Testosterone, Obesity and The Metabolic Syndrome - TRT?

Discussion in 'Men's Health Forum' started by Michael Scally MD, May 24, 2018.

  1. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    testosterone, Obesity and The Metabolic Syndrome in Males - Do We Need to Replace Steroids?
    Testosterone, obesity and the metabolic syndrome in males-do we need to replace steroids? | ECE2018

    Background: In men with obesity and the metabolic syndrome there is an increased prevalence of low serum testosterone. Overweight and moderate obesity is associated mainly with low total testosterone (T) secondary to decreased concentrations of SHBG, which are strongly inversely associated with indices of adiposity and insulin resistance, and preserved free T levels.

    In more severe obesity and metabolic abnormalities (often with type 2 diabetes) low total T can be accompanied by low free T, usually without appropriate increase of gonadotropins indicating contribution of altered central regulation of gonadal function, of which the underlying mechanisms remain to be fully elucidated.

    These observations have raised the question whether treatment with T may be needed or beneficial. The main issues involved will be reviewed.

    Main points: Are these men hypogonadal? A large proportion of the men with low total T and preserved free T should not be considered as hypogonadal. Those with low free T might be considered hypogonadal if they also present with symptoms of hypogonadism (e.g. sexual dysfunction).

    Is low T causal in the risk for – or aggravation of obesity and metabolic syndrome? Although the relation between low T and obesity/metabolic syndrome appear to some extent bidirectional, a critical appraisal of the literature indicates that a causal role of T is likely to be only limited with low T rather the consequence than the cause.

    Is the low T reversible? Weight loss and improved metabolic control can normalize or improve serum T.

    What are the effects of T therapy on the evolution of obesity and metabolic syndrome? Pharmacologic treatment with T can reduce fat mass and increase lean mass, which may have indirect favorable effects on metabolic control. A critical appraisal of controlled studies learn that these effects remain rather limited and can have at best a marginal effect besides more specific approaches such as based on lifestyle, more specific pharmacologic treatment or bariatric surgery.

    Is T therapy effective to treat hypogonadism in obese men or men with metabolic syndrome/type 2 diabetes? Yes treatment is effective although possibly less effective than in lean hypogonadal men.

    How safe is T therapy in these men? Some safety aspects may require special attention (e.g. risk for venous thromboembolism, sleep apnea).

    Conclusion: In the present state-of-the-art obesity and metabolic syndrome as such should not be considered as indications for T therapy. Conversely weight loss and improved metabolic control can normalize low T in men with obesity and metabolic syndrome in the absence of other (organic) causes of hypogonadism.

    In men with obesity and metabolic syndrome and with established hypogonadism (unequivocally low free T and symptoms) T therapy should be considered if measures intended at reducing weight and improving metabolic control fail to normalize or substantially improve serum FreeT.
     
  2. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Male Obesity-related Secondary Hypogonadism - Pathophysiology, Clinical Implications and Management

    The single most significant risk factor for testosterone deficiency in men is obesity. The pathophysiological mechanisms involved in male obesity-related secondary hypogonadism are highly complex.

    Obesity-induced increase in levels of leptin, insulin, proinflammatory cytokines and oestrogen can cause a functional hypogonadotrophic hypogonadism with the defect present at the level of the hypothalamic gonadotrophin-releasing hormone (GnRH) neurons. The resulting hypogonadism by itself can worsen obesity, creating a self-perpetuating cycle.

    Obesity-induced hypogonadism is reversible with substantial weight loss. Lifestyle-measures form the cornerstone of management as they can potentially improve androgen deficiency symptoms irrespective of their effect on testosterone levels.

    In selected patients, bariatric surgery can reverse the obesity-induced hypogonadism. If these measures fail to relieve symptoms and to normalise testosterone levels, in appropriately selected men, testosterone replacement therapy could be started. Aromatase inhibitors and selective oestrogen receptor modulators are not recommended due to lack of consistent clinical trial-based evidence.

    Fernandez CJ, Chacko EC, Pappachan JM. Male Obesity-related Secondary Hypogonadism - Pathophysiology, Clinical Implications and Management. European endocrinology 2019;15:83-90. Male Obesity-related Secondary Hypogonadism – Pathophysiology, Clinical Implications and Management – touchENDOCRINOLOGY
     
  3. Old

    Old Member

    Please correct me but isn't increased SHBG the issue? Seems like a typo

    While there are a some people who really try to lose weight, most think they are trying but eat too much anyway. Often (and this is seen with some bodybuilders trying to lower bodyfat%) people think that exercising more allows them to eat more.
    For these people, giving them TRT would not really work. For that matter, MOST people who have bariatric surgery ultimately fail. Usually, again, eating too much.
    But there are a few who really try but don't loose significant weight, got on TRT/AAS and it worked for them. But IMO, these are a minority.
    People have a psychological addiction to food - stuffing anxiety/depression, unresolved issues, or just plain hedonism ... all are ultimately 'mental' disorders.



    Bariatric surgery and the results are not particularly safe. Seems a terrible first step, THEN try TRT ???