain their impaired fertility status. In this study, we used a large cohort of idiopathic infertile men to determine whether subgroups could be identified by an unbiased clustering approach and whether underlying etiologic factors could be delineated.

Patients and Methods

From our in-house database Androbase®, we retrospectively selected patients (from 2008 to 2018) with idiopathic male infertility (azoo- to normozoospermia) who fit the following selection criteria: FSH ≥ 1 IU/l, testosterone ≥ 8 nmol/l, ejaculate volume ≥ 1.5 ml. Patients with genetic abnormalities or partners with female factors were excluded.For the identified study population (n=2742), we used common andrologic features (somatic, semen and hormonal parameters, including the FSHB c.-211G>T (rs10835638) single nucleotide polymorphism) for subsequent analyses. Cluster analyses were performed for the entire study population and for two sub-cohorts, which were separated by total sperm count (TSC) thresholds: Cohort A (TSC ≥ 1 mill/ejac; n=2422) and Cohort B (TSC < 1 mill/ejac; n=320). For clustering, the partitioning around medoids method was employed, and the quality was evaluated by average silhouette width.

Results

The applied cluster approach for the whole study population yielded two separate clusters, which showed significantly different distributions in bi-testicular volume, FSH and FSHB genotype. Cluster 1 contained all men homozygous for G (wildtype) in FSHB c.-211G>T (100%), while Cluster 2 contained most patients carrying a T allele (>96.6%). In the analyses of sub-cohorts A/B, two clusters each were formed too. Again, the strongest segregation markers between the respective clusters were bi-testicular volume, FSH and FSHB c.-211G>T.

Conclusion

With this first unbiased approach for revealing putative subgroups within a heterogenous group of idiopathic infertile men, we did indeed identify distinct patient clusters. Surprisingly, across all diverse phenotypes of infertility, the strongest segregation markers were FSHB c.-211G>T, FSH, and bi-testicular volume. Further, Cohorts A and B were significantly separated by FSHB genotype (wildtype vs. T-allele carriers), which supports the notion of a contributing genetic factor. Consequently, FSHB genotyping should be implemented as diagnostic routine in patients with idiopathic infertility.

Recommendations on the diagnosis, treatment and monitoring of testosterone deficiency in men

The relative proportional increase of the elderly population within many countries will become one of the most significant social transformations of the twenty-first century and, for the first time in history, persons aged 65 or above outnumbered children under five years of age globally. One in four persons living in Europe and Northern America will be aged 65 or over. One of the goals of ISSAM is to raise awareness of the special health needs of older men. Since a significant number of aging men will eventually become testosterone deficient, the Hypogonadism panel of ISSAM updates its guidelines.

The Lost Penis Syndrome: A New Clinical Entity in Sexual Medicine

INTRODUCTION

The "lost penis syndrome" (LPS) is a term often used in non-clinical settings to describe the subjective perception of the loss of cutaneous and proprioceptive feelings of the male organ during vaginal penetration. Although deserving clinical attention, this syndrome did not receive any consideration in the medical literature. Notwithstanding, it represents a relatively unexceptional condition among patients in sexual medicine clinics, and it is often reported together with other sexual dysfunctions, especially delayed ejaculation, anejaculation, male anorgasmia and inability to maintain a full erection.

OBJECTIVES

To draft a new conceptual characterization of the LPS, defined as a lack of penile somesthetic sensations during sexual penetration due to various causes and leading to several sexual consequences in both partners.

METHODS

Based on an extensive literature review and physiological assumptions, the mechanisms contributing to friction during penovaginal intercourse, and their correlation to LPS, have been explored, as well as other nonanatomical factors possibly contributing to the loss of penile sensations.

RESULTS

Efficient penile erection and sensitivity, optimal vaginal lubrication and trophism contribute to penovaginal friction. Whenever one of these processes does not occur, loss of penile sensation defined as LPS can occur. Sociocultural, psychopathological and age-related (ie, couplepause) factors are also implicated in the etiology. Four types of LPS emerged from the literature review: anatomical and/or functional, behavioral, psychopathological and iatrogenic. According to the subtype, a wide variety of treatments can be employed, including PDE5i, testosterone replacement therapy and vaginal cosmetic surgery, as well as targeted therapy for concomitant sexual comorbidity.

CONCLUSION

We held up the mirror on LPS as a clinically existing multifactorial entity and provided medical features and hypotheses contributing to or causing the occurrence of LPS. In the light of a sociocultural and scientific perspective, we proposed a description and categorization of this syndrome hypothesizing its usefulness in daily clinical practice. Colonnello E, Limoncin E, Ciocca G, et al. The Lost Penis Syndrome: A New Clinical Entity in Sexual Medicine. Sex Med Rev 2021;XX:XXX-XXX.

Clinical efficiency of combination therapy using testosterone replacement therapy, phosphodiesterase 5 inhibitors and Kampo herbal medicine for eugonadal patients with late-onset hypogonadism syndrome

In the present study, the initial treatment efficiency of combination therapy using testosterone replacement therapy (TRT), herbal medicine and phosphodiesterase 5 inhibitors (PDE5i) in male patients with late-onset hypogonadism (LOH) were assessed. A total of 21 patients were enrolled and after 12 weeks, the clinical efficacy was evaluated based on improvement of LOH symptoms via laboratory parameters and several questionnaires, including the Ageing Males' Symptoms (AMS) scale. The overall AMS scores, as well as the psychological, physical and sexual AMS factors prior to and after treatment in the TRT, testosterone enanthate (T enanthate) monotherapy and T enanthate + PDE5i treatment groups were significantly improved. In the herbal medicine group, only the AMS physiological factors were significantly improved after treatment compared with the baseline. The improvement of the overall AMS scores, as well as the physiological and sexual AMS factors, were significantly negatively correlated with the free testosterone (FT) value prior to treatment. In conclusion, treatment with combination therapy using TRT, herbal medicine and PDE5i improved AMS scores in patients with LOH syndrome. Particularly in patients with LOH syndrome and low FT, the symptoms were significantly improved following combination therapy.

Male hypogonadism: therapeutic choices and pharmacological management

Male hypogonadism, defined as an inadequate testosterone production, recognizes a testicular (primary hypogonadism) or a hypothalamic-pituitary dysfunction (central hypogonadism), although combined forms can also occur. Moreover, it has been known that intensive exercise training might be a cause of functional hypogonadism. Many therapeutic choices are currently available, depending on the timing of hypogonadism onset and fertility issue. The aim of this review was to comprehensively supply therapeutic options and schemes currently available for male hypogonadism, including pharmacological management of primary and central forms. Evidence on testosterone formulations, human chorionic gonadotropin, selective estrogen receptor modulators and aromatase inhibitors will be provided.

Testosterone Levels in Adolescents and Young Men with Type 1 Diabetes and Their Association with Diabetic Nephropathy

Simple Summary

Type 2 diabetes(T2D) has been known to be related with obesity, insulin-resistance, impaired glucose control. Low testosterone levels and hypogonadism are also known as clinical characteristics of T2D patients. On the contrary, type 1 diabetes(T1D) happens when insulin is insufficient rather than insulin-resistance. Relationship between T1D and testosterone has not been established enough. In the study, patients with T1D showed higher testosterone levels than the general population. We could also find that higher testosterone levels have positive relationship with nephropathy, one of complications in diabetic patients. Therefore, periodic check-up for testostrone levels may be helpful for preventing nephropathy in T1D.

Abstract

The association between serum testosterone levels and type 1 diabetes (T1D), especially in adolescents and young adults, has not been fully investigated. We aimed to compare testosterone levels between adolescents/young men with T1D and controls and to determine the factors affecting testosterone levels. We enrolled 47 men with T1D and 32 controls aged 15–29 years. We evaluated anthropometric measurements, lipid profiles, diabetic complications, and levels of serum luteinizing hormone, follicle-stimulating hormone, hemoglobin A1c, 24-h urine albumin, insulin autoantibody, and total serum testosterone. We assessed the correlation between serum testosterone levels and clinical characteristics. Total testosterone levels were higher in T1D patients than in controls (694.6 ± 182.2 vs. 554.1 ± 147.3 ng/dL, p = 0.001), and 24-h urine albumin level positively correlated with total testosterone levels (correlation coefficient 0.415, p = 0.004). T1D patients with nephropathy showed higher total testosterone levels than those without nephropathy (778.4 ± 198.9 vs. 655.4 ± 162.5 ng/dL, p = 0.029). However, diabetic nephropathy and testosterone levels were not significantly associated after adjusting for confounders (β ± SE 77.5 ± 55.2, p = 0.169). Further longitudinal studies are imperative to confirm a causal relationship between testosterone levels and T1D.

Testosterone, HIV, and cardiovascular disease risk

There has been a recent increase in the use of testosterone supplementation among young adults in the United States, despite the controversy of testosterone replacement therapy (TRT) and cardiovascular safety. The lower testosterone levels and earlier age of TRT use in persons living with HIV (PLHIV) is of particular relevance for this population because cardiovascular disease (CVD) comorbidities are known to be increased among PLHIV. There is very limited data on TRT in PLHIV, as such, in this article, we sought to compile current evidence regarding the diagnosis and management of testosterone deficiency and its link to CVD risk including among PLHIV.

Erectile Dysfunction and Decreased Libido in Klinefelter Syndrome: A Prevalence Meta-Analysis and Meta-Regression Study

BACKGROUND

Only few studies have assessed sexual dysfunction in men with Klinefelter syndrome (KS).

AIM

To define pooled prevalence estimates and correlates of erectile dysfunction (ED) and decreased libido (DL) in KS.

METHODS

A thorough search of Medline, Embase and Web of Science was performed to identify suitable studies. Quality of the articles was scored using the Assessment Tool for Prevalence Studies. Data were combined using random effect models and the between-studies heterogeneity was assessed by the Cochrane's Q and I². The sources of heterogeneity were investigated by meta-regression and sub-group analyses. Funnel plot, Begg's rank correlation and trim-and-fill test were used to assess publication bias.

MAIN OUTCOME MEASURE

The pooled prevalence of ED and DL in KS as well as 95% confidence intervals (CIs) were estimated from the proportion of cases of sexual dysfunction and the sample size. Variables that could affect the estimates were identified by linear meta-regression models.

RESULTS

Sixteen studies included collectively gave information about ED and DL in 482 and 368 KS men, respectively, resulting in a pooled prevalence of 28% (95% CI: 19%-36%) for ED and 51% (95% CI: 36%-66%) for DL, with a large heterogeneity. The trim-and-fill adjustment for publication bias produced a negligible effect on the pooled estimates. At the meta-regression analyses, a higher prevalence of ED was significantly associated with an older age but not with lower testosterone levels. In series with a mean age >35 years, the ED prevalence estimate increased up to 38% (95% CI: 31%-44%) with no heterogeneity (I²=0.0%, P=0.6). On the contrary, the prevalence of DL increased significantly as testosterone levels decreased, without a significant relationship with age.

CLINICAL IMPLICATIONS

While DL would largely reflect an androgen deficiency, in older men with KS, erectile function should be assessed irrespective of testosterone levels.

STRENGTH & LIMITATIONS

This is the first meta-analysis defining pooled prevalence estimates and correlates of ED and DL in KS. Nevertheless, caution is required when interpreting results, due to the high risk of bias in many studies, as well as the dearth of data about psychosocial and/or psychosexological variables and age at the diagnosis.

CONCLUSIONS

ED and DL represent common clinical complaints in KS. While the prevalence of ED would increase with age, DL gets more common as serum testosterone decreases. Further studies are warranted to elucidate the pathogenetic mechanism(s) underlying the age-dependent increase in the prevalence of ED, apparently unrelated to the androgenic status. A Barbonetti, S D'Andrea, W Vena, et al. Erectile Dysfunction and Decreased Libido in Klinefelter Syndrome: A Prevalence Meta-Analysis and Meta-Regression Study. J Sex Med 2021;18:1054-1064.

Late-onset hypogonadism: Clinical evidence, biological aspects and evolutionary considerations

The growing life expectancy in modern societies has raised scientific interest in identifying medical interventions to alleviate age-associated pathologies such as vascular calcification, cognitive decline, sarcopenia, osteoporosis and sexual dysfunction. Although no such single treatment has thus far been established in humans, some clinicians and patients have set their hopes on testosterone replacement therapy (TRT) as a potential "fountain of youth" for aging men. While TRT has proven effective in ameliorating distinct symptoms of late-onset hypogonadism (LOH), its safety remains to be demonstrated. Besides humans, multiple other species exhibit age-related reductions in circulating testosterone levels, raising the question whether such changes are an inherent, pathological feature of growing organismal age or rather reflect an adaptive response. In this manuscript, we apply key principles of evolutionary medicine to testosterone biology and LOH to provide a novel perspective on these two fields. Additionally, we discuss insightful data derived from the animal kingdom to illustrate the plasticity of individual testosterone trajectories across the lifespan, outline cost-benefit-considerations of TRT in LOH and highlight potential caveats of such therapies.

Clinical and biochemical correlates of hypogonadism in men with type 2 diabetes mellitus

Introduction

there is an association between hypogonadism and obesity, chronic hyperglycaemia, and ageing in men with type 2 diabetes mellitus (T2DM). T2DM is known to be associated with low testosterone. There is a paucity of data on the risk factors of hypogonadism in Nigerian men with T2DM. The objective of this study was to determine the clinical and biochemical correlates of hypogonadism and clinical predictors of low total testosterone levels in men with T2DM.

Methods

this was a cross-sectional study consisting of 358 men with T2DM and 179 non-diabetic men (controls). Structured Androgen Deficiency in the Ageing Male questionnaire was administered. Clinical and biochemical parameters were measured. Free testosterone was calculated from albumin, SHBG and total testosterone using Vermeulen´s method. Hypogonadism was defined as fasting TT as < 8 nmol/L with or without symptoms or TT of 8-12 nmol/L with symptoms of androgen deficiency. Low testosterone was defined as serum total testosterone levels ≤ 12 nmol/L.

Results

the mean (±SD) total testosterone of men with T2DM and controls were 8.79±3.35 nmol/L and 15.41±3.79 nmol/L respectively (p < 0.001). The risk of hypogonadism was associated with central obesity (Odds ratio [OR] 2.24, 95% confidence interval [CI] 0.38-13.07), systolic hypertension (OR 3.93, 95% CI 0.67-23.10), hyperglycaemia (OR 2.48, 95% CI 0.37-16.46) and hypercholesterolaemia (OR 2.50, 95% CI 0.43-14.61). In a multivariable regression analysis, there was a significant negative correlation between total testosterone and triglycerides (r -1.85, 95% CI -3.58 - 0.12, P = 0.04) and HDL cholesterol (r -1.25, 95% CI -5.95-3.45, P = 0.02).

Conclusion

this study shows that in men with T2DM, triglycerides and HDL cholesterol are independent correlates of hypogonadism but not central adiposity, systolic blood pressure and glycaemia. Further large prospective studies are recommended.

[Testicular sperm extraction in male infertility : Indications, success rates, practical implementation, and possible complications]

BACKGROUND

Unwanted childlessness is a burden on a couple's relationship. The therapeutic spectrum of male infertility has increased significantly in recent years so that even azoospermia patients can be given biological paternity by testicular sperm extraction (TESE).

OBJECTIVES

The indications, success rates, practical implementation, and possible complications of conventional and microscopic TESE in male infertility are presented in this review.

METHODS

A nonsystematic search of the relevant literature was carried out.

RESULTS

In obstructive azoospermia (OA), primarily desobstructive surgical procedures are used, while TESE is the surgical procedure of choice in nonobstructive azoospermia (NOA). In the latter, sperm extraction can be performed conventionally or microscopically (mTESE) assisted, whereby the latter offers an advantage in terms of sperm detection rate in the case of small testicular volumes (<12 ml), chemotherapy, Klinefelter's disease and AZFc microdeletions. The sperm detection rate of TESE is about 50%. Postoperative controls are useful because of the possible induction of symptomatic hypogonadism.

CONCLUSION

Before performing TESE, determining the hormone status and human genetic clarification are necessary. Any costs incurred and the possibility of missing sperm proof must be discussed. Close cooperation between andrologists, gynecologists, reproductive physicians, and human geneticists is necessary. All in all, TESE is a safe surgical procedure with a low complication rate.

Sexual Dysfunction: A Neglected and Overlooked Issue in Adult GH Deficiency: The Management of AGHD Study

Context

Although sexuality influences well-being and quality of life (QoL), studies on sexual dysfunction (SD) in adult growth hormone deficiency (AGHD) patients are lacking.

Objective

To investigate the prevalence of SD in AGHD patients grouped according to recombinant human growth hormone (r-hGH) therapy.

Design

Prospective, cross-over, 24 months, monocentric study.

Setting

Real-life clinical setting in a tertiary, endocrinological center.

Patients

83 AGHD patients (31 women, 52 men, mean age 56.3 ± 14.7 years) were enrolled according to stringent criteria.

Intervention(s)

Patients already on long-term r-hGH therapy (Group 1, n = 32) vs untreated (Group 2, n = 51).

Main outcome measure(s)

Serum hormones, QoL Satisfaction in Hypopituitarism (QLS-H) and QoL Assessment of GHD in Adults (QoL-AGHDA) questionnaires for QoL, Index for Erectile Function-15 (IIEF-15) in men, and Female Sexual Function Index (FSFI) in women for SD.

Results

The overall prevalence of SD was 71.2% (60% men, 89% women). All IIEF-15 scores were lower (P = 0.001) and erectile dysfunction was more prevalent in Group 2 (75%) than Group 1 (35%). IGF-1 was correlated to scores of all IIEF-15 domains, particularly with that of erectile function (EF) (R²=0.123, P = 0.019). EF domain score correlated with QLS-H (P < 0.005) and QoL-AGHDA (P = 0.001). Despite the high prevalence of female SD also in untreated AGHD women, FSFI scores did not correlate with IGF-1 levels and QoL scores.

Conclusions

SD is highly prevalent in AGHD patients, especially in those untreated. SD represents an overlooked and neglected issue in AGHD, regardless the contribution of sexual life on QoL. The evaluation of sexual function should be integrated in the global assessment of AGHD patients.

Recovery of serum testosterone following neoadjuvant androgen deprivation therapy in Japanese prostate cancer patients treated with low-dose rate brachytherapy

OBJECTIVE

To investigate the time course of total testosterone (TT) recovery after cessation of androgen deprivation therapy (ADT) in Japanese patients treated with brachytherapy.

METHODS

In total, 125 patients with prostate cancer received 6 months of neoadjuvant ADT (nADT) followed by low-dose rate (LDR) brachytherapy. TT was measured every 3 months after cessation of nADT, and some predictive factors affecting TT recovery were analyzed.

RESULTS

The cumulative incidence rates of TT recovery to normal levels (TT ≥ 3.0 ng/mL) after 12 and 24 months cessation were 49.6% and 81.6%, respectively. The median interval to recover to normal TT was 15 months. In multivariate analysis, the use of a gonadotropin-releasing hormone (GnRH) antagonist as nADT significantly earlier improved to recovery to normal TT level (p = 0.046). Conversely, higher body mass index (BMI) and hypertension significantly prolonged TT recovery to normal (p = 0.026 and p = 0.026, respectively).

CONCLUSIONS

Approximately one-fifth of patients still had low TT levels 2 years after the cessation of 6 months nADT before LDR brachytherapy. Use of a GnRH agonist, higher BMI, and hypertension were the predictive factors for slower TT recovery to normal TT levels after the cessation of nADT.

Testosterone for Androgen Deficiency-Like Symptoms in Men Without Pathologic Hypogonadism: A Randomized, Placebo-Controlled Cross-over With Masked Choice Extension Clinical Trial

BACKGROUND

Off-label testosterone prescribing for androgen deficiency (AD)-like sexual and energy symptoms of older men without pathologic hypogonadism has increased dramatically without convincing evidence of efficacy.

METHODS

In a randomized, double-blind, placebo-controlled study with three phases, we entered 45 men aged at least 40 years without pathologic hypogonadism but with AD-like energy and/or sexual symptoms to either daily testosterone or placebo gel treatment for 6 weeks in a cross-over study design with a third, mandatory extension phase in which participants chose which previous treatment they preferred to repeat while remaining masked to their original treatment. Primary endpoints were energy and sexual symptoms as assessed by a visual analog scale (Lead Symptom Score [LSS]).

RESULTS

Increasing serum testosterone to the healthy young male range produced no significant benefit more than placebo for energy or sexual LSS. Covariate effects of age, body mass index, and pretreatment baseline serum testosterone on quality-of-life scales were detected. Only 1 out of 22 indices from seven quality-of-life scales was significantly improved by testosterone treatment over placebo. Participants did not choose testosterone significantly more than placebo as their preferred treatment in the third phase.

CONCLUSIONS

Six-week testosterone treatment does not improve energy or sexual symptoms more than placebo in symptomatic men without pathologic hypogonadism.

Current National and International Guidelines for the Management of Male Hypogonadism: Helping Clinicians to Navigate Variation in Diagnostic Criteria and Treatment Recommendations

Male hypogonadism-rebadged by some as testosterone deficiency syndrome-is a clinical and biochemical diagnosis of increasing worldwide interest. Organic male hypogonadism-usually permanent-is well-established, but aging men may also exhibit lower serum testosterone levels; principally due to burden of extra-gonadal comorbidities such as obesity, diabetes and metabolic syndrome, but with an underlying intact hypothalamo-pituitary-testicular (HPT) axis capable of springing back into operation once comorbidities are addressed. Despite encouraging observational data and plausible theoretical underpinning, evidence for efficacy and safety of testosterone in this "aging" group of men is lacking; addressing comorbid illnesses remains the key priority instead. Nevertheless, in recent years, accumulation of misleading information online has triggered a global tsunami of testosterone prescriptions. Despite this, many men with organic hypogonadism remain undiagnosed or untreated; many more face a diagnostic odyssey before achieving care by the appropriate specialist. As testosterone therapy is not without risk several clinical practice guidelines have been published specialist societies to guide physicians on best practice. However, these are heterogeneous in key areas, reflecting divergent approaches to the same evidence basis. Herein, we navigate the major clinical practice guidelines on male hypogonadism and test their respective recommendations against current best evidence.

Endocrinological and symptomatic characteristics of patients with late-onset hypogonadism classified by functional categories based on testosterone and luteinizing hormone levels

OBJECTIVES

To define the characteristics of patients with late-onset hypogonadism based on endocrinological findings.

METHODS

We assessed age, body mass index, laboratory/endocrinological profiles and symptom-specific questionnaire scores of 967 men with late-onset hypogonadism symptoms. The patients comprised four groups by testosterone and luteinizing hormone concentrations: normal group, compensated hypogonadism group, primary hypogonadism group and secondary hypogonadism group. We compared characteristics between the normal group and compensated hypogonadism group in men with normal testosterone concentration, and the primary hypogonadism group and secondary hypogonadism group in hypogonadal men after age adjustment.

RESULTS

The normal group, compensated hypogonadism group, primary hypogonadism group and secondary hypogonadism group accounted for 83.6%, 3.4%, 0.8% and 12.2% of patients, respectively. Despite age adjustment, serum dehydroepiandrosterone sulfate and insulin-like growth factor 1 concentrations were significantly lower in the compensated hypogonadism group than the normal group. Only the Aging Males' Symptoms scale mental subscore was significantly different. Serum testosterone and dehydroepiandrosterone sulfate concentrations were significantly lower in the primary hypogonadism group than the secondary hypogonadism group. Only the Aging Males' Symptoms scale sexual subscore was significantly different.

CONCLUSIONS

Most patients with late-onset hypogonadism symptoms are in the normal group, with secondary hypogonadism being much more frequent than primary hypogonadism. Current symptomatic differences among these groups are minor. Classifying patients by testosterone and luteinizing hormone levels might provide useful information for follow up.