Correlation of serum androgens with anthropometric and metabolic indices in healthy, nonobese postmenopausal women

Percent body fat was negatively correlated with Testosterone levels in male

BACKGROUND

Lower testosterone levels in men have been consistently associated with metabolic abnormalities, particularly obesity. This study aims to investigate the relationship between testosterone and obesity by analyzing the correlation between testosterone levels and body fat percentage using data from the NHANES (National Health and Nutrition Examination Survey) database.

METHODS

The study included a total of 5959 participants from the NHANES 2011-2016. Multivariable linear regression models were used to assess the association between testosterone levels and body composition parameters, including total percent fat (TPF), android percent fat (APF), gynoid percent fat (GPF), android to gynoid ratio (A/G), and lean mass percent (LMP). Subgroup analyses stratified by sex were conducted using multivariable linear regression. To account for potential non-linear relationships, fitted smoothing curves and generalized additive models were utilized. A separate analysis of participants with a BMI ≥ 30 kg/m2 was conducted to validate the conclusions.

RESULT

Among males, testosterone levels showed a significant negative correlation with TPF (β = -11.97, P <0.0001), APF (β = -9.36, P<0.0001), GPF (β = -10.29, P <0.0001), and A/G (β = -320.93, P<0.0001), while a positive correlation was observed between LMP and testosterone levels (β = 12.62, P<0.0001). In females, a contrasting pattern emerged in the relationship between testosterone and body fat, but no significant correlation was found between testosterone and body composition in obese women.

CONCLUSIONS

The findings of this study support a negative association between body fat and testosterone levels in males.

Clinical Blood Metabogram: Application to Overweight and Obese Patients

Recently, the concept of a mass spectrometric blood metabogram was introduced, which allows the analysis of the blood metabolome in terms of the time, cost, and reproducibility of clinical laboratory tests. It was demonstrated that the components of the metabogram are related groups of the blood metabolites associated with humoral regulation; the metabolism of lipids, carbohydrates, and amines; lipid intake into the organism; and liver function, thereby providing clinically relevant information. The purpose of this work was to evaluate the relevance of using the metabogram in a disease. To do this, the metabogram was used to analyze patients with various degrees of metabolic alterations associated with obesity. The study involved 20 healthy individuals, 20 overweight individuals, and 60 individuals with class 1, 2, or 3 obesity. The results showed that the metabogram revealed obesity-associated metabolic alterations, including changes in the blood levels of steroids, amino acids, fatty acids, and phospholipids, which are consistent with the available scientific data to date. Therefore, the metabogram allows testing of metabolically unhealthy overweight or obese patients, providing both a general overview of their metabolic alterations and detailing their individual characteristics. It was concluded that the metabogram is an accurate and clinically applicable test for assessing an individual's metabolic status in disease.

Cardiometabolic risk factors and endogenous sex hormones in postmenopausal women: a cross-sectional study

Context

It is uncertain which cardiovascular risk factors are associated with sex hormone levels in postmenopausal women.

Objective

This work aimed to investigate the association between cardiometabolic risk factors and sex hormones in a cross-sectional, observational population study.

Methods

In this Swedish population study, participants were physically examined from 2002 to 2004, and endogenous sex hormones were analyzed by liquid chromatography–tandem mass spectrometry. Women aged 55 years or older with estradiol levels below 20 pg/mL and not using any hormonal therapy were eligible for inclusion in the study (N = 146). Variable selection and bootstrap stability analyses were performed and linear regression models presented, with each of the 8 hormones as outcome variables.

Results

Body mass index (BMI) was positively associated with estradiol (β = 0.054, P < .001), but negatively associated with 17-α-hydroxyprogesterone (β = –0.023, P = .028). Waist-to-hip ratio (WHR) was negatively associated with dihydrotestosterone (β = –2.195, P = .002) and testosterone (β = –1.541, P = .004). The homeostatic model assessment of insulin resistance was positively associated with androstenedione (β = 0.071, P = .032), estradiol (β = 0.091, P = .009), estrone (β = 0.075, P = 0.009), and 17-α-hydroxyprogesterone (β = 0.157, P = .001). Age was positively associated with testosterone (β = 0.017, P = .042). C-reactive protein showed an inverse association with progesterone (β = –0.028, P = .037). Lower low-density lipoprotein cholesterol was associated with higher estradiol levels (β = –0.093, P = .049), whereas lower triglycerides were associated with higher concentrations of dihydrotestosterone (β = –0.208, P = .016).

Conclusion

In postmenopausal women, WHR was strongly inversely associated with androgens, while BMI was positively associated with estrogens.

Obesity, Body Composition, and Sex Hormones: Implications for Cardiovascular Risk

Cardiovascular disease (CVD) continues to be the leading cause of death in adults, highlighting the need to develop novel strategies to mitigate cardiovascular risk. The advancing obesity epidemic is now threatening the gains in CVD risk reduction brought about by contemporary pharmaceutical and surgical interventions. There are sex differences in the development and outcomes of CVD; premenopausal women have significantly lower CVD risk than men of the same age, but women lose this advantage as they transition to menopause, an observation suggesting potential role of sex hormones in determining CVD risk. Clear differences in obesity and regional fat distribution among men and women also exist. While men have relatively high fat in the abdominal area, women tend to distribute a larger proportion of their fat in the lower body. Considering that regional body fat distribution is an important CVD risk factor, differences in how men and women store their body fat may partly contribute to sex-based alterations in CVD risk as well. This article presents findings related to the role of obesity and sex hormones in determining CVD risk. Evidence for the role of sex hormones in determining body composition in men and women is also presented. Lastly, the clinical potential for using sex hormones to alter body composition and reduce CVD risk is outlined. © 2022 American Physiological Society. Compr Physiol 12:1-45, 2022.

Steroid secretion in healthy aging

Nowadays, people spend a considerable amount of their lives as older adults, but this longer lifespan is often accompanied by an increase in chronic conditions and disease, resulting in reduced quality of life and unprecedented societal and economic burden. Healthy aging is therefore increasingly recognized as a healthcare priority. Physical and mental adaptations to changes over the life course, and the maintenance of well-being, represent pivotal challenges in healthy aging. To capture the complexity of healthy aging, we propose a specific phenotype based on body composition, cognition, mood, and sexual function as indicators of different dimensions of healthy aging. With increasing age, sex hormones as well as glucocorticoids undergo significant alterations, and different patterns emerge for women and men. This review describes age-related patterns of change for women and men, and sheds light on the underlying mechanisms. Furthermore, an overview is provided of the challenges for healthy aging resulting from these age-related steroid alterations. While clinical practice guidelines recommend hormonal treatment only in the case of consistently low hormone levels and symptoms of hormone deficiency, physical exercise and a healthy lifestyle emerge as preventive strategies which can counter age-related hormonal changes and at best prevent chronic conditions.

Are we close to defining a metabolomic signature of human obesity? A systematic review of metabolomics studies

INTRODUCTION

Obesity is a disorder characterized by a disproportionate increase in body weight in relation to height, mainly due to the accumulation of fat, and is considered a pandemic of the present century by many international health institutions. It is associated with several non-communicable chronic diseases, namely, metabolic syndrome, type 2 diabetes mellitus (T2DM), cardiovascular diseases (CVD), and cancer. Metabolomics is a useful tool to evaluate changes in metabolites due to being overweight and obesity at the body fluid and cellular levels and to ascertain metabolic changes in metabolically unhealthy overweight and obese individuals (MUHO) compared to metabolically healthy individuals (MHO).

OBJECTIVES

We aimed to conduct a systematic review (SR) of human studies focused on identifying metabolomic signatures in obese individuals and obesity-related metabolic alterations, such as inflammation or oxidative stress.

METHODS

We reviewed the literature to identify studies investigating the metabolomics profile of human obesity and that were published up to May 7th, 2019 in SCOPUS and PubMed through an SR. The quality of reporting was evaluated using an adapted of QUADOMICS.

RESULTS

Thirty-three articles were included and classified according to four types of approaches. (i) studying the metabolic signature of obesity, (ii) studying the differential responses of obese and non-obese subjects to dietary challenges (iii) studies that used metabolomics to predict weight loss and aimed to assess the effects of weight loss interventions on the metabolomics profiles of overweight or obese human subjects (iv) articles that studied the effects of specific dietary patterns or dietary compounds on obesity-related metabolic alterations in humans.

CONCLUSION

The present SR provides state-of-the-art information about the use of metabolomics as an approach to understanding the dynamics of metabolic processes involved in human obesity and emphasizes metabolic signatures related to obesity phenotypes.

Circulating steroid levels as correlates of adipose tissue phenotype in premenopausal women

Background Obesity-related alterations in the circulating steroid hormone profile remain equivocal in women. Our objective was to identify circulating steroid levels that relate to increased adiposity and altered adipose phenotype in premenopausal women. Materials and methods In a sample of 42 premenopausal women [age 46 ± 3 years; body mass index (BMI) 27.1 ± 4.2 kg/m2], 19 plasma steroids were quantified by electrospray ionization-liquid chromatography-tandem mass spectroscopy (ESI-LC-MS/MS). Body composition and fat distribution were assessed by dual-energy X-ray absorptiometry (DXA) and computed tomography (CT), respectively. Markers of adipose tissue function including adipocyte size distributions, radiological attenuation and macrophage infiltration were also analyzed in surgically obtained visceral and subcutaneous fat samples. Results Many negative correlations were observed between adiposity measurements such as BMI, body fat percentage or total abdominal adipose tissue area and plasma levels of androstenedione (Δ4) (r = -0.33 to -0.39, p ≤ 0.04), androsterone (ADT) (r = -0.30 to -0.38, p ≤ 0.05) and steroid precursor pregnenolone (PREG) (r = -0.36 to -0.46, p ≤ 0.02). Visceral adipocyte hypertrophy was observed in patients with low PREG concentrations (p < 0.05). Visceral adipose tissue radiologic attenuation, a potential marker of adipocyte size, was also positively correlated with PREG levels (r = 0.33, p < 0.05). Low levels of PREG were related to increased number of macrophages infiltrating visceral and subcutaneous adipose tissue (p < 0.05). Conclusion Plasma levels of androgens and their precursors are lower in women with increased adiposity and visceral adipocyte hypertrophy. Low circulating PREG concentration may represent a marker of adipose tissue dysfunction.

The relation among steroid hormone levels, lipid profile and menopausal symptom severity

INTRODUCTION

Many postmenopausal women experience hot flashes, night sweats, non-specific emotional and psychological distresses. Our aim was to investigate the relation among steroid hormone levels, lipid profile and menopausal symptom severity using the menopause rating scale (MRS).

METHODS

A cross-sectional study was performed at our outpatient clinic with natural postmenopausal women. A total of 444 women were included in this study. The basic characteristics of the study population, such as age, gravidity, parity, time to menopause onset and body mass index (BMI) were recorded. Venous blood samples were collected from subjects after overnight fasting. The levels of high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, total cholesterol, triglyceride (TG), fasting plasma glucose, C-reactive protein, thyroid-stimulating hormone (TSH), cortisol, estradiol (E2), progesterone, testosterone and dehydroepiandrostenedione sulfate (DHEA-S) were analyzed. The MRS questionnaire validated for the Turkish population was used to assess the menopausal symptoms.

RESULTS

There was a statistically significant difference between mild and severe total symptom scores for TG, and elevated TG levels were observed in the severe group (p = 0.04). Elevated testosterone levels were observed with severe psychological symptom and total symptom scores. There were significant differences in progesterone level in psychological, urogenital, and total scores and lower levels were seen in severe symptom groups. There was a significant negative correlation between urogenital symptom scores and progesterone levels (p < 0.001).

DISCUSSION

Elevated levels of testosterone were related to severe psychological symptom and total menopausal symptom scores. A decrease in progesterone levels was related to high psychological, urogenital and total menopausal symptom scores. Elevated TG levels were also related to the total severe symptom scores.

The different role of sex hormones on female cardiovascular physiology and function: not only oestrogens

Human response to different physiologic stimuli and cardiovascular (CV) adaptation to various pathologies seem to be gender specific. Sex-steroid hormones have been postulated as the major contributors towards these sex-related differences. This review will discuss current evidence on gender differences in CV function and remodelling, and will present the different role of the principal sex-steroid hormones on female heart. Starting from a review of sex hormones synthesis, receptors and CV signalling, we will summarize the current knowledge concerning the role of sex hormones on the regulation of our daily activities throughout the life, via the modulation of autonomic nervous system, excitation-contraction coupling pathway and ion channels activity. Many unresolved questions remain even if oestrogen effects on myocardial remodelling and function have been extensively studied. So this work will focus attention also on the controversial and complex relationship existing between androgens, progesterone and female heart.

Androgens, body fat Distribution and Adipogenesis

Androgens are regulators of important adipocyte functions such as adipogenesis, lipid storage, and lipolysis. Through depot-specific impact on the cells of each fat compartment, androgens could modulate body fat distribution patterns in humans. Testosterone and dihydrotestosterone have been shown to inhibit the differentiation of preadipocytes to lipid-storing adipocytes in several models including primary cultures of human adipocytes from both men and women. Androgen effects have also been observed on some markers of lipid metabolism such as LPL activity, fatty acid uptake, and lipolysis. Possible depot-specific and sex-specific effects have been observed in some but not all models. Transformation of androgen precursors to active androgens or their inactivation by enzymes that are expressed and functional in adipose tissue may contribute to modulate the local availability of active hormones. These phenomena, along with putative depot-specific interactions with glucocorticoids may contribute to human body fat distribution patterns.

Aromatase inhibitors affect vaginal proliferation and steroid hormone receptors

OBJECTIVE

Women with breast cancer who are treated with aromatase inhibitors often experience vaginal atrophy symptoms and sexual dysfunction. This work aims to study proliferation and the presence and distribution of steroid hormone receptors in vaginal biopsies in relation to vaginal atrophy and vaginal pH in women with breast cancer who are on adjuvant endocrine treatment and in healthy postmenopausal women.

METHODS

This is a cross-sectional study that compares postmenopausal aromatase inhibitor-treated women with breast cancer (n = 15) with tamoxifen-treated women with breast cancer (n = 16) and age-matched postmenopausal women without treatment (n = 19) or with vaginal estrogen therapy (n = 16). Immunohistochemistry was used to study proliferation and steroid hormone receptor staining intensity. Data was correlated with estrogen and androgen levels, vaginal atrophy scores, and vaginal pH.

RESULTS

Aromatase inhibitor-treated women had a lower grade of proliferation, weaker progesterone receptor staining, and stronger androgen receptor staining, which correlated with plasma estrone levels, vaginal atrophy scores, and vaginal pH.

CONCLUSIONS

Women with aromatase inhibitor-treated breast cancer exhibit reduced proliferation and altered steroid hormone receptor staining intensity in the vagina, which are related to clinical signs of vaginal atrophy. Although these effects are most probably attributable to estrogen suppression, a possible local inhibition of aromatase cannot be ruled out.

Differential effect of oral dehydroepiandrosterone-sulphate on metabolic syndrome features in pre- and postmenopausal obese women

OBJECTIVE

To analyze the effect in obese pre- and postmenopausal women of a daily dose of 100 mg dehydroepiandrosterone-sulphate (DHEA-S) provided over a period of 3 months as replacement therapy against metabolic syndrome.

CONTEXT

Although DHEA-S appears to be effective against certain features of metabolic syndrome, its usefulness against this syndrome as a whole has not been evaluated to date.

DESIGN/PATIENTS

A randomized, double-blind placebo-controlled trial was conducted involving 61 postmenopausal women, who received DHEA-S (n = 41) or placebo (n = 20) for 3 months. The effect of DHEA-S treatment on the same postmenopausal women was compared with the effects observed in a group of premenopausal women (n = 20).

MEASUREMENTS

Anthropometric measurements were taken at the beginning and at the end of the treatment. Similarly, different parameters that define metabolic syndrome and other cardiometabolic variables were determined.

RESULTS

Dehydroepiandrosterone-sulphate replacement produced weight loss in the obese women studied. Moreover, waist circumference, glucose and systolic and diastolic blood pressure, among other metabolic syndrome parameters, improved in the postmenopausal group, who showed a significant reduction in the total metabolic syndrome score (P < 0·05). In contrast, in premenopausal women, the effect of DHEA-S was limited to obesity parameters, and no effect was observed on metabolic syndrome components. No significant changes were evident in the placebo group.

CONCLUSIONS

An oral dose of DHEA-S is useful for weight loss. In obese postmenopausal women, the hormone significantly improves plasma biochemical levels and anthropometric characteristics, leading to a better metabolic profile, which highlights the usefulness of this therapy against metabolic syndrome in this group of women.

Association of circulating adiponectin with testosterone in women during the menopausal transition

OBJECTIVE

We examined (1) the change in circulating adiponectin in women during the menopausal transition and (2) the associations of adiponectin levels with estrogen, androgen and sex hormone-binding globulin (SHBG) in women during the menopausal transition.

METHODS

We conducted a cross-sectional study in 235 healthy women and divided them into 7 stages by menstrual regularity and follicle-stimulating hormone (FSH) level. Serum levels of adiponectin, estradiol, total testosterone, dehydroepiandrosterone-sulfate (DHEA-S) and SHBG were measured. Levels of free and bioavailable testosterone were calculated by using total testosterone, albumin and SHBG.

RESULTS

Serum adiponectin levels showed a U-curve, levels being low in early and late menopausal transition and gradually becoming higher after menopause. Adiponectin levels were negatively correlated with levels of free testosterone, bioavailable testosterone and DHEA-S and were positively correlated with SHBG in postmenopausal women for whom more than 1 year had passed since menopause. Adiponectin level was not correlated with estradiol level.

CONCLUSION

Circulating adiponectin level shows a U-curve during the menopausal transition and adiponectin level is associated with levels of free and bioavailable testosterone and DHEA-S in postmenopause.

Menopause and risk of diabetes in the Diabetes Prevention Program

OBJECTIVE

The study objectives were to examine the association between menopause status and diabetes risk among women with glucose intolerance and to determine if menopause status modifies response to diabetes prevention interventions.

METHODS

The study population included women in premenopause (n = 708), women in natural postmenopause (n = 328), and women with bilateral oophorectomy (n = 201) in the Diabetes Prevention Program, a randomized placebo-controlled trial of lifestyle intervention and metformin among glucose-intolerant adults. Associations between menopause and diabetes risk were evaluated using Cox proportional hazard models that adjusted for demographic variables (age, race/ethnicity, family history of diabetes, history of gestational diabetes mellitus), waist circumference, insulin resistance, and corrected insulin response. Similar models were constructed after stratification by menopause type and hormone therapy use.

RESULTS

After adjustment for age, there was no association between natural menopause or bilateral oophorectomy and diabetes risk. Differences by study arm were observed in women who reported bilateral oophorectomy. In the lifestyle arm, women with bilateral oophorectomy had a lower adjusted hazard for diabetes (hazard ratio [HR], 0.19; 95% CI, 0.04-0.94), although observations were too few to determine if this was independent of hormone therapy use. No significant differences were seen in the metformin (HR, 1.29; 95% CI, 0.63-2.64) or placebo arms (HR, 1.37; 95% CI, 0.74-2.55).

CONCLUSIONS

Among women at high risk for diabetes, natural menopause was not associated with diabetes risk and did not affect response to diabetes prevention interventions. In the lifestyle intervention, bilateral oophorectomy was associated with a decreased diabetes risk.

Relationship of androgens to body composition, energy and substrate metabolism and aerobic capacity in healthy, young women

OBJECTIVE

To evaluate the role of physiologic levels of androgens and their precursors in the regulation of body composition, energy and substrate metabolism and aerobic capacity in healthy, cycling, premenopausal women.

EXPERIMENTAL

We evaluated 30 young (27±1 year) premenopausal, non-obese (23±0.5 kg/m(2)), normally-cycling women, without clinical or chemical evidence of hyperandrogenism or hyperinsulinemia, for parameters of total and regional body composition, glucose tolerance, aerobic capacity and resting energy expenditure and substrate oxidation. Serum was assayed for androgens and androgen precursors by techniques optimized to assess the low androgen levels in this population.

RESULTS

Higher serum testosterone levels correlated with greater fat mass (r=0.377; p=0.04), but not abdominal adiposity or other metabolic/physiologic variables. Additionally, dehydroepiandrosterone (DHEA) was negatively related to visceral fat content (r=-0.569; p=0.02). Other serum androgens did not correlate with total or regional adiposity, skeletal muscle mass, aerobic capacity, glucose tolerance, or resting energy and substrate metabolism.

CONCLUSION

In this group of non-obese, premenopausal women with no clinical or chemical evidence of hyperandrogenemia, serum testosterone levels were positively related with fat mass, but not with abdominal adiposity; whereas, DHEA was negatively related to visceral adiposity. Our data suggest that within the normal physiologic range, testosterone is a predictor of overall adiposity, but that this effect does not appear to be associated with concomitant alterations in resting energy or substrate metabolism that could predispose to weight gain.

Higher DHEA-S (dehydroepiandrosterone sulfate) levels are associated with depressive symptoms during the menopausal transition: results from the PENN Ovarian Aging Study

The influence of sex hormones on mood during the menopausal transition has been the subject of ongoing investigation. Because dehydroepiandrosterone sulfate (DHEA-S) has been associated with several indicators of healthy aging, we conducted a population-based study of midlife women to determine the relationship between DHEA-S levels and depressive symptoms and major depression during the transition through menopause. Unexpectedly, the original report revealed a positive correlation between DHEA-S levels and depressive symptoms at baseline. The cohort was studied over 11 years to determine whether the positive association between DHEA-S levels and depression persists through the menopausal transition. We conducted a longitudinal cohort study with 11 assessments during an 11-year interval in Philadelphia, Pennsylvania, using a randomly identified, population-based sample of 436 African American and Caucasian premenopausal women aged 35 to 47 years at enrollment. For outcome measures, we used the Center for Epidemiologic Studies Depression Scale and standardized diagnosis of major depression. In a multivariable model, DHEA-S levels were positively associated with depressive symptoms when adjusted for age, menopausal stage, race, smoking status, and body mass index. There was no association between DHEA-S levels and a diagnosis of major depression. DHEA-S levels were positively associated with depressive symptoms through the menopausal transition. No association with major depression was apparent during the menopausal transition, but results may have limited power due to low prevalence of major depression in this cohort. These findings suggest that taking DHEA supplements may increase depressive symptoms for some women, and women and their physicians should be cautious about instituting DHEA replacement therapy during the menopausal transition.

Dehydroepiandrosterone sulfate and postmenopausal women

PURPOSE OF REVIEW

Levels of dehydroepiandrosterone (DHEA) are known to decline with age. In an era of increasing use of supplements to better life, the benefits of DHEA in the aging female population are controversial. The goal of this article is to critically review published studies to determine if there is a role for DHEA supplementation in postmenopausal women.

RECENT FINDINGS

Daily administration of oral DHEA achieves serum concentrations similar to those of women in their 20s. Several observational studies have shown that lower DHEA levels are associated with increased cardiovascular risk in women; however, interventional trials show no improvement in atherosclerosis or cardiovascular risk factors, and a lowering of HDL cholesterol levels. DHEA supplementation modestly increases bone mineral density in conjunction with adjuvant therapies and improves cognition in those with mild-to-moderate cognitive impairment, but does not affect cognition in unimpaired women. Use of intravaginal DHEA, but not oral DHEA, alleviates vaginal atrophy and improves sexual function in postmenopausal women.

SUMMARY

On the basis of current evidence, there is no role for oral DHEA supplementation in healthy, postmenopausal women. Where benefits have been shown, long-term studies are needed to confirm these benefits and verify the safety profile of DHEA.

The relationship between testosterone deficiency and frailty in elderly men

The vulnerable health status usually preceding the onset of overt disability is often referred to as frailty. A stringent definition is elusive but it can be viewed as a physiological syndrome, characterized by decreased reserve and diminished resistance to stressors, resulting from a cumulative decline across multiple physiological systems and causing vulnerability to adverse outcomes. Elements of frailty are related to the neurological system, metabolism, joints, bones, and muscles. Sarcopenia seems to be the major determinant of frailty. Several components of the frailty syndrome are related to loss of physiological actions of testosterone (T). T and/or its aromatized metabolite, estradiol, are necessary for maintenance of bone mineral density. Furthermore, T stimulates erythrocyte formation. T has a profound effect on body composition. Androgens promote differentiation of mesenchymal pluripotent cells into the myogenic lineage and inhibit differentiation into the adipogenic lineage. Skeletal muscles of older men are as responsive to the anabolic effects of T as of younger men. Thus, although frailty is obviously a complex syndrome, some elements are androgen-associated and these can improve in men with subnormal T levels when treated with T. Evidence suggests that T treatment in frail elderly men with low T improves body composition, quality of life, and physical function, including increased axial bone mineral density and body composition. The data available to date strongly suggest a relationship between T-deficiency and frailty and warrant further basic and clinical investigations to extend these observations to the management of elderly men with frailty.