Anemia and testosterone deficiency risk: insights from NHANES data analysis and a Mendelian randomization analysis

BACKGROUND

Previous research has shown that testosterone deficiency (TD) increases the risk of anemia, but it is unclear whether anemia affects testosterone levels. This study investigated the influence of anemia on testosterone levels.

METHODS

Utilizing data from six NHANES cycles, including demographic, testosterone levels, and hemoglobin concentrations, we employed multivariable-adjusted logistic regression to investigate the relationship between anemia and testosterone levels. Moreover, a two-sample Mendelian randomization (MR) study employing genome-wide association study (GWAS) data examined the causal relationship. Kaplan-Meier survival estimation was used to compared the overall survival (OS) of anemic and nonanemic patients with low testosterone and normal testosterone levels.

RESULTS

The inclusion of 21,786 participants (2318 with anemia and19,468 without anemia) revealed that nonanemic patients exhibited higher testosterone levels than did anemic patients (β = 22.616, 95% CI: 3.873-41.359, p = 0.01807). MR analysis confirmed anemia as a cause of TD (OR = 1.045, 95% CI: 1.020-1.071, p < 0.001). Anemic males with low testosterone had reduced OS compared to those with normal levels (p < 0.001).

CONCLUSIONS

Anemia emerged as a potential risk factor for TD, highlighting a bidirectional relationship between these conditions. Additional prospective investigations are essential for the validation and reinforcement of our findings.

Testosterone deficiency worsens mitochondrial dysfunction in APP/PS1 mice

Background

Recent studies show testosterone (T) deficiency worsens cognitive impairment in Alzheimer's disease (AD) patients. Mitochondrial dysfunction, as an early event of AD, is becoming critical hallmark of AD pathogenesis. However, currently, whether T deficiency exacerbates mitochondrial dysfunction of men with AD remains unclear.

Objective

The purpose of this study is to explore the effects of T deficiency on mitochondrial dysfunction of male AD mouse models and its potential mechanisms.

Methods

Alzheimer's disease animal model with T deficiency was performed by castration to 3-month-old male APP/PS1 mice. Hippocampal mitochondrial function of mice was analyzed by spectrophotometry and flow cytometry. The gene expression levels related to mitochondrial biogenesis and mitochondrial dynamics were determined through quantitative real-time PCR (qPCR) and western blot analysis. SH-SY5Y cells treated with flutamide, T and/or H2O2 were processed for analyzing the potential mechanisms of T on mitochondrial dysfunction.

Results

Testosterone deficiency significantly aggravated the cognitive deficits and hippocampal pathologic damage of male APP/PS1 mice. These effects were consistent with exacerbated mitochondrial dysfunction by gonadectomy to male APP/PS1 mice, reflected by further increase in oxidative damage and decrease in mitochondrial membrane potential, complex IV activity and ATP levels. More importantly, T deficiency induced the exacerbation of compromised mitochondrial homeostasis in male APP/PS1 mice by exerting detrimental effects on mitochondrial biogenesis and mitochondrial dynamics at mRNA and protein level, leading to more defective mitochondria accumulated in the hippocampus. In vitro studies using SH-SY5Y cells validated T's protective effects on the H2O2-induced mitochondrial dysfunction, mitochondrial biogenesis impairment, and mitochondrial dynamics imbalance. Administering androgen receptor (AR) antagonist flutamide weakened the beneficial effects of T pretreatment on H2O2-treated SH-SY5Y cells, demonstrating a critical role of classical AR pathway in maintaining mitochondrial function.

Conclusion

Testosterone deficiency exacerbates hippocampal mitochondrial dysfunction of male APP/PS1 mice by accumulating more defective mitochondria. Thus, appropriate T levels in the early stage of AD might be beneficial in delaying AD pathology by improving mitochondrial biogenesis and mitochondrial dynamics.

Analysis of diurnal variation in serum testosterone levels in men with symptoms of testosterone deficiency

BACKGROUND

Testosterone (T) plays a crucial role in various physiological functions in men, and understanding the variations in T levels during the day is essential for diagnosing and treating testosterone deficiency (TD).

AIM

We sought to evaluate the reduction in serum total T (TT) levels throughout the day in men with symptoms of testosterone deficiency and to determine the variables having an impact on the extent of this decline.

METHODS

The study population consisted of a group of men who within 3 months of each other had all undergone both early morning and afternoon TT level measurements. We did not include patients with a history of a prior orchiectomy, testosterone levels below 100 ng/dL or above 1000 ng/dL, a history of androgen deprivation therapy, or patients on T therapy. Statistical analyses were conducted using descriptive statistics, t-tests, chi-square tests, and correlation calculations. Liquid chromatography-tandem mass spectrometry was used to measure TT, and a change in TT levels greater than 100 ng/dL was considered significant. Using multivariable and univariable analysis, we attempted to define predictors of a decrease in afternoon TT levels.

OUTCOMES

The majority of men showed no significant difference in T levels between morning and afternoon.

RESULTS

In total, 506 men with a median age of 65 years were analyzed. The most common comorbidities were hypertension and hyperlipidemia. Levels of TT were measured in the morning and afternoon, and no significant differences in mean T levels based on the time of the test were found. Age was not significantly associated with T levels.

CLINICAL IMPLICATIONS

There was a weak negative correlation between age and the difference between morning and afternoon T levels, with younger men showing more significant variations in T levels. The most considerable differences in T levels were observed in men younger than 30 years. There were no predictors of the magnitude of the T decrease in the afternoon.

STRENGTHS AND LIMITATIONS

Strengths of the study include the number of subjects and the use of liquid chromatography-tandem mass spectrometry for T measurement. Limitations include failure to measure morning and afternoon T levels on the same day, the retrospective nature of the study, and a smaller sample size of patients younger than 30 years.

CONCLUSION

In this study we found no strong link between age and daily T fluctuation, but we observed a decrease in the magnitude of variation with aging. The group experiencing the most significant decline in daily T had higher morning and consistently normal afternoon T levels.

Assessing men with opioid use disorder for testosterone deficiency after the development of symptoms

OBJECTIVE

Individuals with opioid use disorder (OUD) have reduced life expectancy and inferior outcomes when treated for depression, diabetes, and fractures. Their elevated risk of testosterone deficiency may contribute to all of these relationships, however few individuals prescribed opioids are evaluated with testosterone assays. The purpose of this study is to determine whether patients with opioid use disorder are evaluated for testosterone deficiency after development of a symptom that may merit investigation, such as erectile dysfunction (ED).

METHOD

We conducted a retrospective longitudinal cohort study that utilized data from a national database called TriNetX. Patients were eligible for inclusion if they were 20 to 90 years of age, male, and diagnosed with erectile dysfunction. We utilized descriptive statistics and logistic regression to address study aims.

RESULTS

Testosterone testing was uncommon for all patients with ED. Among 20,658 patients, it was assessed in 11.2% with OUD and 15.1% without OUD. Among those screened, 40% individuals with OUD and ED had testosterone deficiency. Odds of screening those with OUD were lower than matched controls (RR 0.74).

CONCLUSIONS

Individuals with OUD are at increased risk of testosterone deficiency than the general population, but nearly 90% are not evaluated for this condition even after development symptoms. That 40% of individuals assessed were classified as testosterone deficient suggests endocrine disorders may be contributing to increased fracture risk, chronic pain, and severe depression commonly encountered in patients with OUD. Addressing this care gap may reduce morbidity and mortality associated with opioid use disorder.

The testis, eunuchs, and testosterone: a historical review over the ages and around the world

INTRODUCTION

Testosterone therapy for men with testosterone deficiency is widely used, yet remains controversial. The rich and fascinating history of the testicles, including human castration, provides a valuable perspective on this important topic.

OBJECTIVES

This study reviewed the history of testosterone from antiquity to the modern day.

METHODS

Primary sources consisted of books and relevant articles, augmented by a MEDLINE search using the key words "testis," "testicles," "castration," "eunuchs," "testosterone," and "testicular function."

RESULTS

An early scientific observation was that castration reduced sexual development and activity, originating with domestication of animals approximately 10 000 years ago. Human castration appears in ancient Egyptian mythology more than 4000 years ago, in Greek mythology from 8th century BCE, and in the Bible. The history of eunuchs in China spanned 2000 years, beginning with the Hsia dynasty (2205-1766 BCE). The concept that the testicles produced some factor responsible for male sexual development and behavior was thus known throughout the world since the beginning of recorded history. Testosterone was isolated and synthesized in 1935 and was soon available as a treatment. Multiple benefits of testosterone therapy were apparent by 1940. Recent large, controlled testosterone studies have conclusively demonstrated sexual and general health benefits, with a strong safety profile.

CONCLUSION

Testosterone has been a known substance for <1% of the historical timeline, yet knowledge that the testes were responsible for male sexual development and behavior has been known since the beginning of recorded history. Today, modern evidence has demonstrated the importance of normal levels of testosterone for general health as well as sexual function and desire. Yet, testosterone therapy remains controversial. We believe this historical review provides a helpful perspective on this age-old issue.

The association between testosterone deficiency and nocturia: Insights from The National Health and Nutrition Examination Survey data set

AIMS

To examine the association between testosterone deficiency (TD) and nocturia in males, with specific attention to age and cardiovascular disease (CVD) comorbidity.

METHODS

This cross-sectional study utilized the National Health and Nutrition Examination Survey (NHANES) data from 2011 to 2016, assessing 6137 adult male participants. TD was defined by a serum total testosterone (TT) concentration less than 300 ng/dL. Nocturia was determined based on participants' responses to a standard NHANES question regarding the frequency of urination during the night.

RESULTS

The study observed a significant association between TD and nocturia (adjusted odds ratio [95% confidence interval] = 1.211 [1.060-1.384], p = 0.005). Moreover, a U-shape pattern was noted in the relationship between serum TT concentration and the relative odds of nocturia. Subgroup analysis revealed a robust correlation between TD and nocturia in those over 60 years old, and those with hypertension, dyslipidemia, and CVDs.

CONCLUSION

Our findings suggest a positive correlation between TD and nocturia, particularly among elderly individuals with CVD. This association underscores the potential therapeutic significance of addressing TD in the management of nocturia. Furthermore, longitudinal studies are needed to establish a causal relationship between TD and nocturia.

Dose-response association between 24-hour total movement activity and testosterone deficiency in adult males

Background and objectives

Previous studies on the relationship between physical activity and testosterone are limited and controversial. Hence we investigated whether high level of physical activity is associated with a low risk of testosterone deficiency (TD).

Methods

This cross-sectional analysis was conducted in a representative sample of US adult males who participated in the 2011-2014 cycle of the National Health and Nutrition Examination Survey (NHANES). We used the monitor independent movement summary (MIMS) to assess activity intensity, a novel physical activity metrics developed using raw data collected by accelerometers. Multivariable regression and smooth curve fitting was used to describe the relationships between physical activity and TD, and segmented regression model were used to analyze the threshold effect between them. Sensitivity analysis was conducted using interaction and stratified analysis.

Results

A U-shaped relationship between daily MIMS units and risk of TD was observed. The optimal value of daily MIMS units for the lowest risk of TD was 14.77 (×103), the risk of TD decreased by 5% in patients per unit increase of daily MIMS units when daily MIMS units <14.77 (×103) (adjusted OR = 0.95, 95%CI: 0.91, 0.99), but increased by 12% per unit increase of daily MIMS units when daily MIMS units ≥14.77 (×103) (adjusted OR = 1.12, 95%CI: 1.01, 1.23). In sensitivity analyses, the threshold effect was also similar according to baseline characteristics (P-interaction >0.05).

Conclusion

In a nationally representative sample of US adult males, light to moderate intensity physical activity is associated with a lower odds of TD, while high-intensity physical activity is associated with a higher risk of TD.

Research trends in testosterone deficiency and management: A bibliometric analysis approach to quality improvement in urology resident education

INTRODUCTION

Previous work has demonstrated a deficiency in urology resident education when it comes to andrology and male infertility. We analyzed the top 100 most frequently cited and influential articles published on testosterone deficiency and its associated therapy, allowing trainees and clinicians to review and understand the characteristics of impactful literature for self-directed learning purposes.

METHODS

The ISI Web of Knowledge database was used to find articles on testosterone deficiency, hypogonadism, and replacement therapies. Relevant, peer-reviewed, English articles were included. Article details, including title, citation count, publication year, and more, were gathered. Articles were classified based on content (e.g. clinical outcomes, anatomy, and trends) using defined criteria.

RESULTS

The top 300 most cited were reviewed with 100 included. The most cited article had 774 citations, averaging 234 in the top 100. Publication years had peaks in 2003-2004 and 2006-2007. The US led in publications (56), followed by England (16), Germany (14), and Italy (13). Common affiliations included US Department of Veteran Affairs, Veterans Health Administration, RIC Research Education Clinical Center, and University of California System. Articles were categorized as LOE 2 (47), LOE 1 (22), and LOE 5 (21). Articles focused on clinical outcomes (71.7%), anatomy/biomechanics/physiology (14.1%), clinical guidelines (8.1%), and screening (4%). The "Journal of Clinical Endocrinology & Metabolism" published 26 of the top 100 cited articles.

CONCLUSIONS

This analysis highlights influential articles regarding testosterone deficiency and management. The discussed articles have significant clinical and therapeutic implications for the practicing urologist which may bolster deficits in current resident education.

Testosterone replacement therapy is not associated with increased prostate cancer incidence, prostate cancer-specific, or cardiovascular disease-specific mortality in Finnish men

BACKGROUND

Concerns have been expressed over the safety of testosterone replacement therapy (TRT) in men with late-onset hypogonadism (LOH). Previous studies have shown controversial results regarding the association of TRT with the risk of cardiovascular events or prostate cancer (PCa) incidence, aggressiveness, and mortality. This study explores the overall risk of PCa and risk by tumor grade and stage, as well as mortality from PCa and cardiovascular disease (CVD), among men treated with TRT compared to men without LOH and TRT use.

MATERIALS AND METHODS

The study included 78,615 men of age 55-67 years at baseline from the Finnish Randomized Study of Screening for Prostate Cancer (FinRSPC). Follow-up started at randomization and ended at death, emigration, or a common closing date January 1st, 2017. Cox proportional hazards regression model with time-dependent variables and adjustment for age, trial arm, use of other medications, and Charlson comorbidity index was used. Comprehensive information on TRT purchases during 1995-2015 was obtained from the Finnish National Prescription Database. PCa cases were identified from the Finnish Cancer Registry and causes of death obtained from Statistics Finland.

RESULTS

Over the course of 18 years of follow-up, 2919 men were on TRT, and 285 PCa cases were diagnosed among them. TRT users did not exhibit a higher incidence or mortality rate of PCa compared to non-users. On the contrary, men using TRT had lower PCa mortality than non-users (HR = 0.52; 95% CI 0.3-0.91). Additionally, TRT users had slightly lower CVD and all-cause mortality compared to non-users (HR = 0.87; 95% CI 0.75-1.01 and HR = 0.93; 95% CI 0.87-1.0, respectively). No time- or dose-dependency of TRT use was evident in any of the analyses.

CONCLUSION

Men using TRT were not associated to increased risk for PCa and did not experience increased PCa- or CVD-specific mortality compared to non-users. Further studies considering blood testosterone levels are warranted.

Metabolic dysfunction-associated fatty liver disease is an early predictor for testosterone deficiency in aging men without metabolic syndrome

Background and aims

Metabolic dysfunction-associated fatty liver disease (MAFLD) has emerged as a valuable marker for identifying individuals at increased risk of metabolic dysfunction, liver-related complications, and cardiovascular disease. However, the association between MAFLD and testosterone deficiency (TD) in aging men remains poorly understood. This study aimed to investigate the association between MAFLD and the risk of TD in aging Taiwanese men, with a specific focus on those without metabolic syndrome (MetS).

Methods

A free health screening program was conducted for Taiwanese men aged over 40 years in Kaohsiung, Taiwan. Participants underwent physical examinations, completed questionnaires regarding demographics, medical history, and clinical symptoms of TD, and provided 20-mL whole blood samples for biochemical, adipocytokine, and hormonal evaluations. Fatty liver index was used to evaluate the risk of fatty liver. Diagnostic criteria for MAFLD included fatty liver along with overweight/obesity, type 2 diabetes, or evidence of metabolic dysregulation.

Results

A total of 631 men (mean age: 54.4 ± 8.4 years) were enrolled. The prevalence rates of TD and MetS were significantly higher in men with MAFLD compared to those without (both p < 0.001). Additionally, the presence of MAFLD showed a significant correlation with adipocytokines associated with insulin resistance, such as adiponectin, leptin, and retinol-binding protein-4 (RBP-4) levels (all p < 0.001). Among men without MetS, those with MAFLD had a 3.89- and 4.74-fold higher risk of total testosterone < 300 ng/dL and TD, respectively, after adjusting for potential covariates.

Conclusion

MAFLD is associated with an elevated risk of TD in aging Taiwanese men, particularly in the absence of MetS. This finding suggests that MAFLD could serve as an early predictor of TD, facilitating the identification of high-risk individuals and enabling timely interventions. Further research is needed to validate these findings and explore the underlying mechanisms linking MAFLD, TD, and MetS in diverse populations.

Hypopituitarism After Mild Traumatic Brain Injury: A Case Report

Hypopituitarism is characterized by an underactive pituitary gland and may result in growth hormone deficiency, hypothyroidism, testosterone deficiency, and/or adrenal insufficiency. Traumatic brain injury (TBI) exposure is a known risk factor for hypopituitarism. However, patients with hypopituitarism secondary to TBI exposure may go undiagnosed because the signs and symptoms of hypopituitarism can be subtle. This case report describes a 40-year-old male US military veteran who endorsed fatigue, sexual dysfunction, and weight gain several years after experiencing multiple mild TBIs during his military service. He ultimately underwent a full neuroendocrine workup that revealed low testosterone in addition to previously diagnosed hypothyroidism with a resolution of symptoms after starting testosterone therapy.

Association between the prevalence rates of circadian syndrome and testosterone deficiency in US males: data from NHANES (2011-2016)

Objective

The objective of this study is to explore the association between the prevalence rates of circadian syndrome (CircS) and testosterone deficiency (TD).

Materials and methods

Cross-sectional analysis was conducted on the basis of the National Health and Nutrition Examination Survey 2011-2016. The target population was males aged ≥20 years old. A total of three multivariable logistic regression models were built to elucidate the association between the prevalence rates of CircS and TD. Interactive and stratified analyses were employed to explore whether some variables can modify the above association. Sensitivity analyses were also conducted to verify the stability of the results with extreme values removed.

Results

A total of 3,436 eligible participants were involved. Multivariable logistic regression in the fully adjusted model suggested the CircS group had a significantly higher prevalence rate of TD compared with the non-CircS group (OR = 2.284, 95%CI 1.569 to 3.323). No significant correlation between the number of CircS components and TD was observed in any of the three models. The interactive and stratified analyses showed the association was more obvious in the population with moderate or vigorous activities. The results were robust after extreme data were excluded.

Conclusion

There is a positive association between the prevalence rates of CircS and TD in US men. The association becomes more obvious owing to moderate or vigorous activities.

Efficacy and safety outcomes of a compounded testosterone pellet versus a branded testosterone pellet in men with testosterone deficiency: a single-center, open-label, randomized trial

Background

Testosterone deficiency (TD) is a prevalent condition, especially in men ≥45 years old, and testosterone therapy (TTh) can improve the quality of life in these patients.

Aim

To evaluate the safety profile of compounded subcutaneous testosterone pellets and to compare the efficacy between compounded and market brand testosterone pellets for TTh: E100 (Empower Pharmacy) and Testopel (Food and Drug Administration approved), respectively.

Methods

This was a prospective, phase 3, randomized, noninferiority clinical trial. We enrolled 75 men diagnosed with TD and randomized them 1:1 to a market brand group and a compounded pellet group. The patients were implanted with their respective testosterone pellets: Testopel (10 pellets of 75 mg) and E100 (8 pellets of 100 mg).

Outcomes

We evaluated adverse events after implantation and followed men at 2, 4, and 6 months for morning laboratory levels (prior to 10 am): serum testosterone, estradiol, hematocrit, and prostate-specific antigen.

Results

After randomization, 33 participants were enrolled in the Testopel arm and 42 in the E100 arm. Serum testosterone levels were similar between the groups at 2, 4, and 6 months, with most men (82%) dropping to <300 ng/dL by the end of the trial. Adverse events were also similar, such as elevations in prostate-specific antigen, estradiol, and hematocrit. Most dropouts were related to persistent TD symptoms and serum testosterone <300 ng/dL, with similar rates between the groups in the study.

Clinical Implications

Men treated with Testopel and E100 pellets had comparable serum testosterone levels and similar adverse event rates, providing an effective choice of long-term TTh among men with TD.

Strengths and Limitations

Strengths include the prospective, randomized, single-blinded study design and adequate follow-up. Limitations include the lack of external validity and the single-institution cohort.

Conclusion

E100 compounded testosterone pellets are a noninferior option of TTh as compared with Testopel for men presenting with TD.

Association of lipid accumulation products with testosterone deficiency in adult American men: A cross-sectional study

PURPOSE

Testosterone deficiency and changes in testosterone levels are important in men's health and may be associated with fat accumulation. In order to investigate the connection between testosterone and fat accumulation in adult males, we employed lipid accumulation product and compared it to triglyceride-glucose and Homeostasis Model Assessment of Insulin Resistance.

MATERIALS AND METHODS

An intersecting surface research of participators from 2013 to 2014 was carried out using National Health and Nutrition Examination Survey, in addition, participants from 2015 to 2016 were selected. Using multivariate adjusted logistic regression, the connection between lipid accumulation product, testosterone levels, and testosterone insufficiency was investigated, smoothed curve fitting was calculated to integrate non-linear relationships, and subgroup analysis was performed to identify sensitive populations.

RESULTS

After removing all potential confounders, testosterone levels in 1651 subjects tended to decrease with increasing continuous variable lipid accumulation product (β = -0.49, 95% confidence interval [-0.77, -0.22], p = 0.0005) and adding the chance of testosterone deficiency (odds ratio = 1.01, 95% confidence interval [1.01, 1.01], p < 0.0001). In the lipid accumulation product quartile, testosterone levels decreased the most (β = -77.65, 95% confidence interval [-110.99, -44.31], p < 0.0001) and the risk of testosterone deficiency was highest (odds ratio = 2.76, 95% confidence interval [1.47, 5.20], p = 0.0016). The area under the curve values were 0.718 (95% confidence interval: 0.688-0.750) for lipid accumulation product, 0.723 (95% confidence interval: 0.689-0.756) for Homeostasis Model Assessment of Insulin Resistance, and 0.673 (95% confidence interval: 0.640-0.708) for triglyceride-glucose, with no statistical difference between lipid accumulation product and Homeostasis Model Assessment of Insulin Resistance comparisons. The cut-off value of lipid accumulation product ≥52.408 predicted testosterone deficiency with good sensitivity and specificity.

CONCLUSION

Higher lipid accumulation product was linked to a higher incidence of testosterone loss and inadequate, especially in hypertensive and non-smoker. Lipid accumulation product is a better predictor of testosterone deficiency than triglyceride-glucose and does not differ significantly from the Homeostasis Model Assessment of Insulin Resistance phase.

Long vs Short Acting Testosterone Treatments: A Look at the Risks

Prescriptions for testosterone therapy (TT) to treat testosterone deficiency have increased in recent years. The purpose of this review was to evaluate the risks of several treatment modalities to better counsel patients. Both short-acting and long-acting TT has been shown to restore normal serum testosterone levels and improve symptoms of testosterone deficiency. Short-acting pharmacology mimics normal physiology more closely than long-acting TT but requires multiple doses per day. Long-acting TT has a higher rate of patient adherence but is more likely to create supraphysiologic serum testosterone and pathologic sequelae.

Pituitary-testis axis dysfunction following adjuvant androgen deprivation therapy

Men with high-risk, non-metastatic prostate cancer receive adjuvant androgen deprivation therapy (ADT) for at least 2 years according to Danish guidelines. It remains unclarified if patients regain the function of the pituitary-testis axis after cessation of ADT. Thus, we aimed to investigate the function of the pituitary-testis axis following adjuvant ADT. In this study, we included men who underwent external beam radiation therapy and ADT for high-risk prostate cancer. All patients underwent assessment of testosterone deficiency (TD) symptoms, full biochemical assessment of the pituitary-testis axis, and dynamic stimulatory tests of gonadotropin (gonadotropin-releasing hormone (GnRH) test) and testosterone production (human chorionic gonadotrophin (hCG) test). Patients were diagnosed with TD based on a combination of TD symptoms and testosterone below age-specific reference ranges. TD was characterized as primary, secondary, or mixed based on serum gonadotropins and stimulatory tests. We found that among the 51 patients included in the study, the median time on ADT was 3.2 years and median time since ADT cessation was 3.8 years. Twenty-eight patients were diagnosed with TD; 10 had primary TD (testicular dysfunction), 11 secondary TD (pituitary dysfunction), and 7 mixed TD (combined pituitary and testicular dysfunction). An inadequate testosterone response to hCG stimulation was shown in 42 patients, whereas only 11 patients had a subnormal gonadotropin response to GnRH. We conclude that persistent TD is a common long-term consequence of adjuvant ADT in prostate cancer survivors, equally distributed between pituitary and testicular dysfunction. The study emphasizes the necessity for systematic follow-up of full pituitary-testis axis function in patients receiving adjuvant ADT.

Exosomes derived from BMSCs ameliorate cyclophosphamide-induced testosterone deficiency by enhancing the autophagy of Leydig cells via the AMPK-mTOR signaling pathway

Cyclophosphamide-induced testosterone deficiency (CPTD) during the treatment of cancers and autoimmune disorders severely influences the quality of life of patients. Currently, several guidelines recommend patients suffering from CPTD receive testosterone replacement therapy (TRT). However, TRT has many disadvantages underscoring the requirement for alternative, nontoxic treatment strategies. We previously reported bone marrow mesenchymal stem cells-derived exosomes (BMSCs-exos) could alleviate cyclophosphamide (CP)-induced spermatogenesis dysfunction, highlighting their role in the treatment of male reproductive disorders. Therefore, we further investigated whether BMSCs-exos affect autophagy and testosterone synthesis in Leydig cells (LCs). Here, we examined the effects and probed the molecular mechanisms of BMSCs-exos on CPTD in vivo and in vitro by detecting the expression levels of genes and proteins related to autophagy and testosterone synthesis. Furthermore, the testosterone concentration in serum and cell-conditioned medium, and the photophosphorylation protein levels of adenosine monophosphate-activated protein kinase (AMPK) and mammalian target of rapamycin (mTOR) were measured. Our results suggest that BMSCs-exos could be absorbed by LCs through the blood-testis barrier in mice, promoting autophagy in LCs and improving the CP-induced low serum testosterone levels. BMSCs-exos inhibited cell death in CP-exposed LCs, regulated the AMPK-mTOR signaling pathway to promote autophagy in LCs, and then improved the low testosterone synthesis ability of CP-induced LCs. Moreover, the autophagy inhibitor, 3-methyladenine (3-MA), significantly reversed the therapeutic effects of BMSCs-exos. These findings suggest that BMSCs-exos promote LC autophagy by regulating the AMPK-mTOR signaling pathway, thereby ameliorating CPTD. This study provides novel evidence for the clinical improvement of CPTD using BMSCs-exos.

Safety Aspects and Rational Use of Testosterone Undecanoate in the Treatment of Testosterone Deficiency: Clinical Insights

Testosterone deficiency is diagnosed by a serum total testosterone level below 300 ng/dL in combination with symptoms such as decreased energy and libido. These symptoms can be ameliorated by restoring serum testosterone to the physiologic range with testosterone therapy (TT). There are numerous forms of testosterone therapy, such as injectable, transdermal, nasal, and subcutaneous applications. There are also multiple formulations of injection, such as testosterone cypionate, testosterone enanthate, and testosterone undecanoate. Testosterone undecanoate (TU) is a long-acting ester formulation of testosterone that can be provided in an injectable or oral form. Oral testosterone undecanoate is marketed as Andriol, Jatenzo, Tlando, and Kyzatrex. Oral TU provides a convenient option for many patients, which may increase compliance with TT. Injectable testosterone undecanoate is marketed as Aveed and Nebido. Injectable TT remains the most cost-effective therapeutic option and is appropriate for most patients as an initial therapy. This review describes the pharmacokinetics of these testosterone undecanoate products and provides a guide for prescribers using these medications. While many forms of testosterone are appropriate for TT, a patient-centered discussion focused on goals of care should best guide physician prescription of these medications.

Lower urinary tract symptoms are associated with clinically relevant depression, anxiety, and stress symptoms

OBJECTIVES

To investigate the correlation between lower urinary tract symptoms (LUTS), erectile dysfunction (ED), and testosterone deficiency (TD) with depressive, stress, and anxiety symptoms.

MATERIAL AND METHODS

From October 2019 to March 2020, 113 males were included. Inclusion criteria: age 40-75, no clinical suspicion of prostate cancer, no serious cardiovascular comorbidities. All patients completed a set of questionnaires: International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF-5), and Depression Anxiety Stress Scales (DASS-21).

RESULTS

Median age was 62 years (range 40-74), mean IPSS score was 10.94 (SD 7.75), mean IIEF-5 score 13.12 (SD 7.08), and mean DASS-21 score 11.35 (SD 8.24). According to DASS-21 subscales, 28 (24.8%) patients had depressive symptoms, 25 (22.1%) anxiety symptoms, and 25 (22.1%) stress symptoms. Depression was associated with LUTS (14.5 vs. 8 score, p = .002). Similarly, stress symptoms were associated with LUTS (IPSS 15 vs. 7 score, p = .0001) and with ED (IIEF-5 5 vs. 15 score, p = .01). Positive Spearman's rho correlations between LUTS and all three, depression, anxiety, and stress symptoms were found (p values <.001).

CONCLUSIONS

LUTS is associated with depression, anxiety, and stress symptoms. Screening for these symptoms could help with individual counseling and management.

[Evolution of views on the etiology and pathogenesis of lower urinary tract symptoms for men]

The review article in the format of a "Lecture for Doctors" examines the evolution of terminology reflecting various disorders of urination and understanding their etiology and pathogenesis from a methodological and historical point of view. Symptoms of the lower urinary tract (LUTS) is a new term that replaced the term "Dysuria" that previously existed in the literature and suggests the allocation of various groups of symptoms depending on the violation of key functions of the bladder, which greatly facilitates obtaining reliable information about the state of urination in a particular patient. However, for a long time, LUTS were identified exclusively with urological pathology. Thanks to the fundamental research of recent decades, it has become obvious that LUTS is an interdisciplinary problem involving various specialists in the process of diagnosis and correction. One of the current trends in the study of the urination pathophysiology is the influence of systemic hormonal and metabolic disorders in men, which are considered as independent factors of the LUTS. The role of testosterone deficiency in the pathogenesis of LUTS is highlighted and the safety and effectiveness of testosterone replacement therapy (TRT) in hypogonadal men with LUTS is shown.

An Individualized Approach to Managing Testosterone Therapy in the Primary Care Setting

The incidence of testosterone deficiency and the use of testosterone therapy have increased in recent years, and currently the majority of testosterone prescriptions in the United States and Canada are written by primary care physicians. Meanwhile, the range of available testosterone therapy formulations has widened to include buccal tablets, intramuscular injections, transdermal gels, intranasal gel, subcutaneous injections, oral capsules, and subdermal pellets, each with unique pharmacokinetic and clinical characteristics. Despite the growing use of testosterone therapy and its overall efficacy and safety as demonstrated in clinical trials, concerns exist about the potential impact of testosterone therapy on spermatogenesis and fertility, development of prostate cancer, and risk of polycythemia and cardiovascular events. In addition, ongoing research aims to better characterize the effects of testosterone therapy in specific populations, such as patients aged 65 years and older, patients with obesity and type 2 diabetes, and transgender patients. The range of treatment options and the diversity of patients' goals, preferences, comorbidities, and risk factors necessitate an individualized approach to testosterone therapy that considers each patient's clinical needs alongside the distinct features of different testosterone formulations.

Testosterone recovery therapy targeting dysfunctional Leydig cells

INTRODUCTION

Erectile dysfunction (ED) is associated with diabetes mellitus with an estimated prevalence of 52.5% in the diabetic population. The first-line therapy for ED are phosphodiesterase type 5 inhibitors (PDE5i), but data suggests that diabetic men may be less responsive than non-diabetic men. Thus, other treatments, including intracavernosal injections, intraurethral prostaglandin, vacuum erection devices, and penile prosthetic surgery, should be considered in management of diabetic men with ED refractory to PDE5i. Furthermore, combination therapy of PDE5i and other oral treatments such as arginine or L-carnitine may have synergistic effects resulting in better outcomes. In addition, there are novel therapies such as low-intensity shockwave therapy and stem cell therapy which may also be effective targeted treatment modalities. Furthermore, studies suggest that ED can be improved by targeting concurrent comorbidities or metabolic diseases such as depression, hypertension, hypogonadism, and dyslipidaemia. We present an evidence-based narrative review focussing on the management of ED in diabetic men who have not responded to PDE5i.

CONCLUSIONS

Both clinicians and patients should be aware of the different management options in Diabetic patients who have responded to PDE5i.

Examining Male Predominance of Severe COVID-19 Outcomes: A Systematic Review

Although not universal, many epidemiological data sources signal that a higher proportion of males than females with confirmed Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infections have adverse outcomes, such as intensive care unit (ICU) admission and death. Though likely multifactorial, the various hypotheses that have been proposed as underlying factors behind this trend are related to greater smoking prevalence among males, testosterone (T) deficiency causing an inflammatory storm, androgen-driven pathogenesis of SARS-CoV-2, a protective effect of estrogen in females, and inborn errors of cytokine immunity. This review aims at examining the evidence and at assessing the likelihood that the factors being investigated are contributory to the reported trend of male predominance of severe COVID-19 cases. Sources were obtained using the PubMed database and were selected based on their relevance to one of the primary hypotheses attempting to explain the strong male sex bias of severe SARS-CoV-2 infections. Emphasis was placed on meta-analyses and population-based studies. Sources are current through February 22, 2022. A severe COVID-19 case or outcome is defined in this review as a progression of the SARS-CoV-2 virus that results in either admission to an ICU for management of symptoms and clinical stabilization or which leads to death. Although the trend of male predominance of severe COVID-19 cases is likely multifactorial, the hypothesis of T deficiency causing an inflammatory storm has support from many studies with limited conflicting evidence. An inborn error in cytokine immunity is also well supported, but it needs more studies to add support to the hypothesis. The immunologic protective effect of estrogen is supported by multiple studies, but it also has conflicting evidence. It appears less likely that the trend is caused solely by an increased prevalence of smoking among males or an androgen-driven pathogenesis, based on the extent of conflicting evidence.

Accurate measurement of total and free testosterone levels for the diagnosis of androgen disorders

The circulating concentrations of total and free testosterone vary substantially in people over time due to biologic factors as well as due to measurement variation. Accurate measurement of total and free testosterone is essential for making the diagnosis of androgen disorders. Total testosterone should ideally be measured in a fasting state in the morning using a reliable assay, such as liquid chromatography tandem mass spectrometry, in a laboratory that is certified by an accuracy-based benchmark. Free testosterone levels should be measured in men in whom alterations in binding protein concentrations are suspected or in whom total testosterone levels are only slightly above or slightly below the lower limit of the normal male range for testosterone.

Increased risk of testosterone deficiency is associated with the systemic immune-inflammation index: a population-based cohort study

PURPOSE

This study aimed to explore the relationship between serum testosterone levels and systemic immune-inflammation index (SII).

METHODS

Complete SII and serum testosterone data of men over 20 years of age were retrieved from the 2011-2016 National Health and Nutrition Examination Survey to conduct a prevalence survey. To calculate SII, the platelet count was multiplied by the neutrophil-to-lymphocyte count ratio. Isotope dilution liquid chromatography and tandem mass spectrometry were employed to measure serum testosterone concentration. Testosterone deficiency (TD) was defined as a serum testosterone level ≤ 300ng/dl. Weighted proportions and multivariable regression analyses were used to analyze the association between SII and TD.

RESULTS

Overall, the data of 7389 participants were analyzed, The SII ranged from 1.53 - 6297.60. Of the participants, 28.42% had a low serum testosterone level (≤ 300 ng/dl). In the fully adjusted multivariable logistic model, the second quartile (OR: 1.27, p = 0.0737), the third quartile (OR: 1.43, p = 0.0090), and the fourth quartile (OR:1.48, p = 0.0042) of SII significantly increased the TD incidence rate, with the lowest quartile of the SII as a reference. For subgroup analysis, statistically significant associations were observed in participants aged 20-40, obese, non-hypertensive, and non-diabetic. The interaction test revealed no significant effect on this connection.

CONCLUSIONS

There was a positive relationship between a high SII and an increased prevalence of TD in a nationwide sample of adult men in the United States. Further prospective studies on a larger scale are warranted to confirm the causality between SII and TD.

Correlation Between Gut Microbiota and Testosterone in Male Patients With Type 2 Diabetes Mellitus

OBJECTIVE

This study aimed at investigating the association between testosterone levels and gut microbiota in male patients with type 2 diabetes mellitus (T2DM) and providing a new strategy to elucidate the pathological mechanism of testosterone deficiency in T2DM patients.

METHODS

In an observational study including 46 T2DM male patients, the peripheral venous blood and fecal samples of all subjects were collected. The V3-V4 regions of bacterial 16S rDNA were amplified and sequenced. Alpha and beta diversities were calculated by QIIME software. The possible association between gut microbial community and clinical indicators was assessed using the Spearman correlation coefficient. The association between the relative abundance of bacteria and testosterone levels was discovered using linear regression analysis in R language.

RESULTS

There was no substantial difference in alpha and beta diversity. Blautia and Lachnospirales were significantly much higher in the testosterone deficiency group. Linear regression analysis showed that the abundance of Firmicutes at the phylum level and Lachnospirales at the order level were negatively correlated with testosterone level. After correcting for C-reactive protein (CRP) and homeostatic model assessment of insulin resistance (HOMA-IR), the relative abundance of Lachnospirales still had a significant negative correlation with testosterone level. Meanwhile, at the genus level, Lachnoclostridium, Blautia, and Bergeyella had a statistically significant negative association with testosterone level, respectively. Blautia was positively associated with FPG and total cholesterol level. Streptococcus was found positively associated with insulin, connecting peptide, and index of homeostatic model assessment of insulin resistance.

CONCLUSION

T2DM patients with testosterone deficiency have different gut microbiota compositions compared with T2DM patients alone. Low serum testosterone patients tend to have an increased abundance of opportunistic pathogens, which may be related to the occurrence and development of testosterone deficiency.

Clomiphene Citrate for Men with Hypogonadism - A Systematic Review & Meta-analysis

BACKGROUND

Male hypogonadism is a clinical and biochemical androgen insufficiency syndrome, becoming more prevalent with age. Exogenous testosterone is first choice therapy, with several side-effects, including negative feedback of the hypothalamic-pituitary-gonadal axis, resulting in suppression of intratesticular testosterone production and spermatogenesis. To preserve these testicular functions while treating male hypogonadism clomiphene citrate (CC) is used as off-label therapy. This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of CC therapy for men with hypogonadism.

METHODS

The EMBASE, PubMed, Cochrane databases were searched in May 2021, for effectiveness studies of men with hypogonadism treated with CC. Both intervention and observational studies were included. The Effective Public Health Practice Project Quality Assessment Tool, a validated instrument was used to assess methodological study quality. The primary outcome measure was the evaluation of serum hormone concentration. Secondary outcomes were symptoms of hypogonadism, metabolic- and lipid profile, side-effects, safety aspects.

RESULTS

We included 19 studies, comprising four randomized controlled trials and 15 observational studies, resulting in 1642 patients. Seventeen studies were included in the meta-analysis, with a total of 1279 patients. Therapy and follow-up duration varied between one and a half and 52 months. Total testosterone (TT) increased with 2.60 (95% CI 1.82 - 3.38) during CC treatment. An increase was also seen in free testosterone, luteinizing hormone, follicle stimulating hormone, sex hormone-binding globulin and estradiol. Different symptom scoring methods were used in the included studies. The most frequently used instrument was the Androgen Deficiency in Aging Males-questionnaire, which score improved during treatment. Reported side-effects were only prevalent in less than 10% of the study populations and no serious adverse events were reported.

CONCLUSION

CC is an effective therapy for improving both biochemical as well as clinical symptoms of males suffering from hypogonadism. CC has few reported side-effects and good safety aspects. This article is protected by copyright. All rights reserved.

[Depression in men with testosterone deficiency]

OBJECTIVE

Clinical assessment of depression in men with testosterone deficiency to improve differential diagnosis of this type of depression.

MATERIAL AND METHODS

Thirty-seven men (mean age 50.1±9.08 years) with depressive episode and testosterone level ≤12.1 nmol/l were included in the main group. Depressive episode was diagnosed based on ICD-10 criteria (F-32). Additional assessment of physical and psychometrics parameters was evaluated. Forty men (mean age 42.3±10.53 years) with depression based on ICD-10 criteria (F32, F33) and testosterone level >12.1 nmol/l were included in the comparison group.

RESULTS

Symptoms of depression in men with testosterone deficiency were less severe and led to less functional disturbance. There were some clinical differences in symptoms and syndromes. Single-episode course with manifestation at a later age was more typical for the main group while the comparison group was mostly characterized by recurrent episodes manifesting at an earlier age.

CONCLUSION

Depression in men with testosterone deficiency has a number of differences that must be taken into account when diagnosing and choosing treatment tactics.

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.

Amodiaquine promotes testosterone production and de novo synthesis of cholesterol and triglycerides in Leydig cells

Testosterone is a hormone essential for male reproductive function. It is produced primarily by Leydig cells in the testicle through activation of steroidogenic acute regulatory protein and a series of steroidogenic enzymes, including a cytochrome P450 side-chain cleavage enzyme (cytochome P450 family 11 subfamily A member 1), 17α-hydroxylase (cytochrome P450 family 17 subfamily A member 1), and 3β-hydroxysteroid dehydrogenase. These steroidogenic enzymes are mainly regulated at the transcriptional level, and their expression is increased by the nuclear receptor 4A1. However, the effect on Leydig cell function of a small molecule-activating ligand, amodiaquine (AQ), is unknown. We found that AQ effectively and significantly increased testosterone production in TM3 and primary Leydig cells through enhanced expression of steroidogenic acute regulatory protein, cytochome P450 family 11 subfamily A member 1, cytochrome P450 family 17 subfamily A member 1, and 3β-hydroxysteroid dehydrogenase. Concurrently, AQ dose-dependently increased the expression of 3-hydroxy-3-methylglutaryl-CoA reductase, a key enzyme in the cholesterol synthesis pathway, through induction of the transcriptional and DNA-binding activities of nuclear receptor 4A1, contributing to increased cholesterol synthesis in Leydig cells. Furthermore, AQ increased the expression of fatty acid synthase and diacylglycerol acyltransferase and potentiated de novo synthesis of fatty acids and triglycerides (TGs). Lipidomics profiling further confirmed a significant elevation of intracellular lipid and TG levels by AQ in Leydig cells. These results demonstrated that AQ effectively promotes testosterone production and de novo synthesis of cholesterol and TG in Leydig cells, indicating that AQ may be beneficial for treating patients with Leydig cell dysfunction and subsequent testosterone deficiency.

Long-term testosterone undecanoate treatment in the elderly testosterone deficient male: An observational cohort study

BACKGROUND

Quarterly intramuscular injections with long-acting testosterone undecanoate (TU) provide stable serum testosterone concentrations over time and are therefore preferred by many testosterone-deficient patients. However, the use of long-acting TU in elderly patients is limited due to lack of safety and feasibility studies.

OBJECTIVE

To investigate long-acting TU pharmacokinetics and assess differences in treatment regimens and risk of adverse outcomes in younger versus elderly testosterone-deficient patients.

MATERIALS AND METHODS

Single-center longitudinal observational study. Patients who initiated long-acting TU treatment between 2005 and 2010 were included. Elderly patients were born before 1956 and younger patients between 1965 and 1985. TU dose was adjusted yearly through shortening or prolongation of time between injections. Treatment targets were as follows: (1) free testosterone between 0 and -1 SD from the age-adjusted mean, (2) no symptoms of testosterone deficiency, and (3) hematocrit within the normal range.

RESULTS

The study population consisted of 63 elderly and 63 younger patients. Median follow-up time during testosterone replacement was 12.1 years. Increasing intervals between TU injections were performed 44% more often in the elderly compared to younger patients and time between TU injections were prolonged 4% more in the elderly patients. The hematocrit, as well as the hematocrit for a given serum testosterone (hematocrit: testosterone ratio), increased with treatment time but did not differ between age groups. During follow-up, 40% of patients-both elderly and younger-experienced polycythemia. Risk of polycythemia did not differ with age.

DISCUSSION AND CONCLUSION

An increased number of adjustments of TU dose are necessary in elderly patients in order to reach treatment targets. TU treatment in elderly testosterone-deficient patients is not associated with an increased risk of polycythemia compared to younger patients if age-adjusted treatment targets are reached.

Pharmacokinetics of testosterone therapies in relation to diurnal variation of serum testosterone levels as men age

Background

To improve symptoms associated with testosterone deficiency, many testosterone therapies are available that aim to restore serum testosterone (T) levels to the normal physiologic range. The magnitude, frequency, and duration between peak and trough T concentrations vary with route of administration, and none reflect normal endogenous daily diurnal T variations.

Objective

To compare pharmacokinetic profiles of serum T from approved T formulations with endogenous diurnal T variations in young and older men, and to consider whether there may be value in mimicking the diurnal T rhythmicity with exogenous testosterone therapies as men age.

Materials and methods

A literature search of studies examining the diurnal variation of endogenous T in healthy men and men with testosterone deficiency was performed using PubMed in January 2020. Additional searches for serum T pharmacokinetic profiles of various testosterone therapy formulations were also conducted. Prescribing information for various T formulations was also reviewed.

Discussion and conclusion

Endogenous diurnal T variation is well described and appears to be blunted naturally as men age. Men with testosterone deficiency lack diurnal T variation and exhibit a flatter T profile compared with eugonadal men. Some T replacement options provide intraday T level variations similar to normal circadian secretion, and others provide a flatter exposure profile reflective of depot release. Others provide profiles that exceed the frequency and physiologic range of the natural diurnal variation of T. All exogenous T replacement dosing targets an increase in average T levels to within the normal physiologic range and improves symptoms associated with low T, but no single testosterone therapy can exactly mimic the normal diurnal T patterns seen in younger men and the blunted circadian T secretion of older men.

Testosterone and Cognitive Impairment or Dementia in Middle-Aged or Aging Males: Causation and Intervention, a Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

To investigate the association between testosterone levels and the risk of dementia and to assess the effectiveness of testosterone supplement treatment in patients with cognitive impairment or dementia.

METHODS

We searched Pubmed, Cochrane Library, and EMBASE on September 30, 2019.

RESULTS

The risk factor portion of the review included 27 studies with 18 599 participants. Studies revealed inconsistent findings on the association between testosterone levels and the risk of all-cause dementia or Alzheimer disease (AD). The result from our meta-analysis showed an increased risk of all-cause dementia with decreasing total testosterone (total-T, 4572 participants, hazard ratio: 1.14, 95% CI: 1.04-1.26). Some studies also found an increased risk of AD with a lower level of total-T, free testosterone, and bioavailable testosterone. Testosterone supplement treatment may improve general cognitive function and motor response in the short term as measured by the Developmental Test of Visual-Motor Integration (mean difference [MD]: 4.4, 95% CI: 1.20-7.59) and the Mini-Mental State Examination (MD: 3.4, 95% CI: 0.83-5.97) and verbal memory as measured by story recall delay at 3 months (MD: 8.4, 95% CI: 0.49-16.3).

CONCLUSION

Lower levels of testosterone may be associated with an increased risk of all-cause dementia or AD. Testosterone supplement treatment may or may not improve general cognitive function in patients with cognitive impairment/AD.

Management of late-onset hypogonadism: person-centred thresholds, targets, techniques and tools

Late-onset hypogonadism (LOH) is a complex and highly debatable syndrome in ageing men, which is characterised by reduced testosterone levels associated with classical symptoms of androgen deficiency. This article discusses the complex issues surrounding its management related to patient-centric thresholds and therapeutic targets. It specifically highlights the need to consider symptoms as the starting point, the key milestones in the management and the target of treatment, while ensuring safety at all times. The diagnosis of LOH requires a high index of suspicion and early identification of symptoms followed by appropriate investigations. The threshold for initiation of treatment has to be person centric and requires individualised decisions. The dose, preparation, route and follow up after testosterone initiation also may vary among different people. A person-centred approach is key to the successful management of this complex, nebulous yet debilitating disease.

Testosterone Deficiency, Long-Term Testosterone Therapy, and Inflammation

OBJECTIVES

We aimed to evaluate the association of testosterone deficiency with inflammation and how long-term testosterone therapy affects inflammation biomarkers over time.

METHODS

We conducted a 2-component study. First, we conducted a cross-sectional study using the recently released 2015-2016 National Health and Nutrition Examination Survey (NHANES) data to examine the association between testosterone deficiency and inflammation biomarkers including high sensitivity C-reactive protein (hsCRP), liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in the US general population. Then we conducted a longitudinal study to investigate the longitudinal effect of testosterone therapy on inflammation biomarkers and the risk of cardiovascular events, using data from 776 hypogonadal men based on a registry study in Germany with up to 11 years' follow-up.

RESULTS

The adjusted odds ratios (ORs) describing the associations between testosterone deficiency and hsCRP ≥ 3mg/L, ALT > 40U/L, and AST > 40U/L were 1.81 (P-value < 0.001), 1.46 (P-value = 0.009), and 0.99 (P-value = 0.971), respectively. In the control group, CRP, ALT, and AST levels increased by 0.003 (95%CI: -0.001, 0.007) mg/L, 0.157 U/L (95%CI: 0.145, 0.170), and 0.147 (95%CI: 0.136, 0.159) U/L per month, while in the treatment group, CRP, ALT, and AST levels decreased by 0.05 (95%CI: -0.055, -0.046) mg/L, 0.142 U/L (95%CI: -0.154, -0.130), and 0.148 (95%CI: -0.158, -0.137) U/L per month.

CONCLUSION

Testosterone deficiency was associated with an increased level of inflammation; long-term testosterone therapy alleviated inflammation among hypogonadal men, which may contribute to the reduced cardiovascular risk. Future large trials are warranted to confirm our observational study findings.

Both comorbidity burden and low testosterone can explain symptoms and signs of testosterone deficiency in men consulting for sexual dysfunction

Low testosterone (T) is frequent in men with chronic illnesses. The clinical features of T deficiency (TD) overlap with those of chronic diseases. The aim of this study is to evaluate the relative contribution of chronic disease score (CDS) and low T to the presence of TD symptoms. A consecutive series of 3862 men (aged 52.1 ± 13.1 years) consulting for sexual dysfunction were studied. Several clinical and biochemical parameters were collected, including the structured interview, ANDROTEST, for the assessment of TD symptoms. Penile color Doppler ultrasound (PCDU) was also performed. Based on the medications taken, the CDS was calculated. For a subset of 1687 men, information on mortality was collected (follow-up of 4.3 ± 2.6 years). Higher CDS was associated with lower free and total T (TT) as well as with higher ANDROTEST score. When introducing CDS and TT in multivariable models adjusted for age, severe erectile dysfunction and impaired morning erections were associated with both CDS (odds ratio and 95% confidence interaval, OR [95% CI] = 1.25 [1.13; 1.37] and 1.38 [1.29; 1.48], respectively) and low TT (OR [95% CI] = 1.11 [1.00; 1.23] and 1.13 [1.06; 1.21], respectively). Similar results were obtained for PCDU parameters. Hypoactive sexual desire was associated with low TT (OR [95% CI] = 1.21 [1.13; 1.30]), whereas it was inversely related with CDS (OR [95% CI] = 0.91 [0.84; 0.97]). When considering mortality for major cardiovascular events, TT <8 nmol l⁻¹, but not CDS, was a significant predictor (hazard ratio [95% CI] = 5.57 [1.51; 20.63]). Chronic illnesses are associated with an overt TD. Both chronic diseases and low T can be involved in determining symptoms present in subjects complaining for sexual dysfunction. This should be considered in the diagnostic workup for TD.

Androgen-dependent miR-125a-5p targets LYPLA1 and regulates global protein palmitoylation level in late-onset hypogonadism males

Late-onset hypogonadism (LOH) is defined as a clinical and biochemical syndrome with multiple symptoms caused by testosterone deficiency in aging males. An in-depth exploration of the molecular mechanism underlying LOH development is insufficient. We previously identified miR-125a-5p as a dysregulated microRNA in LOH patients and potential diagnostic biomarker for LOH. The present study demonstrated that plasma miR-125a-5p was upregulated after testosterone supplementation in both LOH patients and castrated mice, and positively associated with the testosterone concentrations, suggesting direct regulation of miR-125a-5p expression by testosterone. Androgen response element in the promoter of miR-125a-5p was subsequently identified. Target gene screening and confirmation verified that LYPLA1, encoding acyl-protein thioesterase 1 which catalyzed protein depalmitoylation process, was a target gene of miR-125a-5p. Furthermore, in cells cultured with testosterone deprivation and organs from castrated mice, testosterone deficiency led to decreased global protein palmitoylation level. In aging males, global protein palmitoylation in peripheral blood showed a notable decline in LOH patients contrast to the normal elderly males. And the palmitoylation level was positively correlative with serum testosterone concentrations. Our results suggested that testosterone could regulate global palmitoylation level through miR-125a-5p/LYPLA1 signaling pathway. Given that protein palmitoylation is pivotal for protein function and constitutes the pathogenesis of various diseases, testosterone/miR-125a-5p/LYPLA1 may contribute to the molecular mechanism underlying multiple symptoms caused by testosterone deficiency in LOH patients, and aberrant global palmitoylation could be a potential biomarker for LOH.

Secondary azoospermia after sleeve gastrectomy: a case report

Objective

To report the first case of secondary azoospermia after sleeve gastrectomy.

Design

Case report.

Setting

Academic male infertility clinic.

Patient(s)

A 33-year-old man with secondary azoospermia and primary testicular failure with testosterone deficiency after laparoscopic sleeve gastrectomy.

Intervention(s)

Hormonal therapy with anastrozole for 10 months and diagnostic testicular biopsy.

Main Outcome Measure(s)

Semen analyses and testicular histopathology.

Result(s)

Non-obstructive azoospermia persisted at 20 months after surgery despite hormonal therapy with anastrozole. Testicular histopathology revealed the presence of Sertoli cells only.

Conclusion(s)

Although further research is need to determine the relationship between sleeve gastrectomy and secondary infertility, men should be informed of the potentially deleterious effects of this surgery on semen parameters.

Serum testosterone concentrations in male patients with end-stage kidney disease treated with haemodialysis

INTRODUCTION

Testosterone deficiency is frequently found in male patients with chronic kidney disease (CKD) and may participate in the pathogenesis of osteoporosis, sarcopaenia, anaemia, impotence, infertility, and other comorbidities observed in these patients. The aim of the study was the evaluation of the frequency of testosterone deficiency in male patients with CKD on maintenance haemodialysis (HD).

MATERIAL AND METHODS

In 79 male HD patients, serum total (TT), free (FT) testosterone, C-reactive protein (CRP), and interleukin 6 (IL-6) serum concentrations were assessed before an HD procedure. Patients were divided into three subgroups based on age categories: 19-39 years (18 patients), 40-59 years (34 patients), and ≥ 60 years (27 patients). TT insufficiency and deficiency were diagnosed when the serum TT concentration was below 4.0 ng/mL and 2.9 ng/mL, respectively. FT deficiency was diagnosed in patients with serum FT concentration below 8.9, 6.6, and 4.9 pg/mL in the abovementioned age subgroups, respectively.

RESULTS

In the abovementioned age subgroups the serum TT concentration was 5.9 (4.6-7.1), 4.8 (3.9-5.4), and 4.6 (3.9-5.3) ng/mL, respectively. The serum FT concentration was 7.9 (5.2-10.1), 6.1 (5.1-7.2), and 6.0 (5.0-7.1) pg/mL, respectively. In the whole group TT insufficiency was found in 40%, TT deficiency in 15% of patients, and FT deficiency in 50% of patients. Significant negative correlations were found between both serum TT and FT concentrations and age (r = -0.23, p = 0.05 and r = -0.27, p = 0.02, respectively). Additionally, negative correlations were found between both serum TT and FT and IL-6 concentrations (r = -0.43, p < 0.05 and r = -0.29, p < 0.05), respectively.

CONCLUSIONS

1. Testosterone deficiency is common in male patients with chronic kidney disease treated with HD. 2. In HD patients the serum testosterone concentration decreases with age. 3. Chronic inflammation may participate in the pathogenesis of testosterone deficiency in haemodialysis patients.

An update on the available and emerging pharmacotherapy for adults with testosterone deficiency available in the USA

Introduction: Testosterone deficiency (TD) is defined as low serum testosterone associated with symptoms and signs. There has been an increasing prevalence of TD in recent decades, especially in males aged 15-39. Many of these men will require long-term testosterone therapy (TT). Although the end-goals for all treatments are essentially the same, strategies for increasing serum testosterone should be decided individually.Areas covered: This review focuses on the pharmacological management of TD in adults which includes TT with different routes of administration, such as transdermal, buccal, intramuscular and subcutaneous injections, pellets, nasal gel, and oral (pills). The authors review the options for TT available in the USA with emphasis on newer therapies. Furthermore, they examine the efficacy of these therapies with comparison between potential advantages or disadvantages related to dosing, administration method, and adverse events.Expert opinion: Treating TD can be difficult due to the wide range of available medications, diverse side effects related to testosterone replacement and route-of-administration, and necessity for long-term therapy. The combination of pharmacological and non-pharmacological therapies can improve symptoms of TD and patient satisfaction. Each patient should be managed individually, and clinicians should consider available treatment regimens based on the route-of-administration, efficacy, safety, and cost based on a shared decision-making approach.

Fatty liver index is associated with the risk of testosterone deficiency in aging men without metabolic syndrome

OBJECTIVES

Non-alcoholic fatty liver disease (NAFLD) is suggested to be a precursor of metabolic syndrome (MetS) and could influence the risk of testosterone deficiency (TD). Fatty liver index (FLI) is a simple and useful screening tool for NAFLD. We determined the association between the risk of NAFLD assessed by FLI and TD in aging Taiwanese men, especially those without MetS.

MATERIALS AND METHODS

A free health screening program was conducted for men (age: >40 years) in a medical center in Kaohsiung, Taiwan. All participants underwent a physical examination; answered a questionnaire assessing demographics, medical history, and clinical symptoms of TD; and provided 20-mL whole blood samples for biochemical, adipocytokine, and hormonal evaluations. The risk of NAFLD was evaluated using FLI. The presence of NAFLD was ruled out if FLI value was <25 and ruled in if FLI value was ≥35.

RESULTS

A total of 552 men (mean age: 54.7 ± 7.7 years) were enrolled. The prevalence rates of TD and MetS were significantly higher among men with NAFLD than those without NAFLD (both p < 0.001). FLI was significantly correlated with total testosterone (TT) and adipocytokines associated with insulin resistance, such as adiponectin, leptin, and retinol-binding protein-4 (RBP-4) levels, respectively (all p < 0.001). Among men without MetS, those at risk of and with NAFLD had a 3.82 and 8.50 times higher risk of TD, respectively, than those without NAFLD after adjusting for potential covariates.

CONCLUSION

The FLI is associated with the risk of TD in aging Taiwanese men, especially in those without MetS. Our findings also suggest that insulin resistance may be an important link among the inter-relationships of NAFLD, MetS, and TD. Further population-based studies with larger sample sizes of different ethnicities are warranted to confirm these preliminary results.

Testosterone deficiency in men receiving immunotherapy for malignant melanoma

Immunotherapy has been established as a standard of care for patients with malignant melanoma, however, the long-term side-effects of immunotherapy are still emerging. Studies over the last decade have documented increasing reports of endocrine dysfunction following the initiation of immunotherapy. Our study aimed to detect the proportion of men who have low testosterone before, during, and or/after receiving immunotherapy for malignant melanoma, and to determine the proportion of men who receive testosterone replacement therapy after detection of low testosterone. We performed retrospective chart review of patients with malignant melanoma treated with immunotherapy. Low testosterone was identified in 34 out of 49 patients at some point during their treatment with immunotherapy. Despite low testosterone levels in two-thirds of patients, only three patients were treated with testosterone replacement therapy. In addition to laboratory evidence of low testosterone, patients were also symptomatic as 43 out of 49 patients reported fatigue to their providers. Four patients developed hypophysitis and subsequent hypopituitarism, all of whom were receiving Ipilimumab. We conclude that patients with stage 3 or 4 melanoma treated with immunotherapy appear to be at an increased risk of developing testosterone deficiency during their treatment.

Metabolic syndrome, levels of androgens, and changes of erectile dysfunction and quality of life impairment 1 year after radical prostatectomy

Robust data evaluating the association of preoperative parameters of the patients with quality of life after radical prostatectomy are lacking. We investigated whether clinical and biological preoperative characteristics of the patients were associated with impaired patient-reported quality of life (QoL) and sexual outcomes 1 year after radical prostatectomy. We evaluated patient-reported outcomes among the 1343 men participating in the AndroCan trial (NCT02235142). QoL and erectile dysfunction (ED) were assessed before and 1 year after radical prostatectomy using validated self-assessment questionnaires (Aging Male's Symptoms [AMS] and the 5-item abridged version of the International Index of Erectile Function [IIEF5]). At baseline, 1194 patients (88.9%) accepted to participate. A total of 750 (55.8%) patients answered the 1-year postoperative questionnaires. Out of them, only 378 (50.4% of responders) provided answers that could be used for calculations. One year after prostatectomy, ED had worsened by 8.0 (95% confidence interval [CI]: 7.3–8.7; P < 0.0001) out of a maximum of 20. The global AMS score has worsened by 2.8 (95% CI: 1.7–3.8; P < 0.0001). ED scores 1 year postsurgery were positively correlated with preoperative age and percentage of fat mass, and negatively correlated with total cholesterol, dehydroepiandrosterone (DHEA), and androstenediol (D5); AMS were poorly correlated with preoperative parameters. QoL and sexual symptoms significantly worsened after radical prostatectomy. Baseline bioavailable testosterone levels were significantly correlated with smaller changes on AMS somatic subscores postprostatectomy. These findings may be used to inform patients with newly diagnosed prostate cancer.

Aqueous Extracts of Morus alba Root Bark and Cornus officinalis Fruit Protect against Osteoarthritis Symptoms in Testosterone-Deficient and Osteoarthritis-Induced Rats

Water extracts of both Morus alba L. root bark (MBW) and Cornus officinalis Siebold and Zucc fruit (CFW) have traditionally been used to promote men's health in the elderly in Asia. We determined that the 12-week consumption of MBW and CFW could alleviate testosterone-deficiency syndrome and osteoarthritis (OA) symptoms in testosterone-deficient rats, and the action mechanisms were explored. Rats with bilateral orchiectomy (ORX) were fed a 45% fat diet containing either 0.5% MBW (ORX-MBW), 0.5% CFW(ORX-CFW), or 0.5% dextrin (ORX-CON). Sham-operated rats also received 0.5% dextrin (Non-ORX-CON). After 8 weeks of treatment, all rats had an injection of monoiodoacetate (MIA) into the left knee, and they continued the same diet for the additional 4 weeks. ORX-CFW and ORX-MBW partially prevented the reduction of serum testosterone concentrations and decreased insulin resistance, compared to the ORX-CON. ORX-CFW and ORX-MBW protected against the reduction of bone mineral density (BMD) and lean body mass (LBM) compared to the ORX-CON. The limping and edema scores were lower in the order of the ORX-CON, ORX-CRF = ORX-MBW, and Non-ORX-CON (p < 0.05). The scores for pain behaviors, measured by weight-distribution on the OA leg and maximum running velocity on a treadmill, significantly decreased in the same order as limping scores. ORX-MBW protected against the increased expression of matrix metalloproteinase (MMP)-3 and MMP-13 and reduced the production of inflammatory markers such as TNF-α and IL-1β, by MIA in the articular cartilage, compared to the ORX-CON (p < 0.05). The cartilage damage near the tidemark of the knee and proteoglycan loss was significantly less in ORX-MBW than ORX-CON. In conclusion, MBW, possibly CFW, could be effective alternative therapeutic agents for preventing osteoarthritis in testosterone-deficient elderly men.

Andropause symptoms and sickness absence in Japanese male workers: a prospective study

OBJECTIVE

The purpose of the study was to investigate the association between andropause symptoms and sickness absence in Japanese male workers over 2 years.

METHODS

A baseline survey asking about andropause symptoms, along with blood sampling for testosterone level, was conducted in June 2009. A total of 418 men (mean age = 52.4 years, SD = 8.6) participated and were followed through 2011. Hazard ratios (HRs) and 95% confidence intervals (CIs) for sickness absence were calculated using Cox proportional hazard models.

RESULTS

During the follow-up period, 31 of 35 participants who took sickness absences had physical illnesses. A higher andropause symptom score was associated with an increased risk of sickness absence. Testosterone deficiency (<350 ng/dL) was not associated with sickness absence. Among the subscales of andropause symptoms, the somatic symptom score was positively associated with sickness absence, whereas testosterone deficiency combined with high sexual symptoms was not associated with sickness absence. Results were similar when limited to sickness absence because of physical illness. No significant interaction between andropause symptoms and testosterone deficiency was found.

CONCLUSIONS

Non-specific andropause symptoms unrelated to testosterone deficiency were positively associated with sickness absence.

Important lessons about testosterone therapy- weight loss vs. testosterone therapy for symptom resolution, classical vs. functional hypogonadism, and shortterm vs. lifelong testosterone therapy

In this commentary, we highlight important findings from a notable RCT by Ng Tang Fui et al. 2016 which investigated the effects of testosterone treatment in dieting obese men. First, a myopic focus on weight loss can detract from important improvements in body composition. Second, while weight loss in obese men may increase testosterone levels, this increase is commonly not enough to result in an improvement in symptoms associated with testosterone deficiency. Third, the RCT by Ng Tang Fui et al. adds evidence to the growing number of clinical trials showing that testosterone therapy should not be restricted to men with classical hypogonadism. Finally, the beneficial effects of testosterone therapy are not maintained after cessation of treatment. Currently, the British Society for Sexual Medicine guidelines are the only clinical guidelines which acknowledge that weight loss per se does not automatically translate to resolution of hypogonadal symptoms, that testosterone therapy can greatly benefit men with testosterone deficiency who do not have classical hypogonadism, and that cessation of testosterone therapy causes reappearance of symptoms and reversal of benefits. Lifelong testosterone therapy is therefore recommended for persistent health benefits in most men with testosterone deficiency. Physicians and patients need to be informed of this.

The association between body mass index and testosterone deficiency in aging Chinese men with benign prostatic hyperplasia: results from a cross-sectional study

BACKGROUND AND OBJECTIVES

Evidence has supported obesity as a risk factor for both benign prostate hyperplasia (BPH) and hypogonadism. In this paper, we performed a retrospective study and discussed the prevalence of testosterone deficiency (TD) and its relationship to body mass index (BMI) in aging Chinese men with BPH who have surgical intervention.

MATERIAL AND METHODS

We reviewed the clinical data by age, BMI, medical history, serum prostate-specific antigen (PSA) levels, serum total testosterone (TT) levels, biochemical analysis, and transrectal ultrasound. BMI and other variables were considered to be independent variables in an effort to evaluate any potential associations between these factors and TD status using non-adjusted and multivariate-adjusted regression models.

RESULTS

Of the 795 BPH participants, 27.2% (216) patients had TD. After adjusting for all potential covariates, there was a similar J-shaped relationship between BMI and TD, with an inflection point of 19.2 kg/m². The effect sizes and the confidence intervals on the left and right sides of this inflection point were 0.6 (0.4-1.0) (p = .043) and 1.2 (1.1-1.3) (p < .001), respectively.

CONCLUSION

Nearly one-third of the aging Chinese BPH patients had TD in this study. The association between BMI and TD is not simple. A J-shaped curve correlation was detected. BMI was positively correlated with TD when it was over 19.2 kg/m² and inversely correlated with TD when it was below 19.2 kg/m². Long-term prospective studies are needed to confirm these findings.

Sensitivity, Specificity and Accuracy of Androgen Deficiency in Ageing Male (ADAM) Questionnaire for the Clinical Detection of Androgen Deficiency in the Male Population in Pakistan

INTRODUCTION

Androgen deficiency in relation to the increasing age is quite prevalent worldwide. However, diagnosing it in low-income countries is quite a challenge due to cost concerns. Through this study, we plan to measure the sensitivity and specificity of the Androgen Deficiency in Ageing Male (ADAM) questionnaire in the Pakistani population.

METHODS

A cross-sectional survey study was conducted from September 2019 to November 2019 in a Pakistani tertiary care hospital. Two hundred and fifty-five participants belonging to ages 30-69 years completed the ADAM Questionnaire in the out-patient department. Venous blood samples were taken to check serum total testosterone levels.

RESULTS

The ADAM questionnaire revealed 90.12% sensitivity, 41.3% specificity, 45.34% positive predictive value, 90.80% negative predictive value, and 61.29% accuracy in the Pakistani population.

CONCLUSION

Low specificity and positive predictive value have been shown by the ADAM questionnaire. Hence, it cannot be used as a diagnostic tool to detect androgen deficiency, replacing the blood sample.

Bilateral antler sequestration above the coronet in a red deer (Cervus elaphus) stag-Insights into the process of antler casting

This paper reports a case of delayed velvet shedding and bilateral premature antler casting above the coronets in a young adult red deer stag from Germany. Based on the established role of testosterone in the control of the antler cycle, the antler abnormality is considered to have been the result of a (temporary) androgen deficiency. The basal surfaces (separation planes or seals) of the cast antlers were markedly concave. Scanning electron microscopy revealed that the separation plane was densely covered with Howship's lacunae, denoting intense osteoclastic activity along the border between the proximal (living) and distal (dead) antler portions. Our observations and those of previous studies indicate that antler casting does not occur at a pre-determined separation plane, but along the border between living and dead bone, regardless of the position of this border within the cranial appendages. This is a major difference to autotomy of (living) appendages at fixed breakage planes, as it occurs for instance in lizard tails.