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Effects of Bariatric Surgery in Male Obesity-Associated Hypogonadism

Authors:
Fernanda Augustini Rigon
Fernanda Augustini Rigon
Marcelo Fernando Ronsoni
Marcelo Fernando Ronsoni
Alexandre Hohl at Federal University of Santa Catarina
Alexandre Hohl
Simone van de Sande-Lee at Federal University of Santa Catarina
Simone van de Sande-Lee
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Introduction The prevalence of obesity has grown exponentially over the last several decades. Research has linked male obesity to changes in the gonadal axis, which can induce functional hypogonadism. Bariatric surgery provides sustained weight loss and metabolic improvement. This was a retrospective cohort study to evaluate the male gonadal axis and metabolic profiles of obese individuals during the bariatric pre- and post-operative periods while comparing them to a normal body mass index (BMI) group. Methods Twenty-nine obese men, who underwent bariatric surgery between 2012 and 2016 at the Federal University of Santa Catarina Hospital and a control group (CG) of 29 age-matched men with normal BMI, were analyzed. Bariatric pre- and 6-month post-operative data were compared with the CG. Results The study group (G1) presented an average age, weight, and BMI of 42.8 ± 9.5 years, 155.2 ± 25.8 kg, and 50.6 ± 7.1 kg/m², respectively. The pre-operative total testosterone (TT) G1 values were different from the CG (229.5 ± 96.4 versus 461.5 ± 170.8 ng/dL, p < 0.01). Bariatric surgery promoted a statistically significant improvement in weight, TT, and metabolic profiles in surgical patients. Conclusion Functional hypogonadism is prevalent in obese men, and we must be aware of this diagnosis. Although studies defining the best diagnostic parameters and indication of adequate hormone replacement therapy are lacking, an increase in TT levels during the first 6 months after bariatric surgery was identified in our study. Previous studies have shown that gonadal function can normalize after metabolic improvement.
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ORIGINAL CONTRIBUTIONS
Effects of Bariatric Surgery in Male Obesity-Associated Hypogonadism
Fernanda Augustini Rigon
1
&Marcelo Fernando Ronsoni
1
&Alexandre Hohl
1
&Simone van de Sande-Lee
1,2
Published online: 7 May 2019
#Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
Introduction The prevalence of obesity has grown exponentially over the last several decades. Research has linked male obesity
to changes in the gonadal axis, which can induce functional hypogonadism. Bariatric surgery provides sustained weight loss and
metabolic improvement. This was a retrospective cohort study to evaluate the male gonadal axis and metabolic profiles of obese
individuals during the bariatric pre- and post-operative periods while comparing them to a normal body mass index (BMI) group.
Methods Twenty-nine obese men, who underwent bariatric surgery between 2012 and 2016 at the Federal University of Santa
Catarina Hospital and a control group (CG) of 29 age-matched men with normal BMI, were analyzed. Bariatric pre- and 6-month
post-operative data were compared with the CG.
Results The study group (G1) presented an average age, weight, and BMI of 42.8± 9.5 years, 155.2 ± 25.8 kg, and 50.6 ± 7.1 kg/
m
2
, respectively. The pre-operative total testosterone (TT) G1 values were different from the CG (229.5 ± 96.4 versus 461.5 ±
170.8 ng/dL, p< 0.01). Bariatric surgery promoted a statistically significant improvement in weight, TT, and metabolic profiles in
surgical patients.
Conclusion Functional hypogonadism is prevalent in obese men, and we must be aware of this diagnosis. Although studies
defining the best diagnostic parameters and indication of adequate hormone replacement therapy are lacking, an increase in TT
levels during the first 6 months after bariatric surgery was identified in our study. Previous studies have shown that gonadal
function can normalize after metabolic improvement.
Keywords Obesity .Testosterone .Bariatric surgery .Hypogonadism
Introduction
Obesity has been increasing exponentially over the last several
decades regardless of local socioeconomic status and has be-
come a worldwide epidemic [1,2]. The GBD study showed
that between 1980 and 2015, obesity prevalence doubled in 73
countries and showed an increase in most of the other coun-
tries as well [3].
Excess weight is a significant risk factor for morbidity and
mortality, not only associated with cardiovascular events but
also with Type 2 diabetes mellitus (T2DM), malignant neo-
plasms, and musculoskeletal disorders, causing around three
million deaths a year [4–6].
Several studies have associated male obesity with changes
in sex hormones, which can lead to functional hypogonadism.
This change is characterized by low levels of serum testoster-
one in addition to low or inappropriately normal levels of
follicle stimulating hormone (FSH) and luteinizing hormone
(LH) in the absence of pituitary disease [7–14]. As a conse-
quence, sexual dysfunction (erectile dysfunction and low libi-
do), loss of bone mass and risk of fracture, fatigue, altered
moods and concentration, sarcopenia, increased adipose tis-
sue, dyslipidemia, and other signs and symptoms may be ob-
served [7,15–17].
Mechanisms that culminate in an androgen decrease in
obese individuals are not fully understood. However, it is
*Simone van de Sande-Lee
simonevslee@hotmail.com
Fernanda Augustini Rigon
fernandarigon@hotmail.com
Marcelo Fernando Ronsoni
Ronsoni.marcelo@gmail.com
Alexandre Hohl
alexandrehohl@endocrino.org.br
1
Serviço de Endocrinologia e Metabologia, Hospital Universitário
Polydoro Ernani de São Thiago (HU-UFSC), Florianópolis, SC,
Brazil
2
Departamento de Clínica Médica, Hospital Universitário, 3 andar,
Universidade Federal de Santa Catarina (UFSC),
Florianópolis, Santa Catarina 88040-970, Brazil
Obesity Surgery (2019) 29:2115–2125
https://doi.org/10.1007/s11695-019-03829-0
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... The European Male Aging Study (EMAS) evaluated over 3,000 men aged 40-79 years according to biochemistry and symptoms. Results showed an overall prevalence of 2.1% in men aged 40-79 years and rates of 0.1% in [40][41][42][43][44][45][46][47][48][49] year olds, 0.6% in 50-59 year olds, 3.2% in [60][61][62][63][64][65][66][67][68][69] year olds and 5.1% in [70][71][72][73][74][75][76][77][78][79] year olds (where the syndrome of TD included at least 3 sexual symptoms associated with a total testosterone (TT) level <11 nmol/L and a free testosterone (FT) level <220 pmol/L (<0.22 nmol/L) [8]. However, 75% of men maintained normal testosterone levels into old age, suggesting that TD is not merely a function of aging. ...
... Rigon [41] and colleagues evaluated bariatric surgery in 29 men with a mean baseline weight of 155 ...
The British Society for Sexual Medicine Guidelines on Male Adult Testosterone Deficiency, with Statements for Practice
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Testosterone deficiency (TD) is an increasingly common problem with significant health implications, but its diagnosis and management can be challenging. A multi-disciplinary panel from BSSM reviewed the available literature on TD and provide evidence-based statements for clinical practice. Evidence was derived from Medline, EMBASE and Cochrane searches on hypogonadism, testosterone therapy (T Therapy) and cardiovascular safety from May 2017 to September 2022. This revealed 1,714 articles, including 52 clinical trials and 32 placebo-controlled randomised controlled trials. A total of twenty-five statements are provided, relating to five key areas: screening, diagnosis, initiating T Therapy, benefits and risks of T Therapy, and follow-up. Seven statements are supported by level 1 evidence, eight by level 2, five by level 3, and five by level 4. Recent studies have demonstrated that low levels of testosterone in men are associated with increased risk of incident type 2 diabetes mellitus, worse outcomes in chronic kidney disease and COVID 19 infection with increased all-cause mortality, along with significant quality of life implications. These guidelines should help practitioners to effectively diagnose and manage primary and age-related TD.
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... Escobar -Morreale et al. [16] Meta-analysis, 382 severely obese men Prevalence of MOSH in those referred for bariatric surgery: 64% (95%CI: 50-77) of men Hofstra et al. [17] 149 men aged 18-66 years, BMI 42.7 ± 0.7 kg/m 2 , T2DM in 37% Prevalence of hypogonadism: TT< 3 ng/mL in 57.7% FT < 65 pg/mL in 35.6% ...
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Obesity-related gonadal dysfunction in males has been defined recently as male obesity secondary hypogonadism (MOSH). Affected individuals present with signs and symptoms related to the sex hormone imbalance but also with a burden of metabolic risk factors and occasionally compromised fertility. In pathophysiological terms, excess body fat is associated with leptin and insulin resistance. Accelerated synthesis of leptin and hyperinsulinemia downregulate the expression of kisspeptin receptors and, consequently, the action of kisspeptin. This critical neuropeptide is known to control gonadotropin secretion. In obese males, enhanced activity of the aromatase enzyme is associated with an increase in the conversion of circulating testosterone to estrogen, further promoting a state of hypogonadism. In addition, high fat and low fiber intake alter the intestinal microbiome and the dysfunction of the gut-brain axis. Weight loss appears to be the key to readjusting the function of the hypothalamus-pituitary-gonadal axis. It can be achieved with lifestyle measures in combination with weight loss medications or bariatric surgery. The degree of weight loss appears to resolve the symptoms related to hypogonadism and improve fertility chances. However, the role of hormone replacement is also important, as testosterone replacement has been shown to reduce fat mass and increase the amount of lean body mass while also contributing to weight loss and the regulation of body mass index and waist circumference. This narrative review analyzes the evidence on developing obesity-related endocrinopathies and the available management options. Further research is required to estimate the cut-off of body mass index associated with a higher risk for hypogonadism.
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... Male-obesity-associated secondary hypogonadism (MOSH) is a very prevalent entity ranging from 45-75% in men with moderate to severe obesity, as previously shown [1,2]. MOSH may resolve after the sustained and marked weight loss attained after metabolic surgery, and this occurs in parallel with the amelioration of insulin resistance and the resolution of other metabolic disorders [2,3]. Adipose tissue excess and dysfunction appear to contribute to androgen deficiency in men by effects that involve mainly the hypothalamicpituitary level [4]. ...
The Role of Adiponectin in the Resolution of Male-Obesity-Associated Secondary Hypogonadism after Metabolic Surgery and Its Impact on Cardiovascular Risk
Article
Full-text available
  • Aug 2022
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Management of male obesity-related secondary hypogonadism: A clinical update
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Male hypogonadism and its relationship with metabolic syndrome
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Full-text available
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Male hypogonadism, characterized by reduced testosterone levels, and metabolic syndrome have become prevalent, impacting male quality of life. Objective: To explore the relationship between hypogonadism and metabolic syndrome to understand its role in male health. Method: This is an integrative literature review study, with information collection, in the databases of the National Library of Medicine (MEDLINE/PUBMED and Scientific Electronic Library Online (SciELO), published in the period between 2018 and 2023. Results: Studies have shown that metabolic syndrome increases the risk of chronic diseases, including hypogonadism. The risk of central hypogonadism is eight times higher in men with a BMI ≥ 30 kg/m², related to factors such as hyperestrogenism and insulin resistance. Weight loss, especially abdominal loss, negatively influences free testosterone levels, regardless of age. Conclusion: the presence of hypogonadism suggests insulin resistance and metabolic alterations, associated with dysfunctions such as loss of libido and metabolic syndrome. Tests such as CT scans and genital MRI aid in the diagnosis, which includes hormonal, genetic, and ferretin evaluations. Treatment aims to restore testosterone levels, improving quality of life through hormone replacement.
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Male Fertility and Testosterone Therapy
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Approximately one in twenty men have sperm counts low enough to impair fertility but little progress has been made in answering fundamental questions in andrology or in developing new diagnostic tools or management strategies in infertile men. Many of these problems increase with age, leading to a growing population of men seeking help. To address this, there is a strong movement towards integrating male reproductive and sexual healthcare involving clinicians such as andrologists, urologists, endocrinologists and counselors. This book will emphasize this integrated approach to male reproductive and sexual health throughout the lifespan. Practical advice on how to perform both clinical and laboratory evaluations of infertile men is given, as well as a variety of methods for medically and surgically managing common issues. This text ties together the three major pillars of clinical andrology: clinical care, the andrology laboratory, and translational research.
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The abuse of anabolic-androgenic steroids (AAS) with the aim of increasing muscle mass and strength is increasing among men, currently configuring a public health problem. One consequence is suppression of the hypothalamic-pituitary-gonadal (HPG) axis, resulting in hypogonadism after withdrawal. Severity usually depends on the type of AAS, dose, and duration of use, and may be persistent and even irreversible. AAS-induced hypogonadism management involves establishing a trusting relationship between the patient and the physician, discontinuing the use of AAS, in addition to the judicious use of medications such as testosterone replacement therapy (TRT), selective estrogen receptor modulators (SERM), and human chorionic gonadotropin (hCG). The literature on the subject is still scarce, and more studies are needed for a better understanding of the aspects that involve AAS abuse, to enable prevention actions and the adequate management of adverse effects.KeywordsAnabolic steroidsTestosteroneSynthetic androgensDrug abuseHypogonadismClomipheneHuman chorionic gonadotropin
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The male patient with obesity undergoing bariatric-metabolic surgery: Changes in testosterone levels correlate with weight loss after OAGB and RYGB
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  • SURG OBES RELAT DIS
Background Male obesity secondary hypogonadism (MOSH) is a common disease among men with obesity and can be associated with metabolic syndrome and a variety of metabolic problems ultimately leading to androgen deficiency. Bariatric-metabolic surgery is a well-established treatment option associated with significant weight loss and reduction in metabolic comorbidity. Objectives The objectives were to evaluate the impact of surgery on plasma levels of sexual hormones and their effect on weight loss comparing two surgical methods (OAGB and RYGB) in male patients with obesity. Setting University Hospital, Austria Methods Patients undergoing OAGB and RYGB between 2012 and 2017 were analysed retrospectively. Follow-up in this study up to 24 months. Systemic levels of sexual hormones (luteinizing hormone (LH), follicle stimulating hormone (FSH), total testosterone (TT), sexual hormone binding globin (SHBG), 17beta Estradiol (17bE), androstendion (AS)) were retrieved at each visit. A linear mixed model was used to assess the correlation between changes in testosterone levels and %EWL. Results In 30.8% of all patients, MOSH was present preoperatively. A significant increase of TT was observed postoperatively that led to a complete resolution of hypogonadism within the period observed. Bioavailable testosterone (bTT) and FSH levels significantly increased each month of follow-up after surgery (all p<0.01). Levels of 17bE did not change significantly after surgery. The overall change of TT, comparing preoperative and one-year postoperative TT levels, (ΔTT) significantly correlated with %EWL. Changes in TT levels were not affected by the choice of surgical method. Conclusion Serum plasma testosterone levels rise significantly after bariatric-metabolic surgery in male patients. The change of testosterone levels seems to play a role in continued weight loss after surgery. This is true irrespective of the surgical method used.
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Changes in Testosterone Levels and Sex Hormone-Binding Globulin Levels in Extremely Obese Men after Bariatric Surgery
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Objective. Obesity is a risk factor for hypogonadotropic hypogonadism in men. Weight loss has been shown to improve hypogonadism in obese men. This study evaluated the early changes in sex hormones profile after bariatric surgery. Methods. This is a prospective study including 29 morbidly obese men. Main outcomes were changes in serum levels of total testosterone (TT), free testosterone (cFT), SHBG, estradiol, adiponectin, and leptin at 1 and 6 months after surgery. Results. The mean age of patients was 31 ± 8 years and the mean BMI was 56.8 ± 11.7 kg/m 2 . Fifteen patients underwent Roux-en-Y gastric bypass and 14 patients underwent sleeve gastrectomy. At baseline, 22 patients (75.9%) had either low TT levels (<10.4 nmol/L) or low cFT levels (<225 pmol/L). Total testosterone and SHBG levels increased significantly at 1 month after surgery ( p ≤ 0.001 ). At 6 months after surgery, TT and cFT increased significantly ( p ≤ 0.001 ) and 22 patients (75.9%) had normalized TT and cFT levels. There were no changes in estradiol levels at either 1 month or 6 months after surgery. Conclusions . Increases in TT and SHBG levels occurred early at 1 month after bariatric surgery while improvements in cFT levels were observed at 6 months after bariatric surgery.
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Effects of long-term treatment with testosterone on weight and waist size in 411 hypogonadal men with obesity Classes I-III: Observational data from two registry studies
Article
Full-text available
  • Jul 2015
  • INT J OBESITY
Background/Objectives Long-term testosterone replacement therapy (TRT) up to five years has been shown to produce progressive and sustainable weight loss in hypogonadal men. This study investigated effects of long-term TRT up to eight years in hypogonadal men with different obesity classes.Subjects/Methods From two independent observational registries we identified a total of 411 obese, hypogonadal men receiving TRT in urological clinics. The effects of TRT on anthropometric as well as metabolic parameters were studied for a maximum duration of 8 years, mean follow-up: 6 years. All men received long-acting injections of testosterone undecanoate in 3-monthly intervals.ResultsIn all three classes of obesity, T therapy produced significant weight loss (WL), decrease in waist circumference (WC) and BMI. In patients with class I obesity, mean weight decreased from 102.6±6.4 to 84.1±4.9 kg, change from baseline: -17.4±0.5 kg and -16.8±0.4%. WC in this group of patients decreased from 106.8±7.4 to 95.1±5.3 cm, change from baseline: -10.6±0.3 cm. BMI decreased from 32.69±1.4 to 27.07±1.57, change from baseline: -5.52±0.15 kg/m(2). In patients with class II obesity, weight decreased from 116.8±6.9 to 91.3±6.3 kg, change from baseline: -25.3±0.5 kg and -21.5±0.4%. WC decreased from 113.5±7.5 to 100.0±5.4 cm, change from baseline: -13.9±0.4 cm. BMI decreased from 37.32±1.45 to 29.49±1.71, change from baseline: -8.15±0.17 kg/m(2). In patients with class III obesity, weight decreased from 129.0±5.6 to 98.9±4.8 kg, change from baseline: -30.5±0.7 kg and -23.6±0.5%. WC decreased from 118. 5±5.6 to 103.8±4.9 cm, change from baseline: -14.3±0.4 cm. BMI decreased from 41.93±1.48 to 32.46±1.59, change from baseline -9.96±0.29 kg/m(2).Conclusions Testosterone therapy appears to be an effective approach to achieve sustained weight loss in obese hypogonadal men irrespective of severity of obesity. Based on these findings we suggest that T therapy offers safe and effective treatment strategy of obesity in hypogonadal men.International Journal of Obesity accepted article preview online, 29 July 2015. doi:10.1038/ijo.2015.139.
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Background: Weight lost by obese patients is almost always regained over time. Extended treatment may improve maintenance, but solid evidence is lacking. Purpose: We determined effectiveness of maintenance therapy after a weight loss program. Methods: Together 201 patients (mean age 47 years and BMI 42 kg/m(2), 71% women) were randomly assigned to either a 17-week weight loss program followed by a one-year maintenance program or to a weight loss program without subsequent maintenance intervention. The weight loss program included behavior modification and a very-low-calorie diet, and maintenance program behavior modification. The primary outcome measure was percentage of patients with 5% or more weight loss at the end of maintenance (week 69) and one year later (week 121). Secondary outcomes were weight related changes in lifestyle and quality of life. Results: At week 69, 52% of the patients with and 44% of those without maintenance program had lost weight ≥5%, P = 0.40, and, at week 121, 33% and 34%, P = 0.77, respectively. At week 121 secondary outcomes did not differ between the groups among those successfully followed up. Conclusions: This one-year maintenance program was not effective in preventing weight regain in severely obese patients. Trial Registration. This trial is registered under clinicaltrials.gov Identifier: NCT00590655.
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Long-term Follow-up After Bariatric Surgery A Systematic Review
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  • Sep 2014
Importance Bariatric surgery is an accepted treatment for obesity. Despite extensive literature, few studies report long-term follow-up in cohorts with adequate retention rates.Objective To assess the quality of evidence and treatment effectiveness 2 years after bariatric procedures for weight loss, type 2 diabetes, hypertension, and hyperlipidemia in severely obese adults.Evidence Review MEDLINE and Cochrane databases were searched from 1946 through May 15, 2014. Search terms included bariatric surgery, individual bariatric procedures, and obesity. Studies were included if they described outcomes for gastric bypass, gastric band, or sleeve gastrectomy performed on patients with a body mass index of 35 or greater, had more than 2 years of outcome information, and had follow-up measures for at least 80% of the initial cohort. Two investigators reviewed each study and a third resolved study inclusion disagreements.Findings Of 7371 clinical studies reviewed, 29 studies (0.4%, 7971 patients) met inclusion criteria. All gastric bypass studies (6 prospective cohorts, 5 retrospective cohorts) and sleeve gastrectomy studies (2 retrospective cohorts) had 95% confidence intervals for the reported mean, median, or both exceeding 50% excess weight loss. This amount of excess weight loss occurred in 31% of gastric band studies (9 prospective cohorts, 5 retrospective cohorts). The mean sample-size–weighted percentage of excess weight loss for gastric bypass was 65.7% (n = 3544) vs 45.0% (n = 4109) for gastric band. Nine studies measured comorbidity improvement. For type 2 diabetes (glycated hemoglobin <6.5% without medication), sample-size–weighted remission rates were 66.7% for gastric bypass (n = 428) and 28.6% for gastric band (n = 96). For hypertension (blood pressure <140/90 mm Hg without medication), remission rates were 38.2% for gastric bypass ( n = 808) and 17.4% for gastric band (n = 247). For hyperlipidemia (cholesterol <200 mg/dL, high-density lipoprotein >40 mg/dL, low-density lipoprotein <160 mg/dL, and triglycerides <200 mg/dL), remission rates were 60.4% for gastric bypass (n = 477) and 22.7% for gastric band (n = 97).Conclusions and Relevance Very few bariatric surgery studies report long-term results with sufficient patient follow-up to minimize biased results. Gastric bypass has better outcomes than gastric band procedures for long-term weight loss, type 2 diabetes control and remission, hypertension, and hyperlipidemia. Insufficient evidence exists regarding long-term outcomes for gastric sleeve resections.
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Global, Regional, and National Prevalence of Overweight and Obesity in Children and Adults during 1980–2013: A Systematic Analysis for the Global Burden of Disease Study 2013
Article
Full-text available
  • Aug 2014
Background: In 2010, overweight and obesity were estimated to cause 3·4 million deaths, 3·9% of years of life lost, and 3·8% of disability-adjusted life-years (DALYs) worldwide. The rise in obesity has led to widespread calls for regular monitoring of changes in overweight and obesity prevalence in all populations. Comparable, up-to-date information about levels and trends is essential to quantify population health effects and to prompt decision makers to prioritise action. We estimate the global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013. Methods: We systematically identified surveys, reports, and published studies (n=1769) that included data for height and weight, both through physical measurements and self-reports. We used mixed effects linear regression to correct for bias in self-reports. We obtained data for prevalence of obesity and overweight by age, sex, country, and year (n=19,244) with a spatiotemporal Gaussian process regression model to estimate prevalence with 95% uncertainty intervals (UIs). Findings: Worldwide, the proportion of adults with a body-mass index (BMI) of 25 kg/m(2) or greater increased between 1980 and 2013 from 28·8% (95% UI 28·4-29·3) to 36·9% (36·3-37·4) in men, and from 29·8% (29·3-30·2) to 38·0% (37·5-38·5) in women. Prevalence has increased substantially in children and adolescents in developed countries; 23·8% (22·9-24·7) of boys and 22·6% (21·7-23·6) of girls were overweight or obese in 2013. The prevalence of overweight and obesity has also increased in children and adolescents in developing countries, from 8·1% (7·7-8·6) to 12·9% (12·3-13·5) in 2013 for boys and from 8·4% (8·1-8·8) to 13·4% (13·0-13·9) in girls. In adults, estimated prevalence of obesity exceeded 50% in men in Tonga and in women in Kuwait, Kiribati, Federated States of Micronesia, Libya, Qatar, Tonga, and Samoa. Since 2006, the increase in adult obesity in developed countries has slowed down. Interpretation: Because of the established health risks and substantial increases in prevalence, obesity has become a major global health challenge. Not only is obesity increasing, but no national success stories have been reported in the past 33 years. Urgent global action and leadership is needed to help countries to more effectively intervene. Funding: Bill & Melinda Gates Foundation.
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Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline
Article
  • Mar 2018
Objective To update the “Testosterone Therapy in Men With Androgen Deficiency Syndromes” guideline published in 2010. Participants The participants include an Endocrine Society–appointed task force of 10 medical content experts and a clinical practice guideline methodologist. Evidence This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. Consensus Process One group meeting, several conference calls, and e-mail communications facilitated consensus development. Endocrine Society committees and members and the cosponsoring organization were invited to review and comment on preliminary drafts of the guideline. Conclusions We recommend making a diagnosis of hypogonadism only in men with symptoms and signs consistent with testosterone (T) deficiency and unequivocally and consistently low serum T concentrations. We recommend measuring fasting morning total T concentrations using an accurate and reliable assay as the initial diagnostic test. We recommend confirming the diagnosis by repeating the measurement of morning fasting total T concentrations. In men whose total T is near the lower limit of normal or who have a condition that alters sex hormone–binding globulin, we recommend obtaining a free T concentration using either equilibrium dialysis or estimating it using an accurate formula. In men determined to have androgen deficiency, we recommend additional diagnostic evaluation to ascertain the cause of androgen deficiency. We recommend T therapy for men with symptomatic T deficiency to induce and maintain secondary sex characteristics and correct symptoms of hypogonadism after discussing the potential benefits and risks of therapy and of monitoring therapy and involving the patient in decision making. We recommend against starting T therapy in patients who are planning fertility in the near term or have any of the following conditions: breast or prostate cancer, a palpable prostate nodule or induration, prostate-specific antigen level > 4 ng/mL, prostate-specific antigen > 3 ng/mL in men at increased risk of prostate cancer (e.g., African Americans and men with a first-degree relative with diagnosed prostate cancer) without further urological evaluation, elevated hematocrit, untreated severe obstructive sleep apnea, severe lower urinary tract symptoms, uncontrolled heart failure, myocardial infarction or stroke within the last 6 months, or thrombophilia. We suggest that when clinicians institute T therapy, they aim at achieving T concentrations in the mid-normal range during treatment with any of the approved formulations, taking into consideration patient preference, pharmacokinetics, formulation-specific adverse effects, treatment burden, and cost. Clinicians should monitor men receiving T therapy using a standardized plan that includes: evaluating symptoms, adverse effects, and compliance; measuring serum T and hematocrit concentrations; and evaluating prostate cancer risk during the first year after initiating T therapy.
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Bariatric Surgery and Long-term Durability of Weight Loss
Article
  • Aug 2016
Importance Bariatric surgery induces significant weight loss for severely obese patients, but there is limited evidence of the durability of weight loss compared with nonsurgical matches and across bariatric procedures. Objectives To examine 10-year weight change in a large, multisite, clinical cohort of veterans who underwent Roux-en-Y gastric bypass (RYGB) compared with nonsurgical matches and the 4-year weight change in veterans who underwent RYGB, adjustable gastric banding (AGB), or sleeve gastrectomy (SG). Design, Setting, and Participants In this cohort study, differences in weight change up to 10 years after surgery were estimated in retrospective cohorts of 1787 veterans who underwent RYGB from January 1, 2000, through September 30, 2011 (573 of 700 eligible [81.9%] with 10-year follow-up), and 5305 nonsurgical matches (1274 of 1889 eligible [67.4%] with 10-year follow-up) in mixed-effects models. Differences in weight change up to 4 years were compared among veterans undergoing RYGB (n = 1785), SG (n = 379), and AGB (n = 246). Data analysis was performed from September 9, 2014, to February 12, 2016. Exposures Bariatric surgical procedures and usual care. Main Outcomes and Measures Weight change up to 10 years after surgery through December 31, 2014. Results The 1787 patients undergoing RYGB had a mean (SD) age of 52.1 (8.5) years and 5305 nonsurgical matches had a mean (SD) age of 52.2 (8.4) years. Patients undergoing RYGB and nonsurgical matches had a mean body mass index of 47.7 and 47.1, respectively, and were predominantly male (1306 [73.1%] and 3911 [73.7%], respectively). Patients undergoing RYGB lost 21% (95% CI, 11%-31%) more of their baseline weight at 10 years than nonsurgical matches. A total of 405 of 564 patients undergoing RYGB (71.8%) had more than 20% estimated weight loss, and 224 of 564 (39.7%) had more than 30% estimated weight loss at 10 years compared with 134 of 1247 (10.8%) and 48 of 1247 (3.9%), respectively, of nonsurgical matches. Only 19 of 564 patients undergoing RYGB (3.4%) regained weight back to within an estimated 5% of their baseline weight by 10 years. At 4 years, patients undergoing RYGB lost 27.5% (95% CI, 23.8%-31.2%) of their baseline weight, patients undergoing AGB lost 10.6% (95% CI, 0.6%-20.6%), and patients undergoing SG lost 17.8% (95% CI, 9.7%-25.9%). Patients undergoing RYGB lost 16.9% (95% CI, 6.2%-27.6%) more of their baseline weight than patients undergoing AGB and 9.7% (95% CI, 0.8%-18.6%) more than patients undergoing SG. Conclusions and Relevance Patients in the Veterans Administration health care system lost substantially more weight than nonsurgical matches and sustained most of this weight loss in the long term. Roux-en-Y gastric bypass induced significantly greater weight loss among veterans than SG or AGB at 4 years. These results provide further evidence of the beneficial association between surgery and long-term weight loss that has been demonstrated in shorter-term studies of younger, predominantly female populations.
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Testosterone and obesity
Article
  • Jun 2015
  • OBES REV
Testosterone is a key hormone in the pathology of metabolic diseases such as obesity. Low testosterone levels are associated with increased fat mass (particularly central adiposity) and reduced lean mass in males. These morphological features are linked to metabolic dysfunction, and testosterone deficiency is associated with energy imbalance, impaired glucose control, reduced insulin sensitivity and dyslipidaemia. A bidirectional relationship between testosterone and obesity underpins this association indicated by the hypogonadal-obesity cycle and evidence weight loss can lead to increased testosterone levels. Androgenic effects on enzymatic pathways of fatty acid metabolism, glucose control and energy utilization are apparent and often tissue specific with differential effects noted in different regional fat depots, muscle and liver to potentially explain the mechanisms of testosterone action. Testosterone replacement therapy demonstrates beneficial effects on measures of obesity that are partially explained by both direct metabolic actions on adipose and muscle and also potentially by increasing motivation, vigour and energy allowing obese individuals to engage in more active lifestyles. The degree of these beneficial effects may be dependent on the treatment modality with longer term administration often achieving greater improvements. Testosterone replacement may therefore potentially be an effective adjunctive treatment for weight management in obese men with concomitant hypogonadism. © 2015 World Obesity.
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