EXPERIMENTAL AND THERAPEUTIC MEDICINE 22: 1173, 2021

Clinical efficiency of combination therapy using
testosterone replacement therapy, phosphodiesterase 5
inhibitors and Kampo herbal medicine for eugonadal
patients with late‑onset hypogonadism syndrome
HISASHI TAKEUCHI1‑3 and HIDENORI OKUBO1
1

Department of Urology, Kyoeikai Okubo Hospital, Mitoshi, Ibaraki 310‑0905;
Department of Urology, Tokyo International Ohori Hospital, Tokyo 181‑0013, Japan

2

Received January 3, 2020; Accepted June 17, 2020
DOI: 10.3892/etm.2021.10608
Abstract. In the present study, the initial treatment efficiency
of combination therapy using testosterone replacement
therapy (TRT), herbal medicine and phosphodiesterase 5
inhibitors (PDE5i) in male patients with late‑onset hypo‑
gonadism (LOH) were assessed. A total of 21 patients wereenrolled and after 12 weeks, the clinical efficacy was evalu‑
ated based on improvement of LOH symptoms via laboratory
parameters and several questionnaires, including the Ageing
Males' Symptoms (AMS) scale. The overall AMS scores, aswell as the psychological, physical and sexual AMS factors
prior to and after treatment in the TRT, testosterone enanthate(T enanthate) monotherapy and T enanthate + PDE5i treatmentgroups were significantly improved. In the herbal medicinegroup, only the AMS physiological factors were significantly
improved after treatment compared with the baseline. The
improvement of the overall AMS scores, as well as the physi‑
ological and sexual AMS factors, were significantly negatively
correlated with the free testosterone (FT) value prior to treat‑
ment. In conclusion, treatment with combination therapy using
TRT, herbal medicine and PDE5i improved AMS scores inpatients with LOH syndrome. Particularly in patients with
LOH syndrome and low FT, the symptoms were significantly
improved following combination therapy.
Introduction
Late‑onset hypogonadism (LOH) syndrome is an endocrine
disorder that is characterized by low levels of androgen andCorrespondence to: Dr Hisashi Takeuchi, 3Present address:

Department of Urology, IMS Group, Shinmatsudo Central General
Hospital, Shinmatsudo 1-380, Matsudo, Chiba 270-0034, JapanE‑mail: hisashi917@yahoo.co.jp

Key words: herbal medicine, Kampo, late‑onset hypogonadism

syndrome, testosterone replacement therapy, sexual function,
urinary disfunction, anti‑ageing therapy

a subsequent decline in various physical functions (1). LOH
syndrome has a well‑established concept of disorder in men,but what differentiates it from the so‑called ‘menopausal disor‑ders’ is that testosterone levels included into the diagnostic
criteria (1).
In males, serum testosterone levels remain stable until~40 years of age, after which the circulating total testosterone
and biologically active free testosterone (FT) levels decreaseby 1‑2 and 2‑3% annually, respectively (2,3). Testosterone isstrongly bound to sex hormone‑binding globulin (SHBG) andrelatively loosely bound to albumin. The subsequent additionof FT to these hormones gives the total testosterone (TT).
Furthermore, since albumin‑bound testosterone and FT are
biologically meaningful, they are referred to as bioavailable
testosterone.
The diagnosis of LOH syndrome is based on serum testos‑terone levels, taking clinical symptoms and signs into account.
The European Endocrine Society and the International Society
for the Study of the Ageing Male recommend measuring
TT (4). In Japan, serum FT levels are used as the diagnostic
criterion for LOH syndrome (5), as Okamura et al (6) andIwamoto et al (7) reported that TT does not change with age.
Furthermore, it has also been reported that LOH‑associatedsymptoms are not significantly associated with serum levelsof TT, analog ligand FT, estradiol, luteinizing hormone (LH),
follicle‑stimulating hormone (FSH), dehydroepiandrosterone
sulfate or growth hormone (8).
Regarding the treatment of LOH syndrome, the useof several agents, primarily testosterone replacement
therapy (TRT), has been reported (9). TRT includes admin‑
istration of oral, injectable and skin‑absorbing agents, but inJapan, only testosterone enanthate (T enanthate) injection iscovered by insurance, and 125‑250 mg is usually injected
intramuscularly every 2 weeks. In Europe and the USA, an
increasing number of patients prefer gels (9).
The effects of TRT include improvements in muscle mass,strength, bone density, serum fat profile, insulin sensitivity,
libido and overall health (10). For erectile dysfunction, TRT
was determined to increase the effect of phosphodiesterase 5
inhibitors (PDE5i) (11). In a meta‑analysis of clinical trials on
TRT, the frequency of adverse events in which prostate cancer

2

TAKEUCHI and OKUBO: CLINICAL EFFICIENCY OF COMBINATION THERAPY FOR PATIENTS WITH LOH SYNDROME

occurs in association with TRT did not change between the TRT
treatment group and the placebo group (12). However, certain
patients with low testosterone levels had high‑grade malignan‑cies despite relatively low prostate‑specific antigen (PSA)
levels (13). Therefore, in accordance with Japanese guidelines,
PSA is measured; if it is 2.0 ng/ml or higher, the patient should
be referred to a urologist to rule out prostate cancer (5). LOH
syndrome may lead to a decline in numerous biological func‑
tions linked to activities of daily living (ADL) and qualityof life (QOL), including cognitive function, muscle strength,bone density, sexual function and metabolism (14‑17).
Approximately 20% of males over 60 years of age may have
LOH syndrome. These patients may improve their ADL andprevent lifestyle‑related diseases (LRDs) such as metabolic
syndrome via TRT (16). In a double‑blind clinical trial,
1,677 local residents aged 65 years or above were screened, of
which 274 patients with a weak constitution, weight loss, low
exercise, muscle weakness, fatigue, slow walking and serum
testosterone levels <345 ng/dl, who had no prostate diseaseor dysuria, were randomly assigned to the testosterone gel(50 mg/day) treatment group and the placebo group (18). The
results indicated a significant increase in knee joint muscle
strength, increased body mass index (BMI), decreased fat
mass, improved physical function, and improved QOL index(physical symptoms, sexual function symptoms) within six
months in the TRT treatment group (18).
In addition to TRT, certain therapies for LOH syndrome
commonly include counseling, antidepressants, PDE5i andherbal medicine (Kampo). Various herbal medicines have beenused to treat LOH syndrome (19). Tsujimura et al (20) recently
reported on herbal medicine as a possible treatment option.
Oxidative stress is cited as a cause of various diseases.
Oxidative stress, and occasionally anticancer activity (21),are useful biomarkers for predicting severe erectile dysfunc‑tion (ED) and LOH syndrome in middle‑aged males.
Therefore, PDE5i may improve LOH syndrome symptoms, as
PDE5i has been demonstrated to increase testosterone throughits antioxidant activity (22,23). Amano et al (24) reported that
testosterone ointment (Glowmin; DAITO Pharmaceutical Co.)
applied to patients with LOH syndrome for three months
significantly improved their functional capacity and their
psychological and mental health.
In the present study, the effectiveness of initial treatment by
combination therapy using TRT, herbal medicine and PDE5i
in male patients with LOH were determined. The patients'
clinical background, changes in symptom scores and clinicalparameters were analyzed to verify the effectiveness of thetreatment intervention.
Patients and methods
Patients. Between April 2017 and September 2018, 21 patientswith LOH‑associated symptoms, including chief complaintsof decreased libido, ED, depression and general fatigue,
visited the menopausal outpatient clinic at Kyoei‑kai Okubo
Hospital (Ibaraki, Japan). Those who had undergone previous
treatments were included in the present study (Table I). No
patients with any serious condition, such as malignancy, sleep
apnea syndrome (SAS), suicidal depression or high PSA
levels (>2.0 ng/ml), or who refused treatment, were included

according to Japanese guidelines (5). All patients provided
written informed consent to participate in the present study.
Examination. At their first visit, the patients were evaluatedby reviewing their medical history, a physical examination anddetection of clinical parameters, and their general LOH symp‑
toms were judged according to Heinemann's Ageing Males'
Symptoms (AMS) scale (25). Voiding function was evaluatedby the International Prostate Symptom Score (IPSS) (26)and sexual function was evaluated by the International Index
of Erectile Function‑5 (IIEF‑5) score. Blood screening,
including hemoglobin (Hb), aspartate transaminase, alaninetransaminase, creatinine, total cholesterol (T‑Cho), triglyc‑
eride, blood sugar and PSA, and endocrinological variables[including FT (RIA method), LH and FSH] were determineduntil 11 a.m. prior to monitoring endocrinological variables
for any treatment of LOH. The patients in the present study
had not received any medications for LOH, such as TRT,
previously.
The questionnaire to determine the AMS score as adisease‑specific measure was administered at baseline andafter 12 weeks. The AMS score comprises 17 items scoredon a five‑point scale (25). The 17 items are distributed
over three subdomains: A total of five questions address
psychological factors, seven address physical factors andfive address factors of sexual function. The total AMS
score defines symptom severity as ‘no/little’ (17‑26 points),‘mild’ (27‑36 points), ‘moderate’ (37‑49 points) or ‘severe’(≥50 points) (25).
Furthermore, the IPSS questionnaire for lower urinary
tract symptoms and IIEF‑5 questionnaire for sexual function
were also administered. The IPSS contains seven symptom
questions that assess weak urine stream, intermittency
and straining (voiding symptoms), frequency, urgency andnocturia (storage symptoms), and a feeling of incomplete
bladder emptying (post‑voiding symptom). The response
options range from ‘not at all’ (0 points) to ‘almost always’(5 points), with a maximum total of 35 points. The total IPSS
score defines symptom severity as ‘no/little’ (0‑7 points),‘moderate’ (8‑19 points) or ‘severe’ (≥20 points) (26). The
IIEF‑5 score comprises only five questions and each item isscored on a five‑point ordinal scale, wherein lower values
indicate poor sexual function. The possible IIEF‑5 scores
range from 1 to 25 points (one question may receive a scorefrom 1 to 5; all others may receive scores from 0 to 5); ascore of >21 points is considered to indicate normal erectile
function, whereas scores at or below this cut‑off indicate
ED (27).
Metabolic syndrome (Mets) and the BMI have beenreported to be related, so as an indicator of the potential Metsof the body type of individual patients (28), the BMI was
calculated initially for each patient. According to the World
Health Organization guidelines, a BMI <25 kg/m2 represents
a normal body weight and a BMI ≥25 kg/m 2 represents
overweight status (29). Thus, the patients were then groupedby their BMI‑defined body type using a threshold value of
25 kg/m2 (29). In addition, to determine the impact of diseases,
such as LRDs or psychiatric disorders (PDs), that are closely
linked to LOH syndrome, the patients were further divided
into groups with or without LRDs or PDs (30).

EXPERIMENTAL AND THERAPEUTIC MEDICINE 22: 1173, 2021

Table I. Clinical features of the patients with late‑onset hypo‑
gonadism syndrome (n=21).
Characteristic
Age (years)
BMI (kg/m2)
FT (pg/ml)
LH (mIU/ml)
FSH (mIU/ml)
PRL (ng/ml)
Hb (g/dl)
T‑Cho (mg/dl)
AMS score
IIEF5 score
IPSS score
PD (with/without)
LRD (with/without)Treatment
TRT monotherapy
T enanthate 250 mg
Testosterone ointment
TRT combination(T enanthate 250 mg + PDE5i)
Herbal medicines
Hochuekkito
KamishoyosanShakuyakukanzoto

Value
50 (33‑65)
23.1 (17.0‑35.2)
8.5 (4.9‑15.2)
4.0 (1.4‑11.8)
2.5 (1.1‑7.3)
3.0 (3.5‑64.9)
15.4 (12.9‑16.8)
196 (152‑319)
51 (36‑68)
12 (5‑22)
6 (0‑28)
4/17
9/12
14
13
1
3
4
2
1
1

Values are expressed as median (range) or n. BMI, body mass index;
PD, psychiatric disorders; LRD, lifestyle‑related diseases; FT, freetestosterone; FSH, follicle‑stimulating hormone; PRL, prolactin;
AMS, Ageing Males' Symptoms scale; IEF5, International Index of
Erectile Function‑5; IPSS, International Prostate Scale Score; PDE5i,
phosphodiesterase 5 inhibitors; TRT, testosterone replacement
therapy.

Treatment. After confirming the examination and blood
test results, TRT or an oral treatment, such as herbal
medicines or PDE5i, was provided for each symptom. For
the TRT, T enanthate (250 mg; Enarmon Depot ®; ASKA
Pharmaceutical Co., Ltd.) was administered via intramus‑
cular injection every four weeks for a total of 12 weeks
or testosterone ointment was applied to a 2.5‑cm area
once a day. The most appropriate herbal medicine wasadministered to the patients according to their pathogenic
alterations. A total of three traditional Japanese herbal
medicines, namely Kamishoyosan (TJ‑24), Hochuekkito(TJ‑41) and Shakuyakukanzoto (TJ‑68) (Tsumura & Co.),
were candidates for LOH treatment in the present study.
The composition of each of these three herbal medicines
is described in Table II. The basic selection criteria arepresented in Table III. All herbal drugs were given orally
3 times a day (before meals) to a total dose of 7.5 g/day.
All treatments were repeated over 12 weeks from thestart of treatment. Laboratory and endocrinological values
and LOH‑related symptoms determined prior to and after3

treatment were compared to evaluate the efficacy and safety of
the combination therapy for LOH.
If patients wished to be further treated, their current
treatment was continued or switched to another treatment,
continued for another 12 weeks and then evaluated again via
blood sample analyses. Those results were not included in thepresent study. There were no adverse events that required treat‑ment interruption in any treatment group during the treatment
period.
Statistical analysis. All statistical analyses were performed
using StatView (version 5.0; SAS Institute, Inc.). Continuous
variables were presented as the mean ± SD or the median(range). Based on the AMS scores, the patients were catego‑
rized into three groups: None or mild (17‑26 points and27‑36 points), moderate (37‑49 points) and severe (50 points
or more). The FT was also categorized into three groups:
Low (<8.5 pg/ml), borderline zone (≥8.5 and <11.8 pg/ml)
and normal (≥11.8 pg/ml). In addition, the IPSS scores werecategorized into three groups: Mild (0‑7 points), moderate(8‑19 points) and severe (20 points or more). A χ2 test wasused to compare the age, FT and the presence of PD and LRD
among groups stratified by their AMS score. An unpairedt‑test was used to compare clinical features, including the
AMS score, age, FT, BMI, IPSS score, IIEF‑5 score, and with
LRD groups. Correlations among various clinical parameters
were determined using the Spearman's rank correlation test
(Figs. 5 and 7). P<0.05 was considered to indicate statisticalsignificance.
Results
Clinical features and patient treatment. The clinical charac‑
teristics of the 21 patients with LOH syndrome are presented inTable I. The median patient age was 50 years (range, 33‑65 years).
The median BMI was 23.1 kg/m2 (range, 17.0‑35.2 kg/m2) andthe median AMS score was 51 (range, 36‑68). Only 9 of the
21 patients had an LRD.
The treatment details are as follows: TRT monotherapy in
14 cases (T enanthate 250 mg in 13 cases, testosterone oint‑
ment in 1 case), TRT (T enanthate 250 mg + PDE5i) in 3 casesand herbal medicines in 4 cases (Hochuekkito in 2 cases,
Kamishoyosan in 1 case and Shakuyakukanzoto in 1 case)(Table I).
Comparison of AMS score and age, FT, PDs and LRDs. As
presented in Table IV, the patients were stratified based on the
AMS scores into mild, moderate and severe groups, and it was
examined whether there was any bias in any of the groups interms of age (cut‑off, 50, 55 years), FT (low, borderline zone
and normal), and the presence or absence of PDs and LRDs by
using the χ2 test. There was no significant difference among
any of the groups.
Comparison of FT and BMI and IPSS score. As presented inTable V, the FT values were divided into low, borderline andnormal groups, and it was examined whether there was any
bias among the groups regarding the BMI (cut‑off, 25 kg/m2)
and IPSS score (no/little, moderate and severe). There was no
significant bias among the groups.

4

TAKEUCHI and OKUBO: CLINICAL EFFICIENCY OF COMBINATION THERAPY FOR PATIENTS WITH LOH SYNDROME

Table II. Composition of the three herbal medicines for the treatment of late‑onset hypogonadism syndrome.
Name

Preparation

Herbal components

Kamishoyosan (TJ‑24)

7.5 g of extract granules contain 4.0 g of a dried extract ofthe mixed crude herbs.
		
		
		
		
		
		
		
		
Hochuekkito (TJ‑41)

7.5 g of extract granules contain 5.0 g of a dried extract ofthe mixed crude herbs.

		
		
		
		
		
		
		
Shakuyakukanzoto (TJ‑68)

7.5 g of extract granules contain 2.5 g of a dried extract ofthe mixed crude herbs.

Table III. Index for the selection of herbal medicine corre‑
sponding to the conditions of patients with late‑onset
hypogonadism syndrome.
Formulation
Kamishoyosan (TJ‑24)
Hochuekkito (TJ‑41)
Shakuyakukanzoto (TJ‑68)

Conditions
Shoulder stiffness, fatigue,
anxiety

Severe fatigue, pollakisuria,
erectile dysfunction
Relief of pain, myalgia,
arthralgia, gastric pain,
abdominal pain

Associations between AMS score and various clinicalparameters. Differences in AMS scores between groups strati‑
fied based on various parameters were examined using Student's
t‑test (Fig. 1). There was no significant difference between the
average AMS value between age groups stratified with a cutoff
at 50 and 55 years. There was also no significant difference inthe average AMS value between the normal‑BMI (<25 kg/m2)
and high‑BMI (≥25 kg/m2) groups. There was also no signifi‑
cant difference in the average AMS value between patients withdifferent FT values stratified with a cutoff at 8.5 and 11.8 pg/ml.
Association between the FT value and the AMS score(psychological, physiological and sexual function). The

Bupleurum root, 3.0 g
Peony root, 3.0 g
Atractylodes lancea rhizome, 3.0 g
Angelica root, 3.0 g
Poria sclerotium, 3.0 g
Gardenia fruit, 2.0 g
Moutan bark, 2.0 g
Glycyrrhiza, 1.5 g
Ginger, 1.0 g
Mentha herb, 1.0 g
Astragalus root, 4.0 g
Atractylodes lancea rhizome, 4.0 g
Ginseng, 4.0 g
Angelica root, 3.0 g
Bupleurum root, 2.0 g
Jujube, 2.0 g
Citrus unshiu peel, 6.0 g
Glycyrrhiza, 1.5g
Cimicifuga rhizome, 1.0 g
Ginger, 0.5 g
Peony root, 6.0 g
Glycyrrhiza, 6.0 g

Table IV. Comparison of AMS score between patients stratified
by age, FT, psychiatric disorders and LRDsa before treatment.
Factor

<37

37‑50

>50

Total

Age (years)				
≥55
0
2
5
50‑54
0
1
4
<50
1
3
5

7
5
9

FT (pg/ml)				
>11.8
0
0
3
3
8.5‑11.8
1
3
4
8
<8.5
0
3
7
10
PD				
Yes
0
3
11
14
No
1
3
3
7
LRD				
Yes
0
3
11
14
No
1
3
3
7
Total (n=21)
1
6
14
21
No significant differences were found across table IV for any of
the comparisons. The total AMS score defines symptom severity as‘no/little’ (17‑26 points), ‘mild’ (27‑36 points), ‘moderate’ (37‑49
points) or ‘severe’ (≥50 points) (25). Values are expressed as n. PD,
psychiatric disorders; LRD, lifestyle‑related diseases; FT, free testos‑terone; AMS, Ageing Males' Symptoms scale.
aEXPERIMENTAL AND THERAPEUTIC MEDICINE 22: 1173, 2021

5

Figure 1. Comparisons of AMS scores in patients with late‑onset hypogonadism syndrome stratified based on various clinical parameters. (A) Comparison of
the age (cut‑off, 50 years). (B) Comparison of the age (cut‑off, 55 years). (C) Comparison of the BMI (cut‑off, 25 kg/m2). (D) Comparison of FT values (cut‑off,
11.8 ng/ml). (E) Comparison of FT values (cut‑off, 8.5 ng/ml). Continuous variables were presented as the mean ± standard deviation. BMI, body mass index;
FT, free testosterone; AMS, Ageing Males' Symptoms scale.

Table V. Comparison of FT between patients stratified by BMI
and IPSS scoresa before treatment.
FT (pg/ml)
	-----------------------------------------------------------Parameter<8.5
8.5‑11.8
>11.8

Total

BMI (kg/m2)				
<25
7
5
2
14
≥25
3
3
1
7
IPSS				
>20
3
1
0
4
8‑20
3
2
0
5
<8
4
5
3
12
Total (n=21)
10
8
3
21

Association of various clinical parameters with the FT value.
The association between the FT value and various parameters
was examined using Student's t‑test (Fig. 3). There was no
significant difference in the average FT value between age
groups stratified with a cutoff at 50 and 55 years. There was also
no significant difference in the average FT value between thenormal‑BMI (<25 kg/m2) and high‑BMI (≥25 kg/m2) groups.
Furthermore, there was no significant difference in the average
FT value between different groups of patients stratified basedon the IIEF‑5 scores (cutoff was at 9, 16 and 21). There wasalso no significant difference in the average FT value between
subgroups by IPSS score (no/little, moderate and severe; cutoff
was at 8 and 16, respectively).

No significant differences were found across table V for any of thecomparisons. The FT was also categorized into three groups: Low(<8.5 pg/ml), borderline zone (≥8.5 and <11.8 pg/ml) and normal(≥11.8 pg/ml). Values are expressed as n. FT, free testosterone; IPSS,
International Prostate Scale Score; BMI, body mass index.

Association of LRDs and various parameters. The associationof the presence of LRDs with various parameters was exam‑
ined using Student's t‑test (Fig. 4). There was no significant
difference in the mean values of the AMS, FT and IPSS
scores between patients with and without LRDs. Of note, themean IIEF‑5 score in patients with an LRD was significantly
higher than in those without an LRD, indicating that patientswith an LRD may have a significantly lower sexual function(P=0.0131; Fig. 4C).

possible association of the FT value with each category of
the AMS score (psychological, physiological and sexual func‑tion) was examined using Student's t‑test (Fig. 2). There wasno significant difference in the average AMS score in eachcategory (psychological, bodily and sexual function) between
patients with different FT values stratified with a cutoff
at 8.5 and 11.8 pg/ml.

Correlation between AMS score and various clinical parameters. The correlation between the AMS score and various
clinicopathological parameters, including age, FT, BMI, PSA
and IPSS score, in patients with LOH syndrome was exam‑
ined using Spearman's correlation test (Fig. 5). There was no
significant correlation between the AMS score and age, FT,
BMI, PSA or IPSS score in patients with LOH syndrome.

a6

TAKEUCHI and OKUBO: CLINICAL EFFICIENCY OF COMBINATION THERAPY FOR PATIENTS WITH LOH SYNDROME

Figure 2. Comparison between each category of AMS score (psychological, physiological and sexual function) and FT value in patients with late‑onset hypo‑
gonadism syndrome. (A) Comparison between AMS psychological score and FT values (cut‑off, 11.8 ng/ml). (B) Comparison between AMS psychologicalscore and FT values (cut‑off, 8.5 ng/ml). (C) Comparison between AMS physiological score and FT values (cut‑off, 11.8 ng/ml). (D) Comparison between
AMS physiological score and FT values (cut‑off, 8.5 ng/ml). (E) Comparison between AMS sexual score and FT values (cut‑off, 11.8 ng/ml). (F) Comparison
between AMS sexual score and FT values (cut‑off, 8.5 ng/ml). Continuous variables were presented as the mean ± standard deviation. FT, free testosterone;
AMS, Ageing Males' Symptoms scale.

Figure 3. Comparisons of FT values in patients with late‑onset hypogonadism syndrome stratified based on various clinical parameters. (A) Comparison by
BMI (cut‑off, 25 kg/m2). (B) Comparison by age (cut‑off, 50 kg/m2). (C) Comparison by age (cut‑off, 55 years). (D) Comparison by IIEF5 score (cut‑off, 21).
(E) Comparison by IIEF5 score (cut‑off, 16). (F) Comparison by IIEF5 score (cut‑off, 8). (G) Comparison by IPSS score (cut‑off, 8). (H) Comparison by IPSS
score (cut‑off, 21). Continuous variables were presented as the mean ± standard deviation. FT, free testosterone; BMI, body mass index; IEF5, International
Index of Erectile Function‑5; IPSS, International Prostate Scale Score.

Efficiency of combination therapy using TRT, PDE5i andherbal medicine for patients with LOH syndrome. The AMS
scores (overall, psychological, physiological and sexualfunction) prior to and after each treatment were compared(Table VI). Significant improvements in the overall AMS
scores were observed after treatment in the TRT group,
T enanthate monotherapy treatment group and T enanthateand PDE5i treatment group (P<0.001; Table VIA). In the

EXPERIMENTAL AND THERAPEUTIC MEDICINE 22: 1173, 2021

7

Figure 4. Comparisons of various parameters in patients with late‑onset hypogonadism syndrome with and without LRD. (A) Comparison by AMS score.
(B) Comparison by FT value. (C) Comparison by IIEF5 score. (D) Comparison by IPSS score. Continuous variables were presented as the mean ± standard
deviation. LRD, lifestyle‑related diseases; AMS, Ageing Males' Symptoms scale; FT, free testosterone; IEF5, International Index of Erectile Function‑5; IPSS,
International Prostate Scale Score.

Figure 5. Correlation between AMS score and various clinical parameters in patients with late‑onset hypogonadism syndrome. (A) Correlation with age (years).
(B) Correlation with FT values. (C) Correlation with the BMI. (D) Correlation with PSA values. (E) Correlation by IPSS score. FT, free testosterone; AMS,
Ageing Males' Symptoms scale; IPSS, International Prostate Scale Score; PSA, prostate‑specific antigen.

herbal medicine group, the overall AMS scores were alsoslightly improved after treatment, but there was no statisticalsignificance (P= 0.144).

There was a significant improvement in the physiologicalfactors of the AMS after treatment in all treatment groups(P<0.001; Table VIB). In the TRT group, including the8

TAKEUCHI and OKUBO: CLINICAL EFFICIENCY OF COMBINATION THERAPY FOR PATIENTS WITH LOH SYNDROME

Table VI. AMS scores at baseline and 12 weeks after each treatment.
A, Overall AMS score
Method of treatment

AMS score prior to treatment (median)

AMS score after treatment (median)P‑value52.9±8.854.6±8.2
53.4±7.655.3±8.1
45.5±8.437.5±11.5
38.2±10.6
37.0±9.939.2±10.634.8±16.4<0.001<0.001<0.001<0.001
0.144

AMS score prior to treatment (median)

AMS score after treatment (median)P‑value22.0±4.422.0±3.7
21.3±3.822.0±3.822.0±7.7

16.0±5.515.9±4.415.1±3.816.2±4.4
16.8±9.7<0.001<0.001<0.001<0.001
0.017

AMS score prior to treatment (median)

AMS score after treatment (median)P‑value15.5±3.916.5±3.1
16.6±2.8
16.9±2.6
11.3±4.6

10.3±4.0
10.6±4.0
10.3±4.3
10.9±4.0
9.3±4.0<0.001<0.001<0.001<0.001
0.415

AMS score prior to treatment (median)

AMS score after treatment (median)P‑value15.4±4.1
16.1±4.0
15.4±3.8
16.3±4.0
12.3±3.6

11.1±4.1
11.7±4.2
11.6±4.3
12.1±4.1
8.8±3.0<0.001
0.001
0.015
0.003
0.322

All (n=21)
TRT (n=14)
T enanthate monotherapy
T enanthate and PDE5i
Herbal medicine
B, AMS sub‑score (physiological factors)
Method of treatment
All (n=21)
TRT (n=14)
T enanthate monotherapy
T enanthate and PDE5i
Herbal medicine
C, AMS sub‑score (psychological factors)
Method of treatment
All (n=21)
TRT (n=14)
T enanthate monotherapy
T enanthate and PDE5i
Herbal medicine
D, AMS sub‑score (sexual function)
Method of treatment
All (n=21)
TRT (n=14)
T enanthate monotherapy
T enanthate and PDE5i
Herbal medicine

AMS, Ageing Males' Symptoms scale; PDE5i, phosphodiesterase 5 inhibitors; TRT, testosterone replacement therapy.

T enanthate monotherapy group (P<0.001) and the T enan‑
thate + PDE5i treatment group (P<0.001), a significant
improvement in physiological factors of AMS was achieved
after treatment. In the herbal medicine group, a significant
improvement in the psychological factors of AMS was also
observed after treatment (P=0.017).
There was a significant improvement in the psychologicalfactors of AMS after treatment in various treatment groups(P<0.001; Table VIC). There was a significant improvement in thepsychological factors of AMS after treatment in the TRT groups,
including the T enanthate monotherapy treatment group and theT enanthate + PDE5i treatment group, but there was no signifi‑
cant difference in the herbal treatment group (P=0.415).
There was a significant improvement in the sexual func‑
tional factors of AMS after treatment in several treatmentgroups (P<0.001; Table VID). In the TRT groups, including
the T enanthate monotherapy group and T enanthate + PDE5i
treatment group, the sexual function factors of AMS weresignificantly improved after treatment (P<0.001). In the herbal
medicine group, the AMS sexual functional factors were alsoslightly improved after treatment, but there was no significant
difference (P=0.322).

EXPERIMENTAL AND THERAPEUTIC MEDICINE 22: 1173, 2021

9

Figure 6. Comparison of improvement in AMS score after treatment vs. baseline in patients with late‑onset hypogonadism syndrome stratified by their baseline
AMS or FT score. (A) Comparison of AMS score improvement in patients stratified by their FT value prior to treatment (cut‑off, 8.5 ng/ml). (B) Comparisonof AMS score improvement in patients stratified by their FT value prior to treatment (cut‑off, 11.8 ng/ml). (C) AMS score improvement in patients stratified bytheir AMS score prior to treatment (cut‑off, 50). Continuous variables were presented as the mean ± standard deviation. FT, free testosterone; AMS, Ageing
Males' Symptoms scale.

Figure 7. Correlation between improvement in AMS score (all, psychological factors, physiological factors and sexual factors) after treatment and FT value
prior to treatment in patients with late‑onset hypogonadism syndrome. (A) Correlation between the improvement in overall AMS score and pre‑treatment
FT value. (B) Correlation between the improvement in AMS psychological score and the pre‑treatment FT value. (C) Correlation between the improve‑
ment in AMS physiological score and the pre‑treatment FT value. (D) Correlation between the improvement in AMS sexual score and the pre‑treatment
FT value. FT, free testosterone; AMS, Ageing Males' Symptoms scale.

Associations among AMS score improvement and FT value
prior to treatment or AMS score prior to treatment. The
association of the AMS score improvement with theFT value prior to treatment or the AMS score prior totreatment was examined using Student's t‑test (Fig. 6). The
average difference in the AMS score prior to vs. after treat‑ment, defined as the AMS score improvement via treatment,
was compared between patients with different pre‑treatment
FT values stratified with cutoff values of 8.5 and 11.8 pg/ml.
The results indicated that a lower pre‑treatment FT value
was associated with a greater improvement in AMS. Of

note, the improvement in AMS was significantly higher inthe group with an FT value of <8.5 pg/ml prior to treat‑ment as compared with that in the group with FT ≥8.5 pg/ml(P= 0.0036; Fig. 6B).
The cohort was then divided based on the AMS scoreprior to treatment with a cutoff at 50 points, and the AMS
score improvements via treatment were compared between
these two subgroups. A higher pre‑treatment AMS score
was associated with a greater improvement in AMS scoreafter treatment; however, this difference was not significant.
It may be concluded that patients with a lower FT value and10

TAKEUCHI and OKUBO: CLINICAL EFFICIENCY OF COMBINATION THERAPY FOR PATIENTS WITH LOH SYNDROME

Table VII. Clinical screening factors were not significantly changed after all treatments compared with the baseline value.
Parameter

Prior to treatment (median)After treatment (median)P‑value

LH
T‑cho
Hb
FT
IIEF5 score
IPSS score

2.8±1.5
212.0±47.0
15.3±1.1
8.5±3.0
13.4±5.7
8.6±8.6

1.6±1.8
207.1±33.2
15.4±1.1
9.6±4.0
16.0±5.1
6.4±5.9

0.007
0.439
0.668
0.368
0.010
0.072

FT, free testosterone; Hb, hemoglobin; LH, luteinizing hormone; T‑cho, total cholesterol; IEF5, International Index of Erectile Function‑5;
IPSS, International Prostate Scale Score.

a higher AMS score prior to treatment may exhibit a greater
AMS score improvement following treatment. In particular,
the patient group with a pre‑treatment FT value of <8.5 pg/ml
presented with a significantly higher therapeutic effect.
Correlation between improvement in AMS score (overall,
psychological, physiological and sexual functioning) andFT value prior to treatment. Upon examination using
Spearman's correlation test, the correlation between the
improvement in the AMS score and the pre‑treatment FT value
exhibited a significant negative correlation (P= 0.0239;
Fig. 7A). In other words, patients with a lower FT value prior
to treatment had a greater improvement in AMS score after
the treatment.
Examination of the correlation between the improvement in
the psychological AMS score with the FT value prior to treat‑ment revealed no significant correlation (P= 0.1904; Fig. 7B).
However, the improvement of the AMS score of physiologicaland sexual functioning and the FT value prior to treatment
indicated a significant negative correlation (P= 0.0394 and
P= 0.0406; Fig. 7C and D, respectively). In conclusion, patientswith a lower FT value prior to treatment had significantly
improved overall AMS scores, as well as AMS scored ofphysical and sexual function.
Examination of changes in each clinical factor after vs.
prior to treatment. Combining all treatments, a significant
decrease in serum LH after treatment was observed (P=0.007;
Table VII). Furthermore, slight but insignificant increases in
FT levels, as well as an insignificant decrease in the serum
T‑Cho were detected after treatment. A significant increasein the IIEF‑5 score was observed after treatment (P= 0.01;
Table VII), demonstrating that combination therapy using
TRT, PDE5i and herbal medicine may contribute to the treat‑ment of sexual dysfunction. Furthermore, there was a decreasein the IPSS score after treatment, but it was not significant.
Discussion
In the present study, the treatments were selected based on theclinical background and initial therapeutic effects in 21 males
treated for LOH syndrome as outpatients were evaluated andgood results regarding improvement of the symptoms based on
the AMS score were obtained in each treatment group.

The association between sex hormones and urologicaldiseases has been reported previously (31). In recent years, it
has become widely recognized that menopausal‑like symp‑
toms may occur in middle‑aged and elderly males, as well as infemales, due to decreased androgen production. The term LOH
syndrome is now being used to describe this condition and it
is defined as a ‘syndrome by androgen decrease according to
age that may result in multi‑organ dysfunction and decrease in
QOL’ (1). Testosterone and associated hormonal changes due
to ageing are more clearly reduced by ageing for FT compared
to TT. SHBG increases the decrease in FT and albumin‑boundtestosterone. Adrenal androgens are also on the decline withincreasing age (2,3). Liu et al (32) reported that genetic varia‑
tion among individuals exists in the number of CAG repeats
in the androgen receptor and affects the therapeutic effect ofgenetic polymorphisms, and that the number of repeats andandrogenic activity are inversely related. They also indicatedthat patients with serum TT levels of 340 ng/dl or higher tend
to develop LOH symptoms if they have CAG repeat lengthsof ≥25.
In the present study, patients with FT of <8.5 pg/ml at thefirst visit exhibited a significantly greater improvement in their
AMS score after treatment as compared with those with an
FT of ≥8.5 pg/ml. In addition, there was a negative correlation
between AMS score improvement following treatment andFT levels at the first visit. This suggests that, in patients withlow FT, the symptoms of LOH syndrome may be improved byaggressive intervention using combination therapy with TRT,
herbal medicine and PDE5i. Although various physical, psycho‑
logical or sexual dysfunction symptoms may occur in LOH
syndrome, TRT is considered the first treatment, as androgen
deficiency is the essence of the condition (5). However, it has
also been indicated that an increase in the blood testosterone
concentration due to testosterone administration is caused byaging (33).
In the present study, a significant increase in the IIEF‑5score after treatment was observed, suggesting that combi‑
nation therapy using TRT, herbal medicine and PDE5i may
be effective as a single treatment for sexual dysfunction.
Sexual decline is an important clinical manifestation of LOH
syndrome. In particular, when the three items of low sexualdesire, i.e., decreased nocturnal and morning erections andED, appear together, LOH syndrome is more strongly indi‑cated (34). As for the association between testosterone andEXPERIMENTAL AND THERAPEUTIC MEDICINE 22: 1173, 2021

erectile ability, a Japanese study has reported that IIEF‑5
increases when testosterone increases (35); this trend was also
indicated in a study from the US (36). In the present study,
lower pre‑treatment FT levels were associated with a greater
increase in total AMS score for physical and sexual function
following treatment. Various factors affecting the sexual func‑tion of testosterone have been reported and the basic research
results expected to also be observed in clinical practice areas follows: i) Nitric oxide synthase activity stimulation asa physiological effect; ii) maintenance of penile structureand function as a developmental effect; iii) development,
maintenance, function and plasticity of erectile nerve andpelvic plexus as neurological effects; and iv) improvement inresistance of PDE5i for ED as an anti‑ageing effect (2,3).
Symptoms resulting from changes in testosterone withage are defined as LOH syndrome. However, a decrease intestosterone from various causes may be associated with thedevelopment of symptoms as well as ageing. A study reported
that the rate of testosterone changes is a factor predicting theonset of symptoms of LOH syndrome (37). In addition, thethreshold of symptom manifestation due to the decrease intestosterone varies depending on the organ it affects (38).
Decreased serum testosterone may be associated withspecific symptoms and metabolic risks in males (10). In thepresent study, no significant correlation between PSA andtestosterone was observed. PSA, a tumor marker for prostatecancer, is used as an indicator for prostate cancer diagnosis
and treatment (39). Rastrelli et al (40) reported that PSA was amarker of the testosterone concentration and that it may repre‑
sent a novel indicator for confirming hypogonadism. They also
stated that determining PSA levels may provide insight not
only regarding the circulating levels of TT but also its active
fractions.
In the present study, the efficiency of a combination
treatment using several drugs that have been reported to beefficacious in patients with LOH syndrome, i.e., T enanthate,testosterone ointment, PDE5i and herbal medicines, wasevaluated. The effect of each treatment on LOH syndrome
has been previously reported, primarily that of T enanthate.
Snyder et al (41) reported on a randomized controlled trial(RCT) that examined the effectiveness of TRT for the mostcommon complaints among the middle‑aged and elderly. Theirresults indicated that the effects on sexual function factors,
including sexual activity, libido and erectile ability, physicalfunction factors, including walking distance and vitality,and psychological function, including depression symptoms,
improved in the TRT group. The present report had a patient
cohort recruited based on a tight selection criteria (n=790),
testosterone was controlled within the physiological range
after TRT (41).
In the present study, there were no adverse events requiring
treatment interruption in any group during the drug admin‑
istration period. To date, no RCT with sufficient power toadequately assess the impact of TRT on cardiovascular eventsand death has been performed. A previous retrospective study
including almost 4,000 cases suggested that TRT does notincrease the risk of cardiovascular events (42).
It is unlikely that prostate cancer is caused by TRT. In ameta‑analysis of clinical trials on the use of TRT, the frequency
prostate cancer as an adverse event detected in the placebo

11group and hormone replacement group was not significantly
different, but rather in patients with lower testosterone levels,
the rate of aggressive prostate cancer was relatively high (43).
Although androgen is a steroid hormone that is thought toaffect not only male reproductive organs, but also numerous
other organs, tissues, biological functions and even behav‑
iors, the mechanisms of action of androgens have remained
to be fully elucidated. Conventional side effects that should
be considered when administering TRT include cardiovas‑
cular disease, abnormal lipid metabolism, polycythemia,
fluid retention, prostatic hypertrophy, prostate cancer,
hepatotoxicity, SAS, gynecomastia, acne, testis atrophy,
infertility, and behavioral and mood changes (44,45). In thepresent study, the significant decrease in the plasma levelsof LH following testosterone treatment may have been due
to suppression of LH, the upstream hormone of testos‑terone (46). This is important for clinicians to note, since
it may lead to testicular atrophy and requires monitoring,
including blood tests during the course of treatment for LOH
syndrome.
The present study covered initial treatment for LOH,
over three months from the start of treatment. In patients
who received medical intervention for LOH syndrome, thephysical and sexual function, as well as total AMS scores,
improved after treatment for three months. There was also
a significant improvement in the IIEF‑5 score for sexualfunction factors following treatment. Tsujimura et al (47)administered TRT for patients with LOH for 7.3 months on
average. Their analyses prior to treatment, after treatment andthree months after treatment indicated that, at three months
after treatment, testosterone had returned to pre‑treatment
levels, but the total AMS and physical and psychologicalfactor scores were significantly improved by the treatment
and were maintained at three months after the end of treat‑
ment. Lifelong TRT is not always required for patients withimproved symptoms (47). From this point of view, it appears
to be important to improve symptoms via initial treatment.
Although the present study was limited to an evaluation of
the initial three months of treatment, it is worthwhile due theimportance of the initial treatment.
There is no universally agreed threshold for ‘normal’serum testosterone levels. In addition, there are no generally
accepted lower limits of normal TT. LOH syndrome comprises
non‑specific, indefinite complaints and the symptoms are
particularly similar to those of peripheral depression. The
target serum testosterone levels for TRT are not absolutely
diagnostic. Careful differentiation of whether a symptom isdue to LOH syndrome is important for a more accurate diag‑nosis. To increase the accuracy of LOH syndrome diagnosis,
decreased vigor, decreased energy and motivation, fatigue,
depressive mood and sleep disturbances may also be associ‑ated with LOH syndrome, and physical symptoms may appear
as obesity and increased blood levels of cholesterol. The
association between symptoms and testosterone levels is notclear in numerous cases and inter‑individual differences in theappearance of these symptoms must be taken into account.
Furthermore, the diagnosis should be made by comprehen‑sively considering the decrease in serum testosterone levels,
the aforementioned symptoms and the results of a physicalexamination (48).

12

TAKEUCHI and OKUBO: CLINICAL EFFICIENCY OF COMBINATION THERAPY FOR PATIENTS WITH LOH SYNDROME

According to Japanese guidelines, hormone replacement
therapy is not performed in patients with FT of ≥11.8 pg/ml
and treatments should be considered depending on the symp‑
toms (5). In the present study, herbal medicine treatment wasalso effective. The herbal medicines were not as potent as the
TRT treatments and no significant change was achieved fornumerous parameters. However, the herbal medicines wereinstead given to the patients with less severe LOH at baseline
and with higher FT, so that the magnitude of the changes
required to reach a near‑normal state were not as high. In
particular, there was a significant improvement in the scores
related to physical symptoms of AMS. In herbal medicine,
Hochuekkito has been reported to increase testosterone levels;
Saikouka Ryubon‑Oyakuto has no effect on testosterone levels
but has been reported to improve the symptoms of LOH via
cytokines (19,49).
In relation to Mets, including LRDs and urological diseases,
dysuria and urolithiasis are well known, but other associationsof Mets and LOH syndrome have also been reported (50,51).
Decreased testosterone levels are a significant risk factor
for type 2 diabetes and Mets (52,53). RCTs have graduallydemonstrated the effects of TRT on metabolic factors. A
recent meta‑analysis of the effects TRT on metabolic factors
in a middle‑aged group of patients in their 50s, based on
multiple RCTs, indicated that it should improve insulin sensi‑
tivity and hyperlipidemia in addition to decreasing abdominal
circumference (54).
The limitations of the present study include the small
number of cases, the retrospective study design and the shortobservation period. It is difficult to draw an affirmative conclu‑
sion based on this number of patients. Therefore, the results ofthe present study only suggest certain trends. Future tasks areto acquire cases and follow their long‑term progress, as wellas to determine the effectiveness of each treatment method,side effects and drug combination effects. In addition, drug
treatment and examination of the effects of nutritional therapy
on LOH syndrome are necessary.
In conclusion, among the outpatients with LOH syndrome
who presented at our hospital, improved AMS scores wereobserved in numerous cases following treatment intervention
using combination or single therapy with TRT, herbal medicine
and PDE5i, and the outcomes were favorable.
From these results, it was indicated that lower serum FTlevels prior to treatment were associated with a significantly
greater improvement in AMS score after treatment. In partic‑
ular, the physical and sexual function factors and AMS scores
after treatment were significantly more improved in the groupwith FT <8.5 pg/ml at the first visit. These results suggestthat patients with LOH syndrome with low FT are likely toexperience symptom improvement by treatment intervention.
There was also a significant increase in the IIEF‑5 score after
treatment. This suggests that combination therapy using TRT,
herbal medicine and PDE5i may be effective as a single treat‑ment for sexual dysfunction.
In addition to TRT, numerous treatments have beenreported for LOH syndrome, and these treatments achieved
good results in the present study. Thus, it is required to evaluate
the symptoms of each patient with LOH syndrome to judge
whether they require treatment intervention and determine theappropriate treatment method.

Acknowledgements
Not applicable.
Funding
No funding was received.
Availability of data and materials
The datasets used and/or analyzed during the current study areavailable from the corresponding author on reasonable request.
Authors' contributions
HT designed the study, contributed to analysis and interpreta‑tion of data. HT and HO were involved in the treatment of
actual patients at the hospital, made a contribution to theacquisition of data for this study and confirmed the authenticityof all the raw data. Both authors approved the final version of
the manuscript, and agree to be accountable for all aspects of
the work in ensuring that questions related to the accuracy or
integrity of any part of the work are appropriately investigatedand resolved.
Ethics approval and consent to participate
All procedures of the present study were approved by the
Ethical Committee of Kyoeikai Okubo Hospital (Ibaraki,
Japan). All patients provided written informed consent toparticipate in the present study.
Patient consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
References
1. Nieschlag E, Swerdloff R, Behre HM, Gooren LJ, Kaufman JM,
Legros JJ, Lunenfeld B, Morley JE, Schulman C, Wang C, et al:
Investigation, treatment, and monitoring of late‑onset hypogo‑nadism in males: ISA, ISSAM, and EAU recommendations.
J Androl 27: 135‑137, 2006.
2. Feldman HA, Longcope C, Derby CA, Johannes CB, Araujo AB,
Coviello AD, Bremner WJ and McKinlay JB: Age trends in thelevel of serum testosterone and other hormones in middle‑aged
men: Longitudinal results from the Massachusetts male aging
study. J Clin Endocrinol Metab 87: 589‑598, 2002.
3. Wu FC, Tajar A, Pye SR, Silman AJ, Finn JD, O'Neill TW,
Bartfai G, Casanueva F, Forti G, Giwercman A, et al:
Hypothalamic‑pituitary‑testicular axis disruptions in older
men are differentially linked to age and modi able risk factors:
The European Male Aging Study. J Clin Endocrinol Metab 93:
2737‑2745, 2008.
4. Wang C, Nieschlag E, Swerdloff R, Behre HM, Hellstrom WJ,
Gooren LJ, Kaufman JM, Legros JJ, Lunenfeld B, Morales A, et al:
Investigation, treatment and monitoring of late‑onset hypogonadism
in males: ISA, ISSAM, EAU, EAA and ASA recommendations.
Eur J Endocrinol 159: 507‑514, 2008.
5. Japanese Urological Association/Japanese Men's Health Medicine
Association: LOH symptom group - Aging Male Hypogonadism
Syndrome Medical Guidance. Jihou, Tokyo, 4-7, 2007.

EXPERIMENTAL AND THERAPEUTIC MEDICINE 22: 1173, 2021

6. Okamura K, Ando F and Shimokata H: Serum total and freetestosterone level of Japanese men: A population‑based study. Int
J Urol 12: 810‑814, 2005.
7. Iwamoto T, Yanase T, Horie H, Namiki M and Okuyama A:
Late‑onset hypogonadism (LOH) and androgens: Validity of themeasurement of free testosterone levels in the diagnostic criteria
in Japan. Int J Urol 16: 168‑174, 2009.
8. Miwa Y, Kaneda T and Yokoyama O: Correlation between the
Aging Males' symptoms Scale and sex steroids, gonadotropins,
dehydroepiandrosterone sulfate, and growth hormone levels in
ambulatory men. J Sex Med 3: 723‑726, 2006.
9. Nieschlag E: Testosterone treatment comes of age: New options
for hypogonadal men. Clin Endocrinol (Oxf) 65: 275‑281,
2006.
10. Wang C, Swerdloff RS, Iranmanesh A, Dobs A, Snyder PJ,
Cunningham G, Matsumoto AM, Weber T and Berman N;
Testosterone Gel Study Group: Transdermal testosteron gel
improves sexual function, mood, muscle strength, body compo‑
sition parameters in hypogonadal men. J Clin Endocrinol
Metab 85: 2839‑2853, 2000.
11. Tenover JS: Effects of testosterone supplementation in the aging
male. J Clin Endocrinol Metab 75: 1092‑1098, 1992.
12. Buvat J, Maggi M, Gooren L, Guay AT, Kaufman J,
Morgentaler A, Schulman C, Tan HM, Torres LO, Yassin A and
Zitzmann M: Endocrine aspects of male sexual dysfunctions.
J Sex Med 7: 1627‑1656, 2010.
13. Ide H, Yasuda M, Nishio K, Saito K, Isotani S, Kamiyama Y,
Muto S and Horie S: Development of a nomogram for predicting
high‑grade prostate cancer on biopsy: The significance of serum
testosterone levels. Anticancer Res 28C: 2487‑2492, 2008.
14. Bagatell CJ and Bremner WJ: Androgens in men: Uses andabuses. N Engl J Med 334: 707‑714, 1996.
15. Coates JM and Herbert J: Endogenous steroids and financial risktaking on a London trading floor. Proc Natl Acad Sci USA 105:
6167‑6172, 2008.
16. Muller M, Grobbee DE, den Tonkelaar I, Lamberts SW andvan der Schouw YT: Endogenous sex hormones and metabolic
syndrome in aging men. J Clin Endocrinol Metab 90: 2618‑2623,
2005.
17. Bhasin S, Cunningham GR, Hayes FJ, Matsumoto AM,
Snyder PJ, Swerdloff RS and Montori VM: Testosterone therapy
in adult men with androgen deficiency syndromes: An endocrine
society clinical practice guideline. J Clin Endocrinol Metab 91:
1995‑2010, 2006.
18. Srinivas‑Shankar U, Roberts SA, Connolly MJ, O'Connell MD,
Adams JE, Oldham JA and Wu FC: Effects of testosterone on
muscle strength, physical function, body composition, and qualityof life in intermediate‑frail and frail elderly men: A random‑
ized, double‑blind, placebo‑controlled study. J Clin Endocrinol
Metab 95: 639‑650, 2010.
19. Amano T, Imao T and Takemae K: Clinical efficacy of Japanesetraditional herbal medicine (Kampo) in patients with late‑onset
hypogonadism. Aging Male 13: 166‑173, 2010.
20. Tsujimura A, Takada S, Matsuoka Y, Nakayama J, Takao T,
Miyagawa Y, Nonomura N and Okuyama A: Clinical trial oftreatment with saikokaryukotsuboreito for eugonadal patientswith late‑inset hypogonadism‑related symptoms. Aging Male 11:
95‑99, 2008.
21. Takeuchi H, Taoka R, Mmeje CO, Jinesh GG, Safe S and
Kamat AM: CDODA‑Me decreases specificity protein transcrip‑tion factors and induces apoptosis in bladder cancer cells throughinduction of reactive oxygen species. Urol Oncol 34: 337.e11‑8,
2016.
22. Yasuda M, Ide H, Horie S, Yoshii T, Nishio K, Saito K, Isotani S,
Kamiyama Y, Muto S and Horie S: Salivary 8‑OHdG: A usefulbiomarker for predicting severe ED and hypogonadism. J Sex
Med 5: 1482‑1491, 2008.
23. Podlasek CA, Mulhall J, Davies K, Wingard CJ, Hannan JL,
Bivalacqua TJ, Musicki B, Khera M, González‑Cadavid NF
and Burnett AL II: Translational perspective on the role of
testosterone in sexual function and dysfunction. J Sex Med 13:1183‑1198, 2016.
24. Amano T, Iwamoto T, Sato Y, Imao T and Earle C: The efficacy
and safety of short‑acting testosterone ointment (Glowmin) for
late‑onset hypogonadism in accordance with testosterone circa‑
dian rhythm. Aging Male 21: 170‑175, 2018.
25. Heinemann LA, Zimmermann T, Vermeulen A, Thiel C and
Hummel W: A new ‘aging males’ symptoms' (AMS) rating scale.
Aging Male 2: 105‑114, 1999.

13

26. Barry MJ, Fowler FJ Jr, O'Leary MP, Bruskewitz RC,
Holtgrewe HL, Mebust WK and Cockett AT: The American
urological association symptom index for benign prostatic hyper‑
plasia. The measurement committee of the American urologicalassociation. J Urol 148: 1549‑1557; discussion 1564, 1992.
27. Rosen RC, Cappelleri JC, Smith MD, Lipsky J and Peña BM:
Development and evaluation of an abridged, 5‑item version of
the International index of erectile function (IIEF‑5) as a diag‑nostic tool for erectile dysfunction. Int J Impot Res 11: 319‑326,
1999.
28. Frankenfield DC, Rowe WA, Cooney RN, Smith JS and Becker D:
Limits of body mass index to detect obesity and predict bodycomposition. Nutrition 17: 26‑30, 2001.
29. WHO Expert Consultation: Appropriate body‑mass index for
Asian populations and its implications for policy and interven‑tion strategies. Lancet 363: 157‑163, 2004.
30. Sato Y, Tanda H, Kato S, Onishi S, Nakajima H, Nanbu A,
Nitta T, Koroku M, Akagashi K and Hanzawa T: Prevalence ofmajor depressive disorder in self‑referred patients in a late onset
hypogonadism clinic. Int J Impot Res 19: 407‑410, 2007.
31. Takeuchi H, Mmeje CO, Jinesh GG, Taoka R and Kamat AM:
Sequential gemcitabine and tamoxifen treatment enhances apop‑
tosis and blocks transformation in bladder cancer cells. Oncol
Rep 34: 2738‑2744, 2015.
32. Liu CC, Lee YC, Wang CJ, Yeh HC, Li WM, Wu WJ, Huang CN,
Bao BY, Huang CH and Huang SP: The impact of androgen
receptor CAG repeat polymorphism on andropausal symptoms
in different serum testosterone levels. J Sex Med 9: 2429‑2437,
2012.
33. Coviello AD, Lakshman K, Mazer NA and Bhasin S: Differencesin the apparent metabolic clearance rate of testosterone in young
and older men with gonadotropin suppression receiving gradeddoses of testosterone. J Clin Endocrinol Metab 91: 4669‑4675,
2006.
34. Wu FC, Tajar A, Beynon JM, Pye SR, Silman AJ, Finn JD,
O'Neill TW, Bartfai G, Casanueva FF, Forti G, et al: Identificationof late‑onset hypogonadism in middle‑aged and elderly men.
N Engl J Med 363: 123‑135, 2010.
35. Tsujimura A, Matsumiya K, Matsuoka Y, Takahashi T, Koga M,
Iwasa A, Takeyama M and Okuyama A: Bioavailable testosterone
with age and erectile dysfunction. J Urol 170: 2345‑2347, 2003.
36. Cunningham GR, Stephens‑Shields AJ, Rosen RC, Wang C,
Ellenberg SS, Matsumoto AM, Bhasin S, Molitch ME, Farrar JT,
Cella D, et al: Association of sex hormones with sexual function,
vitality, and physical function of symptomatic older men with
low testosterone levels at baseline in the testosterone trials. J Clin
Endocrinol Metab 100: 1146‑1155, 2015.
37. Holm AC, Fredrikson MG, Theodorsson E, Palmefors LG,
Karlsson PS, Joborn C and Hammar ML: Change in testosterone
concentrations over time is a better predictor than the actual
concentrations for symptoms of late onset hypogonadism. Aging
Male 14: 249‑256, 2011.
38. Zitzmann M, Faber S and Nieschlag E: Association of specificsymptoms and metabolic risks with serum testosterone in older
men. J Clin Endocrinol Metab 91: 4335‑4343, 2006.
39. Takeuchi H, Ohori M and Tachibana M: Clinical significance ofthe prostate‑specific antigen doubling time prior to and following
radical prostatectomy to predict the outcome of prostate cancer.
Mol Clin Oncol 6: 249‑254, 2017.
40. Rastrelli G, Corona G, Vignozzi L, Maseroli E, Silverii A,
Monami M, Mannucci E, Forti G and Maggi M: Serum PSA asa predictor of testosterone deficiency. J Sex Med 10: 2518‑2528,
2013.
41. Snyder PJ, Bhasin S, Cunningham GR, Matsumoto AM,
Stephens‑Shields AJ, Cauley JA, Gill TM, Barrett‑Connor E,
Swerdloff RS, Wang C, et al: Effects of testosterone treatment inolder men. N Engl J Med 374: 611‑624, 2016.
42. Anderson JL, May HT, Lappé DL, Bair T, Le V, Carlquist JF
and Muhlestein JB: Impact of testosterone replacement therapy
on myocardial infarction, stroke, and death in men with low
testosterone concentrations in an integrated health care system.
Am J Cardiol 117: 794‑799, 2016.
43. Feneley MR and Carruthers M: Is testosterone treatment goodfor the prostate? Study of safety during long‑term treatment.
J Sex Med 9: 2138‑2149, 2012.
44. Morales A and Lunenfeld B; International Society for the Studyof the Aging Male: Investigation, treatment and monitoring oflate‑onset hypogonadism in males. Official recommendations of
ISSAM. International Society for the Study of the Aging Male.
Aging Male 5: 74‑86, 2002.

14

TAKEUCHI and OKUBO: CLINICAL EFFICIENCY OF COMBINATION THERAPY FOR PATIENTS WITH LOH SYNDROME

45. Rhoden EL and Morgentaler A: Risks of testosterone‑replace‑ment therapy and recommendations for monitoring. N Engl
J Med 350: 482‑492, 2004.
46. Gregory SJ and Kaiser UB: Regulation of gonadotropins by
inhibin and activin. Semin Reprod Med 22: 253‑267, 2004.
47. Tsujimura A, Takada S, Matsuoka Y, Hirai T, Takao T,
Miyagawa Y, Nonomura N and Okuyama A: Is discontinua‑tion of hormone replacement therapy possible for patients withlate‑onset hypogonadism? Int J Urol 15: 625‑629, 2008.
48. Khera M, Adaikan G, Buvat J, Carrier S, El‑Meliegy A,
Hatzimouratidis K, McCullough A, Morgentaler A, Torres LO
and Salonia A: Diagnosis and treatment of testosterone
deficiency: Recommendations from the Fourth International
consultation for sexual medicine (ICSM 2015). J Sex Med 13:
1787‑1804, 2016.
49. Tsujimura A, Miyagawa Y, Okuda H, Yamamoto K, Fukuhara S,
Nakayama J, Takao T, Nonomura N and Okuyama A: Change incytokine levels after administration of saikokaryuukotsuboreito
or testosterone in patients with symptoms of late‑onset hypogo‑nadism. Aging Male 14: 76‑81, 2011.
50. Kupelian V, McVary KT, Kaplan SA, Hall SA, Link CL,
Aiyer LP, Mollon P, Tamimi N, Rosen RC and McKinlay JB:
Association of lower urinary tract symptoms and the metabolic
syndrome: Results from the Boston Area Community Health
Survey. J Urol 182: 616‑625, 2009.

51. Takeuchi H and Aoyagi T: Clinical characteristics in urolithiasis
formation according to body mass index. Biomed Rep 11: 38‑42,
2019.
52. Brand JS, van der Tweel I, Grobbee DE, Emmelot‑Vonk MH andvan der Schouw YT: Testosterone, sex hormone‑binding globulin
and the metabolic syndrome: A systematic review and meta‑anal‑
ysis of observational studies. Int J Epidemiol 40: 189‑207, 2011.
53. TsujimuraA,MiyagawaY,TakezawaK,OkudaH,FukuharaS,KiuchiH,
Takao T, Yamamoto R, Nishida M, Yamauchi‑Takihara K, et al: Is
low testosterone concentration a risk factor for metabolic syndrome inhealthy middle‑aged men? Urology 82: 814‑819, 2013.
54. Corona G, Monami M, Rastrelli G, Aversa A, Tishova Y, Saad F,
Lenzi A, Forti G, Mannucci E and Maggi M: Testosterone
and metabolic syndrome: A meta‑analysis study. J Sex Med 8:
272‑283, 2011.
This work is licensed under a Creative Commons
Attribution-NonCommercial-NoDerivatives 4.0
International (CC BY-NC-ND 4.0) License.