FERTLTY AND STERLTY Copyright 1987 The Aerican Fertility Society Vol. 47, No.6, June 1987 Printed in UBA. Horone kinetics after intrauscular testosterone cypionate* Howard R. Nankin, M.D.t Medical Service, W. J. B. Dorn Veterans' Hospital, and Departent of Medicine, University of South Carolina School of Medicine, Colubia, South Carolina There have not been reports analyzing in detail the reproductive horone changes in hypogonadal en after usual therapeutic injections of testosterone cypionate (TC). n 11 hypogonadal en 200 g intrauscular TC caused a threefold rise in seru T (peak values, days 2 to 5), a 33% increase in % free T (%FT) (days 2 to 7), and a 4.5-fold rise of absolute FT (peak on days 2 to 3), a 66% increase in % nonsex horone-binding globulin-bound T (%non-shbg-t) (peak days 2 to 7), a sixfold increase in absolute non-shbg-t (peak days 4 to 5), and a threefold rise of estradiol (days 2 to 7). Many of the en achieved androgen concentrations (T, FT, and non SHBG-T) above the respective noral concentrations between days 2 and 7; then steroid values declined to basal levels by days 13 to 14. Non-SHBG-T showed the largest-fold absolute increase and on day 4 to day 5 averaged three ties the ean in noral en. Five en achieved non-shbg-t values several ties the upper liit of our total noral range. Luteinizing horone becae suppressed in en receiving their first intrauscular TC injection and reained suppressed in en receiving chronic TC. Thus, in hypogonadal en, biweekly injections of 200 g TC result in wide variations in circulating androgen levels, fro high to elevated shortly after intrauscular TC declining to basal by days 13 to 14. Fertil Steril47:1004, 1987 Safe and effective testosterone (T) replaceent therapy, in the for of intrauscular injections, has been available for several decades. 1, 2 Testosterone enanthate (TE) and testosterone cypionate (TC) are the injectable esters of ale horone ost often used clinically.2 Although there have been several studies of circulating horone changes after intrauscular TE, only a few studies assessing the effects of TC on reproductive horones in huan beings are available. 3-5 Because TC and TE are thought to be siilar and because injections of 100 to 300 g TE adinistered at 2- to 3-week intervals are the usual Received Noveber 24, 1986; revised and accepted February 16, 1987. *Supported by the Veterans' Adinistration Research Funds and by a research grant fro The Upjohn Copany. treprint requests: Howard R. Nankin, M.D., University of South Carolina School of Medicine, Departent of Medicine, Adinistration Building #28, Colubia, South Carolina 29208. 1004 Nankin ntrauscular testosterone cypionate replaceent dosages, siilar dosages have been used for TC.2-5 n a group of hypo gonadal en whose blood was sapled weekly, 200 g TC caused a several-fold elevation of T at 1 week, lower but noral seru values at 2 and 3 weeks, and a return to hypogonadal values at 4 weeks. 3 Only T levels were deterined, and exact nubers are not available in the latter report. n a randoized cross-over study of six noral 20- to 29-year-old en, a single injection of TC was copared with a single injection of TE. Seven weeks separated the two injections, and 200 g TC was given copared with 194 g TE (so that 140 g T was adinistered each tie). Seru T rose in a siilar anner after both esters, fro about 500 to approxiately 1350 ng/dl at 24 hours, decreasing to basal levels by day 10, falling below basal on days 12 and 14, and then rising to control levels by day 16. Luteinizing horone (LH) and follicle-stiulating horone (FSH) suppression was axial between days 6 Fertility and Sterility
and 10, and dihydrotestosterone was significantly elevated on days 1 to 5 after both esters.4 The conclusion was that coparable dosages of both drugs produced identical results in noral subjects.4 These authors recoended that hypogonadal subjects be given 194 g TE or 200 g TC intrauscularly at intervals closer to 2 weeks than to 3 weeks, but there were no data given on hypogonadal subjects.4 Free testosterone (FT) was thought to represent the physiologically active coponent of circulating ale horone, but recent data suggest that in addition, a ajor portion of albuin-bound T also is active at the tissue level-together these two coponents can be called bioavailable T (BAT).6 Quantifying the T not bound to sex horonebinding globulin (non-shbg-t) gives a reasonable index of BAT.7 n hypogonadal ipotent en, chronic intrauscular TC therapy increased libido and potency, but by day 14 T, FT, estradiol (E2), and non-shbg-twere the sae on placebo or TC. 5 Therefore, the current study was perfored on hypogonadalpatients to evaluate the pattern of T, FT, and non-shbg-t, and also E2 and LH changes in seru during the 14 days after chronic or first-tie adinistration of 200 g intrauscular TC. Venous blood was drawn before and periodically during the 14 days after the injections. The results suggest that supraphysiologic elevations of steroid horones occur during the first week and subnoral androgen levels occur toward the end of the second week with this dosage and frequency of adinistration. SUBJECTS MATERALS AND METHODS The subjects are described in Table 1. Nine ipotent en were originally referred for outpatient evaluation and treatent of erectile dysfunction lasting 6 onths or longer. Each an Table 1. Study Subjects Subject Race" Age Height Weight yr kg 1 W 62 1.95 102 2 W 74 1.82 82 3 B 64 1.70 92 4 W 56 1.78 73 5 W 58 1.70 88 6 W 51 1.96 99 7 W 60 1.82 91 8 W 72 1.78 82 9 B 52 1.82 89 10 W 28 1.98 84 11 W 41 1.82 100 aw, white, B, black. bs/p, status post. cbph, benign prostatic hyperplasia. ddm, diabetes ellitus. eashd, artherosclerotic heart disease. 'NPH, neutral protaine Hagedorn. gpvd, peripheral vascular disease. Diagnoses during study (basal ean seru T) Medications ngldl Essential hypertension Metoprolol, furoseide, pra- (sokes) (372) zosin, clonidine, TC S/p b prostatectoy BPH,c Furoseide, triaterene, essential hypertension etoprolol, dipyridaole, (does not soke) (366) TC DM,d essential hyperten- NPHf insulin, furoseide, sion, ASHD: (does not isosorbide, prazosin soke) (380) Rheuatoid arthritis, Procainaide, toletin, PVD,g ASHD (sokes) ethocarbaol, calciu (335) carbonate Essential hypertension Furoseide, hydralazine (sokes) (178) Testis cancer, surgery Diet-controlled and X ray, DM (does not soke) (360) Essential hypertension Labetalol, hydrochlorothia- (does not soke) (316) zide 25/triaterene 50 Rectal cancer, surgery and TC X ray (sokes) (343) Myelitis, essential hyper- Digoxin, furoseide, acetatension, atrial fibrilla- inophen, ethocartion (sokes) (216) baol, TC Hypogonadotropic hypo- TC gonadis (does not soke) (30) Partial hypo gonadotropic None hypogonadis (does not soke) (323) Vol. 47, No.6, June 1987 Nankin ntrauscular testosterone cypionate 1005
underwent a coplete history and physical exaination, and no contraindications to further evaluation and/or treatent for ipotence were found. Two or three separate orning speciens were drawn on each an for prolactin (PRL), T, and LH. No patient had significantly elevated PRL levels. All of these subjects had ean orning T concentrations < 420 ng/dl, the absolute lower liit of the noral range for 30 young (20 to 45 years), healthy en when this assay was standardized. This lower liit of noral was recently confired (see below). The basal (initial) ean seru T level for each subject is listed in Table 1. The workup we currently use to evaluate ipotent patients has been described. 5 Subject 10 had LHiFSH deficiency diagnosed at age 25 years, and intrauscular T adinistration was started, causing sexual aturation. He is one of the en undergoing chronic therapy in the current report, and his current starting T concentration was 355 ng/dl. Subject 11 had been evaluated for ild secondary hypogonadis and followed for several years without the initiation of therapy. The en in this study started intrauscular T as part of a protocol either to treat ipotence5 or to treat hypogonadotropic hypogonadis (10 and 11). They each agreed to participate in a ultiple sapling study after receiving.200 g TC intrauscularly. Blood was drawn up to eight ties during the next 14 days: between 8:00 A.M. and 10:00 A.M. just before the injection, at 4 hours, and then in the orning on days 2 to 3, 4 to 5, 6 to 7,8 to 10,11 to 12, and 13 to 14. For soe en the ultiple sapling was perfored after the first injection of TC, whereas the others had received biweekly intrauscular TC for 3 onths or longer. Except for chronic therapy in subject 10, all injections were adinistered by a research technician. Verification for treatent in subject 10 was obtained fro his physician. A research technician gave each subject his intrauscular T injection for this kinetic study. The blood saples were allowed to clot, and separated seru was frozen at - 20 C until speciens were analyzed for T, FT, non-shbg-t, E2, and LH. The protocol was approved by The Huan Studies Coittee of the University of South Carolina and The Huan nvestigation Subcoittee of The W. J. B. Dorn Veterans' Hospital. Each subject signed an infored consent agreeent. No untoward probles arose during this study. LABORATORY STUDES All speciens fro one individual were analyzed together for each horone tested. The ethods used have been described.5, 8 TC showed no apparent cross-reactivity in our T radioiunoassay (RA) «0.04%).5 The E2 assay deonstrated < 0.04% cross-reactivity with T.5 We recently deterined the circulating levels in a group of young and old noral volunteers, and the reproducibility for each horone assay is presented in Table 2. Each individual result represents the ean of three deterinations for T, FT, and E2, whereas duplicate saples were analyzed Table 2. Specifics for Laboratory Analyses in Young and Old Men Horone No. of subjects Ages Mean (range) Mean (SD) Total range ntra eva nter eva T (ng/dl) 9 74 (65--83) 527 (153) 334-862 T (ng/dl) 15 28 (22-39) 602 (169) 471-1143 %FT 5 71 (65--83) 3.5 (0.8) 2.9-5.0 FTb 5 71 (65-83) 17.6 (4.3) 13.9-24.6 %FT 10 29 (22-39) 3.7 (0.4) 3.0-4.2 FT 10 29 (22-39) 19.9.(2.1) 17.8-24.0 %non-shbg-t 7 73 (65--83) 31 (8) 18.8-41.6 non-shbg-t" 7 73 (65--83) 158 (41) 110-223 %non-shbg-t 13 28 (22-39) 45 (10) 28.3-65.4 non-shbg-t 13 28 (22-39) 246 (54) 168-340 E2 (pg/l) 5 71 (65-83) 26.6 (7.9) 17.9-35.1 E2 (pg/l) 5 30 (23-39) 21.8 (2.7) 18.3-24.5 LH{U/l) 8 73 (65--83) 5.6 (2.7) 3.0-10.9 LH (U/l) 13 28 (22-39) 3.6 (1.3) 2.1-6.5 antra CV, intraassay coefficient of variation; nter CV, interassay coefficient of variation. bft, absolute FT (ng/dl) (%FT x T). cnon-shbg-t, absolute non-shbg-t (ng/dl). % % 8.2 14.2 6.2 5.6 1.7 10.1 2.9 11.0 3.3 6.6 1006 Nankin ntrauscular testosterone cypionate Fertility and Sterility
for non-shbg-t and LH, for the noral ranges and for the current study population. RESULTS Analysis of data in an earlier study suggested no cuulative effects on T, FT, non-shbg-t, and E2 levels in 10 ipotent hypogonadal en treated with chronic intrauscular TC for 3 onths. 5 Therefore, we cobined all steroid horone results on five en herein studied during chronic intrauscular TC and 6 en who participated after their first intrauscular injections. All of the horone results are depicted in Figures 1 to 4. Two of the subjects undergoing chronic TC (no. 1 and 8) had starting T levels in the noral range (615 and 583 ng/dl, respectively); however, the group ean was 360 ± 166 ng/dl 1 standard deviation (SD). Peak values were reached between 2 and 3 (1108 ± 440 ng/dl) and 4 to 5 days (1112 ± 297 ng/dl) after intrauscular T. Five of the en (nos. 4, 6, 7, 8, and 10) had peak values> 1200 ng/dl. There was a threefold ean T rise and then a progressive decline for the group (Fig. 1). Because ofthe seru volues needed, and liited nuber of speciens that could be analyzed at one tie, %FT (and absolute FT) were deterined less frequently than other horones. %FT rose significantly, but the absolute ean rises were about 33% higher than the starting value. Only two speciens were above the noral range (one for subject 8 was 5.15% on days 4 to 5, and one for subject 11 was 5.56% on days 6 to 7). 1400 1200 1000 100 W Z o 100 a: w - e '" 400 '" w - o MEANS! SE 4h 2-3d 4-$d e-7d.-1od "-12d 13-14d 100 : :. 15 r- 50 " 25 Y i o 6 Figure 1 Coparisons of seru T and E2 concentrations, ean ± standard error, preceding and following 200-g TC injection. Statistical coparisons with starting (0) levels: a, P < 0.05; b, P < 0.02; c, P < 0.01; d, P < 0.005; and e, P < 0.001. 10 MEANS!' SE 50 : " a 40 4 -i c en w -i Z 0 0 30 rn a: -i w - : rn 0 0 Z - 20 2 rn w 9 l- W W 10 1 6 a: L 0 0 4 h 2-3d 4-5d 1-1d l-l0d 1'-12d 13-14d Figure 2 Percent FT and absolute FT concentrations, ean ± standard error, preceding and following 200-g TC injection. The 4-hour, 8- to 10-day, and 11- to 12-day saples were not analyzed because a liited nuber of saples could be deterined at the sae tie (see Materials and Methods). Statistical analysis sybols sae as on Figure 1. However, absolute average FT showed a 4.5-fold rise, and all but one subject (no. 5) had FT above the absolute noral range. FT levels averaged twice noral on days 2 to 3 and days 4 to 5. Absolute values peaked at 65.5, 56.4, 72.2, and 77.5 ng/dl for subjects 4, 6, 7, and 8, respectively (Fig. 2). The total range in both age groups of noral en is fro 13.9 to 24.6 ng/dl. Percent non-shbg-t went fro a ean of 31.9 to 52.0, 55.6, and 53.3 on days 2 to 3, 4 to 5, and 6 to 7, respectively (Fig. 3). These represent increases of about 66%. On calculation of absolute values for non-shbg-t, ean levels rose fro 110.4 ± 32.4 ng/dl (SD) to peak at 663 ± 289 ng/dl on speciens drawn on days 4 to 5 (Fig. 3). This ean is alost three ties the ean for noral young en. All of the current subjects showed increases ranging fro twofold to alost tenfold. The five highest values were 981, 1017, 884,881, and 953 ng/dl for subjects 4,7,8,10, and 11, respectively. All of these values are several ties the upper liit of our noral ranges for young or old en. E2 values rose significantly, too, fro a ean of 26.2 ± 14.9 pg/l to 76.9 ± 26.3 pg/l on days 4 to 5 (Fig. 1). This rise is probably related to conversion of T to E2, as the E2 RA is very specific. For LH, the subjects were divided into one group of six en who were included in this study after their first intrauscular TC injection, and four en who were receiving chronic TC. Subject 10 was not included because he had failure to 0 Vol. 47, No.6, June 1987 Nankin ntrauscular testosterone cypionate 1007
1500 : 4GO l- e!, 100... i 200 6- :J:,00 MEAN o O4h-2-U-4-H.-7d.-'''-'-2d-'3-' '00" 2S" Y, 6 o Figure 3 Percent non-shbg-t and absolute non-shbg-t concentrations, ean ± standard error, following 200-g TC injection. Statistical analysis sybols sae as on Figure 1. undergo sexual aturation because of gonadotropin deficiency. The en who started TC therapy showed LH reductions that persisted through day 14. Basal LH ranged fro 2.0 to 3.5 U/l, and each an deonstrated suppression. Those en receiving chronic TC had suppressed LH during the entire study (Fig. 4). DSCUSSON n the current study 11 hypogonadal en were given 200 g TC intrauscularly, and horone levels were followed periodically over the next 14 days. Most of these en had ild hypogonadis, and only one an had profound hypogonadis secondary to LH and FSH deficiency. The ages of the current study population include two en in the 20- to 45-year-old group (young en), six iddle-aged en (46 to 65 years old), and three en older than 66 years of age (aged group). We have deonstrated reduced non-shbg-t when iddle-aged en or aged en are copared with young en, and reduced FT in aged en, even though total T was the sae in all three groups. 8 Thus, direct coparisons of absolute FT and non SHBG-T between the total study population reported herein and the noral en listed in Table 2 are difficult. However, even coparing starting T, FT, and non -SHBG-T levels to those of the aged. noral group in Table 2 deonstrates reduced androgen levels in the current study population. Absolute levels of T rose 300%, FT rose 450%, non-shbg-t rose 600%, and E2 rose 300% at peak values (days 2 to 3, or 4 to 5) after the intrauscular injection. The steroid levels declined thereafter. Many of the levels reached were well above their respective noral ranges. The %FT rose by about 33%, whereas %non-shbg-t rose about 66%. Deisch and Nickelsen 9 found siilar changes for T, %FT, FT, and %non-shbg-t, after 250 g TE given intrauscularly. The supraphysiologic androgen levels attained during the first few days after intrauscular TC in the current study ay help explain soe of the harful effects of T replaceent.lo t has been suggested that BAT ore accurately reflects effective circulating T than does total T or FT, and non SHBG-T reasonably reflects BAT. 6,7 The rise of non-shbg-t was the largest relative change noted in the current study. However, SHBG-Tcan be calculated (seru T inus non-shbg-t), and it rose fro a ean of 250 ng/dl (360 inus 110) to 447 ng/dl (1110 inus 663). t has been shown that SHBG falls by 33% in noral en treated for 3 onths with TCY Because five of the current en were on chronic TC for ore than 3 onths when the study started, we anticipate that their SHBG would be constant. The first intrauscular TC injection in the other six en ay have caused a reduction in SHBG binding capacity. Whether it was coplete or not, or whether the SHBG would decrease further on chronic intrauscular TC was not evaluated in this study. A reduction in SHBG should increase non-shbg-t. However, TC given for 3 onths did not appear to alter non-shbg-t in speciens drawn 14 days after biweekly injections. 5 The low-t ipotent en currently reported have inappropriately low LH levels. This is a coon finding in such en, and the reason(s) for this is(are) not apparent. 5 At the Minneapolis Veterans' Adinistration Medical Center, 34% of 1180 en were ipotent, and of those worked up 19% had hypogonadis-about equally divided i :f... 3 E :J: 2... FRST NJECTON GROUP n, o------o-j-j. T CHRONC NJECTON GROUP n' 4 MEANStSE C d :::::_S1.ld ::::i===4 O',,,,, ', o 4h 2-3d 4-5d 1-7d 1-Od -12d 13-14d Figure 4 Mean ± standard error, seru LH concentrations in six en receiving their first injections oftc, and in four en receiving chronic intrauscular TC. Statistical analysis sybols sae as on Figure 1. 1008 Nankin ntrauscular testosterone cypionate Fertility and Sterility
into priary and secondary fors. 2 n an editorial, Spark 3 reviewed "Neuroendocrinology and potence," and he described a group of en who had low T levels, noral or low-noral PRL and gonadotropin values, and no deonstrable abnorality of the pituitary or of the hypothalaus. n an talian study of 145 en aged 60 to 91 years, 24 en had hypogonadotropic hypogonadisy However, of 234 healthy Japanese en older than 60 years of age, 53 participants had low seru T and below average LH concentrations, which was correlated with endocrinologic aging. 5 The LH depression after the first dosage of intrauscular TC and the persistently suppressed LH in en receiving chronic TC were expected. 5 Although intrauscular TE and intrauscular TC have been effective and relatively free of side effects, the current study of TC therapy and an earlier report fro our laboratory5 deonstrate wide fluctuations in androgen levels fro supraphysiologic concentrations during the first week to subnoral concentrations by day 14 after injections. Certainly, siilar changes occur with coparable doses and frequency of injection with TE. 2 We are currently evaluating increased frequency of injections with lower dosages of TC in an attept to keep circulating androgen levels physiologic. This ay help iniize side effects and iprove the therapeutic responses. Acknowledgents. Appreciation is expressed to Mrs. Jo Harrington Calkins and Mr. Charles Lane for excellent technical support and to Mrs. Ann Martin for dedicated secretarial support. The TC was kindly supplied by The Upjohn Copany, Kalaazoo, M (Depo Testosterone 200 g/l). REFERENCES 1. Nieschlag E: Current status of testosterone substitution therapy. nt J Androl 5:225, 1982 2. Snyder PJ: Clinical use of androgens. Annu Rev Med 35:207, 1985 3. Wong P-Y, Wood DE, Johnson T: Routine radioiunoassay of plasa testosterone and results for various endocrine disorders. Clin Chern 21:206, 1975 4. Schulte-Beerbo.hl M, Nieschlag E: Coparison of testosterone, dihydrotestosterone, luteinizing horone, and follicle-stiulating horone in seru after injection of testosterone enanthate or testosterone cypionate. Fertil Steril 33:201, 1980 5. Nankin HR, Lin T, Osteran J: Chronic testosterone cypionate therapy in en with secondary ipotence. Fertil Steril 46:300, 1986 6. Cuing DC, Wall SR: Non-sex horone-binding globulin-bound testosterone as a arker for hyperandrogenis. J Clin Endocrinol Metab 61:873, 1985 7. Manni A, Pardridge WM, CeFalu W, Nisula BC, Bardin CW, Santner SJ, Santen RJ: Bioavailability of albuinbound testosterone. J Clin Endocrinol Metab 61:705,1985 8. Nankin HR, Calkins JH: Decreased bioavailable testosterone in aging noral and ipotent en. J Clin Endocrinol Metab 63:1418, 1986 9. Deisch K, Nickelsen T: Distribution of testosterone in plasa proteins during replaceent therapy with testosterone enanthate in patients suffering fro hypogonadis. Andrologia 15:536, 1983 10. Matsuoto AM, Sandblo RE, Schoene RB, Lee KA, Giblin EC, Pierson DLJ, Brener WJ: Testosterone replaceent in hypogonadal en: effects on obstructive sleep apnea, respiratory drives and sleep. Clin Endocrinol 22:713, 1985 11. Plyate SR, Leonard JM, Paulsen CA, Fariss BL, Karpas AE: Sex horone-binding globulin changes with androgen replaceent. J Clin Endocrinol Metab 57:64, 1983 12. Slag MF, Morley JE, Elson MK, Trence DL, Nelson CJ, Nelson AE, Kinlaw WB, Beyer HS, Nuttall FQ, Shafer RB: potence in edical clinic outpatients. JAMA 249:1736, 1983 13. Spark RF: Neuroendocrinology and ipotence (editorial). Ann ntern Med 98:103, 1983 14. Mastrogiacoo, Feghali G, Foresta C, Ruzza G: Andropause: incidence and pathogenesis. Arch Androl 9:293, 1982 15. bayashi H, Kato K, Muta K, Wakasugi H, Matsuoto M: Studies on endocrinological index of aging in ale subjects. Jpn J Med 20:380, 1981 Vol. 47, No.6, June 1987 Nankin ntrauscular testosterone cypionate 1009