REVIEWS

Testosterone and insulin resistance in the

metabolic syndrome and T2DM in men
Preethi M. Rao, Daniel M. Kelly and T. Hugh Jones
Abstract | Obesity, type 2 diabetes mellitus and the metabolic syndrome are major risk factors for
cardiovascular disease. Studies have demonstrated an association between low levels of testosterone
and the above insulin-resistant states, with a prevalence of hypogonadism of up to 50% in men with type 2
diabetes mellitus. Low levels of testosterone are also associated with an increased risk of all-cause and
cardiovascular mortality. Hypogonadism and obesity share a bidirectional relationship as a result of the
complex interplay between adipocytokines, proinflammatory cytokines and hypothalamic hormones that
control the pituitary–testicular axis. Interventional studies have shown beneficial effects of testosterone
on components of the metabolic syndrome, type 2 diabetes mellitus and other cardiovascular risk factors,
including insulin resistance and high levels of cholesterol. Biochemical evidence indicates that testosterone is
involved in promoting glucose utilization by stimulating glucose uptake, glycolysis and mitochondrial oxidative
phosphorylation. Testosterone is also involved in lipid homeostasis in major insulin-responsive target tissues,
such as liver, adipose tissue and skeletal muscle.
Rao, P. M. et al. Nat. Rev. Endocrinol. 9, 479–493 (2013); published online 25 June 2013; doi:10.1038/nrendo.2013.122

Introduction
The WHO’s statistical fact sheet from September 2011
states that cardiovascular disease is the leading cause of
death and disability in the world.1 By 2030, an estimated
23.6 million people will die from cardiovascular disease
every year, mainly from heart disease and stroke.1 The
incidence of cardiovascular mortality, including prema­
ture death, is higher in men than in women.2 According
to the 2012 American Heart Association fact sheet, more
than one in three adult men has some form of cardio­
vascular disease.3 Obesity, the metabolic syndrome and
type 2 diabetes mellitus (T2DM) are major risk factors
for cardiovascular disease. Changes in our dietary habits
and an increasingly sedentary lifestyle have contributed
to the phenomenal rise in rates of obesity throughout
the world. A large number of studies in men over the
past 30 years have shown that low levels of testos­terone
correlate significantly with the incidence of obesity,
the metabolic syndrome, T2DM and cardiovascular
disease. Furthermore, a man with hypogonadism is at
an increased risk of developing these metabolic dis­
orders, which supports the existence of the bidirec­
tional relation­ship between low levels of testosterone
and insulin resistant states.4–9 Insulin resistance can be
defined as a reduced capacity of the tissues to metabo­
lize glucose and free fatty acids. This condition, which
is the central biochemical abnormality in T2DM and
Competing interests
T. H. Jones declares associations with the following companies:
Bayer Healthcare, Clarus, Ferring, Lilly, Merck, ProStrakan. See
the article online for full details of the relationships. The other
authors declare no competing interests.
the metabolic syndrome, is an intermediary cardio­
vascular risk factor that contributes to the development
of impaired glucose metabolism, dyslipidaemia, hyper­
tension, endothelial dysfunction and inflammation,
which all independently promote atherogenesis.
Testosterone has a key role in insulin sensitivity, body
composition, metabolism of lipids and cholesterol,
inflammation and vascular reactivity in men.10 Testos­
terone deficiency is associated with adverse effects on
several classic modifiable risk factors for cardio­vascular
disease,11,12 contrary to the common belief that testos­
terone is ‘bad for the heart’. Furthermore, interventional
studies have shown an improvement in these risk factors
upon treatment with exogenous testosterone. 11,12 In
this Review, we focus on the effects of testosterone on
insulin sensitivity and glycaemic control, cholesterol and
other risk factors for cardiovascular disease. The patho­
physiological mechanisms that link hypogonadism with
body composition, insulin sensitivity and inflammation
and the role of testosterone replacement in the meta­
bolic syndrome and T2DM will be explored in detail.
The metabolic syndrome (Box 1), T2DM (Box 2) and
hypogonadism (Box 3) have been defined. Academic Unit of
Diabetes, Endocrinology
and Metabolism,
Prevalence School of Medicine and
Biomedical Sciences,
Epidemiological studies have consistently reported University of Sheffield,
a high prevalence of low levels of testosterone in men Beech Hill Road,
with the metabolic syndrome and T2DM compared with Sheffield S10 2RX, UK
(P. M. Rao, D. M. Kelly,
the general population.13–16 Furthermore, longitudinal T. H. Jones).
population studies have shown that low levels of testos­
Correspondence to:
terone and sex hormone-binding globulin (SHBG) are T. H. Jones
independent predictors of the future occurrence of these hugh.jones@nhs.net

NATURE REVIEWS | ENDOCRINOLOGY VOLUME 9  |  AUGUST 2013  |  479

© 2013 Macmillan Publishers Limited. All rights reserved
REVIEWS
Key points
■■ Testosterone deficiency is highly prevalent in men with the metabolic syndrome
and type 2 diabetes mellitus
■■ Low levels of testosterone are an independent risk factor that predicts
subsequent development of the metabolic syndrome and type 2 diabetes mellitus
■■ Population studies in community-dwelling men have shown that testosterone
deficiency is associated with increased all-cause mortality and cardiovascular
mortality
■■ The hypogonadal–obesity–adipocytokine hypothesis summarises the complex
interaction of the above components and their contribution to the vicious cycle
of obesity causing hypogonadism and vice versa
■■ Interventional studies of testosterone replacement therapy have shown
improvements in insulin resistance, body composition, glycaemic control, lipid
metabolism and other cardiovascular risk factors
■■ The benefit of testosterone on insulin sensitivity might be attributable to a
complex regulatory influence on insulin signalling and glucose homeostasis
in the major insulin-responsive target tissues
Box 1 | Definition of the metabolic syndrome
This definition is from a joint statement from the
International Diabetes Federation (IDF), the National
Heart, Lung, and Blood Institute (NHLBI), the World Heart
Federation, the International Atherosclerosis Society and
the American Heart Association (AHA) issued in 2009.
Patients need to have three of five criteria to be termed
as having the metabolic syndrome.
■■ Raised waist circumference,* with population and
country-specific definitions
■■ Raised levels of triglycerides‡§ ≥1.7 mmol/l
■■ Reduced levels of HDL cholesterol‡ <1.0 mmol/l in
men and <1.3 mmol/l in women
■■ Raised blood pressure,‡ systolic ≥130 mmHg and/or
diastolic ≥85 mmHg
■■ Raised fasting levels of glucose‡§ ≥5.55 mmol/l
*It is recommended that the IDF cut points be used for
nonEuropeans and either the IDF or AHA/NHLBI cut points used for
people of European origin until more data are available. ‡Drug
treatment for raised levels is an alternate indicator. §The most
commonly used drugs for raised levels of triglycerides and reduced
levels of HDL cholesterol are fibrates and nicotinic acid. A patient
taking one of these drugs can be presumed to have high
triglycerides and low HDL cholesterol. High-dose ω‑3 fatty acid
presumes high triglycerides. Most patients with type 2 diabetes
mellitus will have the metabolic syndrome by the proposed criteria.
conditions.4–7 Circulating testosterone has three major
components: free testosterone (2%); albumin-bound
testosterone (20–40%); and SHBG-bound testosterone
(60–80%).17 Cross-sectional studies have established that
levels of biologically measurable active testos­terone frac­
tions (that is, free and/or bioavailable albumin-bound
testosterone) that are independent of SHBG are con­
siderably reduced in states of insulin resistance. 6,8,13,16
Importantly, free testosterone was measured directly in
one of these studies using equilibrium dialysis, which
is the gold standard assay for accurate measurement of
this fraction.16 These findings dispel concerns that testos­
terone is low solely as a result of reduced levels of SHBG
in men with T2DM and the metabolic syndrome.
The HERITAGE family study found that low levels
of testosterone and SHBG predicted increased accu­
mulation of visceral fat on CT scanning as well as
overall obesity. 18 These findings were supported by
480  |  AUGUST 2013  |  VOLUME 9  www.nature.com/nrendo
© 2013 Macmillan Publishers Limited. All rights reserved
the Tromso study (n = 1,548), which reported negative
independent correlations for testosterone and SHBG
with waist circumference.19 In addition, the Quebec
family study reported that the amount of sub­cutaneous
and visceral fat both had a negative correlation with
levels of testos­terone.20 In a cross-sectional study of
160 men who applied for medical or surgical obesity
therapy, participants were assessed for isolated hypo­
gonadotrophic hypogonadism; 57.5% had subnormal
levels of total testos­terone and 35.6% had low levels of
free testosterone.15
A study published in 2011 has shown that low testos­
terone is more prevalent in men with the metabolic syn­
drome than in age-matched healthy control indivi­­d­uals.21
Total testosterone, calculated free testosterone, and SHBG
were also lower in men with the metabolic syndrome than
in control individuals (P <0.001). Low levels of testos­
terone were observed in 19 (30%) men with the meta­
bolic syndrome but only one (3.1%) of the healthy control
individuals. Men with the metabolic syndrome and
levels of calculated free testosterone <0.225 pmol/l had
significantly higher HOMA‑IR (a biochemical marker
of insulin resistance) values than men with testos­terone
levels within the normal range.
Our group assessed the prevalence of clinical hypo­
gonadism in 355 men with T2DM.13 Overt hypo­gonadism
was defined as the presence of clinical symp­toms of
hypogonadism and low levels of testosterone (total
testos­terone <8 nmol/l and/or bioavailable testosterone
<2.5 nmol/l). Borderline hypogonadism was defined
as the presence of symptoms and levels of total testos­
terone of 8–12 nmol/l or bioavailable testosterone of
2.5–4.0 nmol/l. Overt hypogonadism was seen in 17%
of men with levels of total testosterone <8 nmol/l and
14% of men with levels of bioavailable testosterone
<2.5 nmol/l. Borderline hypogonadism was found in
25% of men with total testosterone of 8–12 nmol/l and
bioavailable testos­terone of 2.5–4.0 nmol/l; 42% of the
men had calculated free testosterone levels <0.25 nmol/l
and ­therefore had hypogonadism.
In another cross-sectional study of 580 men with
T2DM and 69 men with type 1 diabetes mellitus (T1DM),
43% of men with T2DM had reduced levels of total
testos­terone (<10 nmol/l) and 57% had reduced levels
of calculated free testosterone (<0.23 nmol/l). Of the
men with T1DM, 7% had low levels of total testosterone
and 20.3% had low levels of calculated free testos­terone
(<0.23 nmol/l).22 Another cross-sectional study of 115
men with T2DM, 93 men with T1DM and 121 healthy
control individuals reported that 45% and 61% of men
with T2DM had low total testosterone and calculated free
testosterone levels, respectively.23 Total testosterone levels
were not reduced in men with T1DM, but 32% had low
levels of calculated free testosterone. After adjustment for
age and waist circumference, only calculated free testos­
terone in men with T2DM remained reduced compared
with control individuals. A study from Nigeria has also
shown that the prevalence of low levels of testosterone
in men with T2DM is 36%.24 A meta-analysis by Corona
et al.25 confirmed that patients with T2DM have lower

plasma levels of testosterone than individuals who do not
have T2DM.
Testosterone and insulin resistance
Evidence for a bidirectional mechanism
Epidemiological studies as described above consistently
demonstrate an association between low levels of testos­
terone in men and obesity, the metabolic syndrome and
T2DM.13,14,16,26 In an 8‑year follow-up study—the Rancho
Bernardo study—low levels of testosterone predicted
insulin resistance and incident T2DM in older adults
(55–89 years). 6 Both the Massachusetts Male Aging
Study (15-year follow-up) and the NHANES III study
have found an increased risk of the metabolic syndrome
and T2DM in men with low levels of testos­terone, even in
men who were not obese at the beginning of the study.8,9
The Quebec family study evaluated 130 nonsmoking men
and showed that men in the upper tertile of testos­terone
levels had a lower risk of being characterized by three
or more features of the metabolic syndrome (OR 0.24,
P <0.04), independent of age, than did men from the
other tertiles.20 Laaksonen et al.7 looked at the associa­
tion of testosterone and SHBG with development of the
metabolic syndrome and T2DM in men. After 11 years
of follow-up, men with total testosterone, free testos­
terone and SHBG in the lower quartile had an increased
risk of developing the metabolic syndrome (OR 2.3,
1.7, 2.8, respectively) and T2DM (OR 2.3, 1.7 and 4.3,
respectively) after adjustment for age. 27 Low levels of
testosterone are also an independent risk factor and a
biomarker for the future onset of both the metabolic syn­
drome and T2DM.4–7 Furthermore, a well-known con­
sequence of classic hypogonadism is increased fat mass
and decreased lean mass. In addition, the metabolic syn­
drome and T2DM are highly prevalent in patients with
Klinefelter syndrome.28 These established facts support
a bidirectional mechanism between levels of testosterone
and these conditions.
Low levels of total testosterone were previously
believed to reflect reduced levels of SHBG. A landmark
study by Dhindsa and colleagues16 confirmed this associ­
ation by demonstrating that free testosterone measured
by equilibrium dialysis was lower in men with T2DM
than in men without T2DM. This finding is supported
by studies that have reported low levels of measured bio­
available testosterone in patients with T1DM.13,29 As these
assays are usually only available in research laboratories,
mathema­tical equations have been developed to measure
both free and bioavailable testosterone on the basis of
total testosterone, albumin and SHBG levels.17,29–31
The role of SHBG in men with T2DM has been a major
confounding factor in the diagnosis of hypogonadism.
However, low levels of SHBG are also an independent
risk factor for subsequent onset of the metabolic syn­
drome and T2DM.4,32 Production of SHBG is reduced in
states of insulin resistance, including obesity, the meta­
bolic syndrome and T2DM. This reduction might be
because insulin is a potent inhibitor of the production
of SHBG in the liver 33 and the above conditions have
high circulating levels of insulin. However, one study
NATURE REVIEWS | ENDOCRINOLOGY VOLUME 9  |  AUGUST 2013  |  481
© 2013 Macmillan Publishers Limited. All rights reserved
REVIEWS
Box 2 | WHO definition of T1DM and T2DM
1. Diabetes symptoms (that is, polyuria, polydipsia and
unexplained weight loss) plus
■■ a random venous plasma glucose concentration
>11.1 mmol/l or
■■ a fasting plasma glucose concentration >7.0 mmol/l
(whole blood >6.1 mmol/l) or
■■ 2 h plasma glucose concentration >11.1 mmol/l
2 h after 75 g anhydrous glucose in an oral glucose
tolerance test
2. With no symptoms, diagnosis should not be based on
a single glucose determination but requires confirmatory
plasma venous determination. At least one additional
glucose test result on another day with a value in the
diabetic range is essential, either fasting, from a random
sample or from the 2 h postglucose load. If the fasting or
random values are not diagnostic, the 2 h value should
be used.
Abbreviations: T1DM, type 1 diabetes mellitus; T2DM, type 2
diabetes mellitus.
Box 3 | Definition of late-onset hypogonadism
This definition is based on International Society of
Andrology (ISA), International Society for the Study of
Aging Male (ISSAM) and European Association of Urology
(EAU) recommendations.163
Clinical features of hypogonadism:
■■ Diminished sexual desire (libido) and erectile quality
and frequency, particularly nocturnal erections
■■ Changes in mood with concomitant decreases
in intellectual activity, cognitive functions, spatial
orientation ability, fatigue, depressed mood and irritability
■■ Sleep disturbances
■■ Decrease in lean body mass with associated
diminution in muscle volume and strength
■■ Increase in visceral fat
■■ Decrease in body hair and skin alterations
■■ Decreased BMD resulting in osteopaenia, osteoporosis
and increased risk of bone fractures
Plus biochemical evidence of low testosterone:
■■ Total testosterone levels >12 nmol/l (346 ng/dl) or
free testosterone levels >250 pmol/l (72 pg/ml) do not
require testosterone substitution
■■ Total testosterone levels <8 nmol/l (231 ng/dl) or
free testosterone <180 pmol/l (52 pg/ml) require
testosterone substitution
■■ Total testosterone between 8 nmol/l and 12 nmol/l,
trials of treatment can be considered in those in
whom alternative causes of these symptoms have
been excluded
has demonstrated an inverse correlation between insulin
resistance and serum levels of SHBG in 23 men with
T2DM that was independent of serum levels of insulin
or C peptide, as well as being independent of obesity
and accumulation of abdominal fat.34 Although levels
of SHBG are reduced overall in patients with insulin
resistance, these patients do not all have low levels of
this glyco­protein. For example, Kapoor and col­leagues13
found a wide range of levels of SHBG in patients with
T2DM, from well below the normal range to levels above
the normal range. The other major factors affecting
REVIEWS
Box 4 | Factors that affect SHBG levels
Increased SHBG
■■ Ageing
■■ Thyrotoxicosis
■■ Anticonvulsants
■■ Smoking
■■ Acromegaly
■■ HIV
■■ Cirrhosis of liver
■■ Thiazolidinediones
Decreased SHBG
■■ Insulin resistance
■■ Obesity
■■ The metabolic syndrome
■■ Type 2 diabetes mellitus
■■ Hypothyoidism
■■ Glucocorticoids
■■ Anabolic steroids
■■ Low albumin states
■■ Atorvastatin
Abbreviation: SHBG, sex hormone-binding globulin.
levels of SHBG in this group of patients are age and
use of statins or thiazolidine­diones,35,36 as well as other
well-recognized risk factors (Box 4).
Levels of SHBG rise with age,37 which might account
for the disparity in levels of SHBG in patients with
T2DM. Atorvastatin, but not simvastatin, is associated
with reduced levels of SHBG and consequently reduced
levels of total testosterone in men with T2DM, but
does not alter levels of bioavailable testosterone.35 This
finding implies that a homeostatic regulation system
maintains the appropriate physiological level of biologi­
cally active testosterone. The reduction in levels of total
testosterone by atorvastatin is dose dependent, that is,
higher doses result in a greater reduction than low doses.
Simvastatin is a weaker statin than atorvastatin, which
probably explains why simvastatin does not reduce levels
of total testosterone.
Rosiglitazone, which reduces insulin resistance by
~30%, increases levels of total testosterone and SHBG.36
However, rosiglitazone also increased the levels of bio­
available testosterone, which is a further indication that
reduced levels of total testosterone in men with T2DM
cannot be fully accounted for by the changes in levels of
SHBG. In one small study of just 10 healthy men, rosigli­
tazone did reduce total testosterone production or levels
of dihydrotestosterone.38 However, the study did not
measure the levels of SHBG or bioavailable testosterone.
A meta-analysis of 28 cross-sectional studies that
was published in 2011 showed that levels of total testos­
terone were lower in men with T2DM (n = 1,822) than
in healthy control individuals (n = 10,009), with a mean
difference of –2.99 nmol/l (95% CI –3.59 to –2.4), and
the association was independent of age and BMI.17 The
study showed that the level of SHBG was slightly reduced
in patients with T2DM, which is consistent with a state
of insulin resistance; however, the meta-analysis also
showed that measured levels of free testosterone were
appreciably reduced in patients with T2DM. This finding
482  |  AUGUST 2013  |  VOLUME 9  www.nature.com/nrendo
© 2013 Macmillan Publishers Limited. All rights reserved
confirms that the reduction in the levels of testosterone
associated with T2DM cannot be entirely attributed
to decreased levels of SHBG. Furthermore, a similar
associa­tion with free testosterone was demonstrated by
the NHANES III survey, with an odds ratio of preva­
lent T2DM as high as 4.12 (95% CI 1.25–13.5; P = 0.04)
in men with levels of calculated free testosterone in the
lowest tertile, even after adjusting for other confounding
factors such as age, adiposity and ethnicity.8
Insulin resistance and glycaemic control
Liver, muscle and fat are the major tissues that con­
tribute to the total body insulin sensitivity. Excess intake
of calories combined with increasing insulin resistance in
adipose tissue impairs the complete removal of free fatty
acids from the circulation by adipocytes, which leads
to an overspill of free fatty acids into the liver, muscle
and other nonadipose tissues. Hepatic steatosis and
non­alcoholic steatotic hepatitis, intramyocellular fat in
muscle and atherosclerosis are therefore consequences
of insulin resistance.39 Thus, insulin resistance forms a
key target of therapy for many medications, such as met­
formin and thiazolidinediones, that are commonly used
in the treatment of T2DM.
A state of low testosterone is associated with an
increased risk of developing insulin resistance and
T2DM in healthy men.4–6 The Health in Men study
showed that low levels of total testosterone are associ­
ated with insulin resistance independently of measures
of central obesity in older men (>70 years).40
Testosterone is negatively correlated with insulin
resistance and levels of HbA1c.41–43 Several interventional
studies have shown an improvement in insulin resistance
and glycaemic control with testosterone replacement
therapy (TRT).43–47 Our group was the first to demon­
strate that TRT improved insulin resistance and glycae­
mic control in men with hypogonadism who also had
T2DM.43 This finding led to a multicentre European trial,
the Testosterone In Metabolic Syndrome and type 2 dia­
betes study (TIMES 2), which is a large (n = 220) prospec­
tive randomized double-blind placebo controlled study
(RCT) in men with hypogonadism and T2DM and/or the
metabolic syndrome. TRT reduced HOMA-IR by 15.2%
at 6 months and 16.4% at 12 months in the total study
population; similar results were found in the subgroup
of men with hypogonadism and T2DM. Thus, TRT has
a similar efficacy to metformin with regards to insulin
resistance. Metformin is used as a first-line therapy in
T2DM, and the effects of TRT are additive to those of
metformin as 70% of the group with T2DM were already
on metformin. In addition, thiazolidinediones improve
insulin resistance by 30%.48
Testosterone is known to influence body composition,
promoting increased lean mass and suppressing fat mass.
TRT takes several weeks to affect body composition in
men with hypogonadism. However, changes in insulin
sensitivity occur as early as 2 weeks after withdrawal
of sex steroids in young patients (aged 40.8 ± 2.8 years)
with idiopathic hypogonadotrophic hypogonadism.49
BMI remained unchanged. This finding suggests that

the mechanisms controlling insulin sensitivity are more
complex than previously thought, involving short-term
and long-term changes.
Dysregulation of the metabolism of fatty acids that
leads to inappropriate lipid accumulation in myocytes,
hepatocytes and β cells is strongly associated with insulin
resistance in patients with obesity, T2DM and impaired
glucose tolerance. 50–55 TRT decreased the accumula­
tion of fat in the liver, as assessed by CT scanning, and
increased insulin sensitivity compared with placebo
after 18 weeks of treatment in 67 obese men with severe
obstructive sleep apnoea. 56 This finding suggests that
testosterone has a protective effect on the development
of hepatic steatosis.
Testosterone inhibits lipoprotein lipase, which reduces
the uptake of triglycerides by adipocytes in men.57 In
addition, men with low levels of testosterone, including
those with reduced glucose tolerance and T2DM, have
decreased oxidative phosphorylation in muscle mito­
chondria.41 This mitochondrial dysfunction contributes
to the degree of insulin resistance. Testosterone might
also increase insulin sensitivity by suppressing pro­
inflammatory cytokines such as tumour necrosis factor
(TNF) and IL‑6, which are thought to promote insulin
resistance.58,59 The actions of testosterone on insulin sen­
si­tivity are discussed in more detail towards the end of
this Review.
Obesity, inflammation and low testosterone
Obesity, adipocytokines and the chronic hypogonadal
state have a complex pathophysiological interaction that
contributes to a vicious cycle of fat accumulation. This
accumulation of fat causes further reductions in testos­
terone production, which in turn promotes additional fat
deposition (Figure 1).
Testosterone production is regulated by the
­hypothalamic–pituitary–testicular axis. Pulsatile release
of gonadotropin-releasing hormone stimulates the
release of luteinizing hormone (and follicle-­stimulating
hormone), which then stimulate the testes to synthe­
size and secrete testosterone. The axis is regulated by
the direct negative feedback of testosterone on the
hypo­t halamus. Testosterone is metabolized to estra­
diol, primarily in adipose tissue by aromatase, which
has increased activity in visceral fat. Estradiol directly
feeds back and inhibits the hypothalamic–pituitary–­
testicular axis. Aromatase inhibitors and antiestrogens
such as clomiphene increase testosterone levels in men
with secondary hypogonadism, 60,61 which supports
these findings. Furthermore, adipocytokines, includ­
ing the pro­i nflammatory cytokines TNF, IL‑6 and
IL‑1β, inhibit the secretion of testosterone, both at the
hypothalamic–­pituitary and the testicular level.62 Leptin
usually stimulates the release of gonadotropin-releasing
hormone; however, in obesity, where excess leptin is
produced from adipocytes, the hypothalamic–pituitary
axis becomes resistant to leptin.63,64 In addition, leptin
in­h ibits the stimulatory action of gonadotropin on
the Leydig cells of testes, thereby further decreasing
­testosterone production.64
NATURE REVIEWS | ENDOCRINOLOGY VOLUME 9  |  AUGUST 2013  |  483
© 2013 Macmillan Publishers Limited. All rights reserved
REVIEWS
Hypothalamus
–
Kisspeptin
–
–
Pituitary Proinflammatory
gland cytokines
(TNF, IL-1β and IL-6)
Testes
Leptin
–
Size and
number Adipose Insulin
Estradiol Testosterone
tissue resistance
Aromatase
Lipoprotein
Promotes adipocyte maturity
lipase Uptake of
triglycerides
Figure 1 | The hypogonadal–obesity–adipocytokine hypothesis. Increased amounts
of adipose tissue increase the activity of aromatase (which converts testosterone to
estradiol) in adipocytes. Estradiol directly inhibits the hypothalamic–pituitary–testes
axis via Kisspeptin, which leads to decreased testosterone production. Adipose
tissue also produces leptin and proinflammatory cytokines that have a negative
feedback effect on the hypothalamic–pituitary–gonadal axis. Leptin also inhibits the
stimulatory action of gonadotropins on the Leydig cells of the testes, which results
in decreased androgen production from the testes. Reduced levels of testosterone
in the tissues facilitates triglyceride storage in adipocytes by increasing the activity
of lipoprotein lipase. Abbreviation: TNF, tumour necrosis factor.
Kisspeptin (encoded by Kiss1) is a neuropeptide
hormone in the hypothalamus that acts on a G‑protein
coupled receptor to release gonadotropin-releasing
hormone, which causes the release of luteinizing hor­
mone, follicle-stimulating hormone and testos­terone.
Kisspeptin has a key role in the inhibitory effect of
estrogen on the hypothalamus.65,66 Estrogens and leptin
resistance suppress the neuronal kiss­peptin response.67
A study using ovariectomised rats has shown that pro­
inflammatory agents such as lipo­polysaccharide reduce
the expression of Kiss1 mRNA in the hypo­thalamus, as
well as reducing levels of luteiniz­ing hormone.68 These
effects are blocked by anti-­inflammatory agents such
as indomethacin.68
The above argument is that obesity causes hypo­
gonadism; however, evidence suggests that the low
testos­terone state actually promotes an increase in fat
mass through different mechanisms. Testosterone pro­
motes the maturation of pluripotent stem cells toward
myocytes, whereas testosterone deficiency permits
the production of adipocytes. 69 This action is medi­
ated through activation of T‑cell-specific transcription
factor 4 by translocation of an androgen receptor–β-
catenin complex into the nucleus, which downregulates
REVIEWS
the adipogenic transcription factors.70 Testosterone
inhibits lipoprotein lipase and thereby decreases adipo­
genesis and increases lipolysis through β‑adrenergic
receptors.71 Lipoprotein lipase catalyses the extracellular
component of the circulating triglycerides to free fatty
acids, which facilitates their uptake into the adipocyte
where they are then converted back to triglycerides and
stored within the cell. Lack of inhibition of lipoprotein
lipase by testosterone facilitates free fatty acid uptake and
triglyceride storage, which promotes adipocyte maturity.
The sensitivity of the androgen receptor is affected
by the CAG repeat polymorphism in exon 1 of the gene
that encodes the receptor. The lower the number of
CAG repeats the greater the sensitivity of the androgen
receptor. Men with T2DM who have a high number of
CAG repeats within the androgen receptor gene have a
greater waist circumference, BMI, serum levels of leptin
and systo­lic blood pressure than men with a low number
of CAG repeats.72 Hence, more studies are required to
ascertain the relationship between CAG repeats within
the androgen receptor gene and the development
of obesity.
This complex interplay of adipocytokines, the immune
system, obesity and low levels of testosterone is described
by the hypogonadal–obesity–adipocytokine hypo­
thesis,73 which is an extension of Cohen’s hypothesis of
the hypogonadal–obesity cycle.74 In the early stages
of the develop­ment of obesity, homeostatic mechanisms
compensate to maintain testosterone production. These
mechanisms might be particularly efficient in young
men, however, a ‘tipping point’ is reached at which these
mechanisms cannot correct the imbalance and a state
of hypogonadism ensues. The vicious cycle of increas­
ing obesity and reduced levels of testosterone persists,
which causes an increase in insulin resistance and thus
an increased risk of developing the metabolic syndrome,
prediabetes and T2DM.
Testosterone and dyslipidaemia
Dyslipidaemia often occurs in patients with T2DM and
its management is critical to improving cardiovascular
outcomes. Raised levels of total cholesterol and LDL
cholesterol are omitted from the diagnostic criteria of
the metabolic syndrome, whereas low levels of HDL
cholesterol and hypertriglyceridaemia are included in
the definition. Testosterone status affects the various
components of the lipid profile, which is discussed in
this section.
Total and LDL cholesterol
Endogenous testosterone is negatively correlated with
levels of both total and LDL cholesterol;29,75–79 therefore,
men with hypogonadism might be at increased risk of
hypercholesterolaemia. A meta-analysis concluded that
TRT did not have any effect on levels of LDL cholesterol;
however, overall total cholesterol was reduced, with
the effect being most pronounced in men with hypo­
gonadism.80 A major limitation of this meta-analysis
was the heterogeneity of the RCTs included with respect
to the dose, duration of treatment and the preparation
484  |  AUGUST 2013  |  VOLUME 9  www.nature.com/nrendo
© 2013 Macmillan Publishers Limited. All rights reserved
of testosterone used. In two other RCTs, which were
published after the meta-analysis, a decrease in levels of
both total cholesterol and LDL cholesterol was noted in
161 men with late-onset hypogonadism and in 220 men
with the metabolic syndrome and/or T2DM.47,81 TRT
consistently results in decreased levels of total cholesterol
in patients with the metabolic syndrome and T2DM.47,82
HDL cholesterol
Levels of testosterone correlate positively with levels of
HDL cholesterol in cross-sectional studies of healthy men
and those with T2DM.83,84 Interventional studies of TRT
have reported conflicting effects on levels of HDL choles­
terol. The differences might be accounted for by the
differ­ing lengths of the studies, testosterone preparations
used, ages of the patients and the inclusion of patients
with chemically induced hypogonadism and those with
hypogonadism as a result of natural causes. A meta-
analysis showed that testosterone did not have a major
overall effect on levels of HDL cholesterol.85 A reduction
in levels of HDL cholesterol was seen in studies where
levels of testosterone before treatment were increased.85
The magnitude of the decrease in levels of HDL choles­
terol was lower in studies that used testos­terone esters
than in studies that used other preparations. Lipoprotein
lipase is suppressed by testos­terone and is involved in the
production of HDL choles­terol from VLDL cholesterol
and hence this effect con­tributes to low levels of HDL
cholesterol upon treatment with testos­terone.86–88 Langer
et al.89 have suggested that testos­terone decreases levels
of HDL cholesterol by intensifying reverse cholesterol
transport, thereby enabling HDL cholesterol to remove
excess cholesterol from the arterial wall and transport it
to the liver for disposal, which leads to increased catabo­
lism of HDL cholesterol. If this suggestion is correct,
then this effect is more benefi­cial than detrimental in
the process of preventing atherosclerosis.
In summary, the current data surrounding testos­terone
and HDL cholesterol is conflicting and therefore remains
controversial. Some studies have shown that testosterone
decreases levels of HDL cholesterol,90,91 whereas other
studies have not.92,93 Supplementation of testosterone
in the testicular feminized mouse, which has low levels
of testosterone and an insensitive androgen receptor,
demon­strated an increase in levels of HDL cholesterol
compared with control mice.94 This finding suggests that
the effect of testosterone on HDL cholesterol is complex
and mediated through mechanisms that are dependent
on or independent of androgen receptors.
Triglycerides
Hypertriglyceridaemia has been associated with the
development of cardiovascular disease, particularly in
patients with T2DM.95–97 In castrated cholesterol-fed
male rabbits, serum levels of triglycerides were lower
in the testosterone-treated group than in the placebo
group. 98 In a study of 1,619 middle-aged men with
symp­toms of hypogonadism, low levels of testosterone
were associated with raised levels of triglycerides. 77
A prospective observational study of 1,438 men with

hypogonadism who were treated with long-acting intra­
muscular testosterone undecanoate reported a notable
reduction in nonfasting levels of triglyceride from
baseline.99 Some interventional studies have shown a
decrease in levels of triglycerides after TRT,47,100 however,
the majority of interventional studies and randomized
double-blind studies have not found a difference in either
fasting or postprandial serum or chylomicron levels of
triglycerides between testosterone-treated groups and
placebo groups.101
Lipoprotein(a)
Lipoprotein(a) is a powerful independent risk factor for
the development of coronary atherosclerosis.102 In the
TIMES 2 study, TRT reduced levels of lipoprotein(a) in
men with hypo­gonadism with and without T2DM and/
or the metabolic syndrome.47,103 Whether or not reduc­
ing levels of lipoprotein(a) in men reduces their risk of
cardio­vascular disease and ultimately morbidity and
mortality is unknown.
Cardiovascular mortality
The majority of community-based longitudinal popula­
tion studies have shown that low levels of testosterone are
associated with increased all-cause mortality and cardio­
vascular mortality. A large population study (MrOS,
n = 2,416) reported in 2011 that men in the highest
quartile of testosterone levels had a reduced number of
cardiovascular events compared with the lower quartiles
over a median follow-up period of 5 years.104 However,
three meta-analyses found no association between hypo­
gonadism and cardiovascular events.105–107 A review of
cross-sectional studies found that cardiovascular disease
had either a positive or neutral association with low
levels of testosterone.108 Although the evidence for a link
between low levels of testosterone and cardiovascular
disease is controversial and some studies have shown
conflicting outcomes, most of the evidence supports an
association between endogenous testosterone status and
the risk of developing cardiovascular disease.
Erectile dysfunction, which is a common symptom
of hypogonadism, is an independent predictor of sub­
sequent atherosclerotic cardiovascular events in these
men.109,110 Erectile dysfunction is also associated with
increased all-cause mortality, primarily through its
association with mortality as a result of cardiovascular
disease.111 Low levels of testosterone were associated with
an increased 6‑month all-cause mortality in a geriatric
population (average age of 75.4 ± 6.7 years), even after
correcting for other comorbidities.112 The same group
evaluated mortality and low levels of testosterone in 850
male veterans >40 years of age. Mortality over 3.5 years
in men with normal testosterone levels (>12 nmol/l)
was 20.1% (95% CI, 16.2–24.1%) versus 24.6% (95% CI,
19.2–30.0%) in men with equivocal testos­terone levels
(8–12 nmol/l) and 34.9% (95% CI, 28.5–41.4%) in men
with low levels of testosterone (<8 nmol/l).113
The Epic–Norfolk study investigated levels of endo­
genous testosterone and all-cause and cardiovascular
mortality in 11,606 healthy men aged 40–79 years over a
NATURE REVIEWS | ENDOCRINOLOGY VOLUME 9  |  AUGUST 2013  |  485
© 2013 Macmillan Publishers Limited. All rights reserved
REVIEWS
6–10 year follow-up period.114 An association was found
between baseline levels of testosterone and all-cause mor­
tality, cardiovascular mortality and cancer-related deaths
(P <0.001) after correcting for other comorbidities. An
increase of 6 nmol/l serum testosterone (~1 SD) was
associated with a ~14% reduction in the risk of mortality
over the study period. In a longitudinal follow-up study,
930 men with coronary artery disease diagnosed after an
angiography were followed up for 7 years.115 The overall
prevalence of biochemical testosterone deficiency in the
cohort with coronary artery disease using bio­available
testosterone <2.6 nmol/l was 20.9%, using total testos­
terone <8.1 nmol/l was 16.9% and using either was 24%.
Mortality in patients with testosterone deficiency defined
by levels of bioavailable testosterone was 21%, compared
with 12% in patients with normal levels of testosterone.
A meta-analysis found that reduced levels of testos­
terone and increased levels of estradiol correlate with
increased risk of cardiovascular disease and cardio­
vascular mortality.105 Whether low testosterone is just an
association with cardiovascular risk, or an actual cause–
effect relationship, awaits further studies. Alternatively,
low levels of testosterone might be an indication of poor
general health.106
Two retrospective studies have evaluated the effect
of TRT on mortality in men with hypogonadism.113,116
A cohort of 1,031 male veterans aged >40 years were
followed up for up to 4 years.113 TRT was given to 39%
of patients as part of routine care and the remaining
population did not receive any treatment. Mortality was
reduced in those who received TRT (10.3%) compared
with the untreated group (20.7%). Similar findings were
observed during a 6 year follow-up study of 581 men
with T2DM.116 Mortality was 9% in men with a total
testos­terone >10.4 nmol/l, 17.2% in untreated men (total
testosterone <10.4 nmol/l) and 8.4% in men receiving
TRT. Although these are observational studies and not
RCTs, their findings do suggest that TRT might improve
survival in men with hypogonadism.
TRT intervention studies
Four RCTs have been performed in men with hypo­
gonadism and T2DM and/or the metabolic syndrome.
These studies have been supported by two non-­placebo
trials and two prospective observational studies (Table 1).
A double-blind randomized placebo-controlled add-on
crossover trial demonstrated that testosterone replace­
ment in men with hypogonadism and T2DM improved
insulin resistance and glycaemic control.43 Participants
(n = 24) were treated with 200 mg of testosterone intra­
muscularly or placebo every 2 weeks for 3 months
followed by a washout period of 1 month before under­
going the alternate treatment phase. TRT led to a sig­
nificant decrease in HOMA-IR (–1.73 ± 0.67, P = 0.02),
fasting blood glucose (−1.58 ± 0.68 mmol/l, P = 0.03),
HbA 1c (–0.37 ± 0.17%, P = 0.03), total cholesterol
(−0.4 ± 0.17 mmol/l, P = 0.03) and waist circumference
(–1.63 ± 0.71 cm, P = 0.03).43
The TIMES 2 47 trial examined the effect of a 2%
transdermal testosterone gel on insulin resistance,
REVIEWS

Table 1 | Effects of testosterone on glycaemic control and other cardiovascular risk factors
Study Age n Diagnosis Mean Mean Testosterone Treatment Effect on Other outcomes
(years) baseline TT baseline treatment duration HbA1c (%)
(nmol/l) HbA1c (%) (weeks)
Boyanov 57 48 T2DM 9.6 7.3 TU oral 120 mg/d 12 –1.8 BW, WHR,
(2003)118 (P <0.05) % body fat
Kapoor 64 24 T2DM 8.6 7.3 TE im 200 mg 12 –0.37 IR, BW, WHR,
(2006)43 2 weekly (P <0.05) % body fat, TC
and leptin
Gopal 44 22 T2DM 10.1 7.0 TE im 200 mg 12 NS None
(2010)119 2 weekly
Hackett 62 190 T2DM 9.1 7.6 TU im 1,000 mg 30* –0.42%‡ WC, TC
(2011)117 12 weekly (P <0.05)
Jones 60 220 T2DM and/or 9.4 7.3§ Transdermal 26 –0.4§ IR, WC, % body fat
(2011)47 MetS testosterone (P <0.05) TC, LDL‑C, Lp(a)
60 mg/d HDL‑C at
6 months, no
difference at
12 months
Heufelder 57 32 Newly diagnosed 10.5 7.5 Transdermal 52 –0.8 IR, WC, TG
(2009)100 T2DM and MetS testosterone (P <0.05) HDL‑C, CRP, PAI‑1
50 mg/d
Kalinchenko 71 184 MetS 6.7 ND TU im 1,000 mg 30 Not checked IR, WC, BMI, leptin,
(2010)82 (TRT group) 12 weekly CRP, TNF, IL‑1β
7.5
(placebo group)
Zitzmann 49 1,493 Men with 9.6 7.9 TU im 36–52 –1.1 WC, TG, TC,
(2013)99 hypogonadism (P <0.0001) LDL‑C, BP
HDL‑C
Bhattacharya 52 581 Men on Testim 9.0 (men Not Transdermal 52 Not checked FBS, WC, BP
(2011)120 registry with MetS) checked testosterone
(213 had MetS 10.9 (men 5–10 g/d
at baseline) without MetS)
Aversa 58 50 MetS 8.3 5.7 TU im 1,000 mg 52 –1.1 IR, WC, CRP
(2010)167 12 weekly (P <0.05)
*A further 52 weeks open labelled. ‡Patients with poorly controlled diabetes (baseline HbA1c >7.5%). §Patients with type 2 diabetes mellitus only. Abbreviations: BP, blood pressure; BW, body
weight; CRP, C-reactive protein; FBS, fasting blood glucose; HDL‑C, HDL cholesterol; im, intramuscular; IR, insulin resistance; LDL-C, LDL cholesterol; Lp(a), lipoprotein(a); MetS, the metabolic
syndrome; ND, not done; NS, not significant; PAI-1, plasminogen activator inhibitor-1; T2DM, type 2 diabetes mellitus; TC, total cholesterol; TE, testosterone esters; TG, triglycerides; TNF,
tumour necrosis factor; TT, total testosterone; TRT, testosterone replacement therapy; TU, testosterone undecanoate; WC, waist circumference; WHR, waist:hip ratio.

glycaemic control and other cardio­vascular risk factors
over a 12-month treatment period; no changes in hypo­
glycaemic or lipid-lowering medication were allowed
in the first 6 months. At the end of phase 1 (6 months),
serum levels of total testos­t erone in the patients
who had received the treatment had increased by
19.0 ± 22.1 nmol/l versus 0.1 ± 2.9 nmol/l in the placebo
group (P <0.001). TRT reduced HOMA‑IR in the overall
population by 15.2% at 6 months (P = 0.018) and 16.4%
at 12 months (P = 0.006) in those with T2DM. In patients
with T2DM, glycaemic control was con­siderably better in
the testosterone-treated group than in the placebo group
at 9 months (–0.446%, P = 0.035), although alterations in
medications were allowed after 6 months. No change
in HOMA‑B (a measure of insulin secretion) was
observed. Levels of total and LDL cholesterol (des­pite
many patients being treated with statins), and lipo­
protein(a) decreased. A small fall was observed in
levels of HDL cholesterol at 6 months that became non­
significant after 12 months. A placebo controlled RCT
was performed to investigate the effects of intra­muscular
injection of long-acting testosterone undecanoate in
men with hypogonadism and the metabolic syndrome
(n = 184).82 This trial found a reduction in HOMA‑IR,
waist circumference, BMI, leptin and inflammatory
cytokines (such as IL‑1β, TNF and C‑reactive protein),
but no changes in the lipid profile.
The BLAST study 117 was an RCT conducted in
­primary-care settings. Patients were randomly assigned
to either receive testosterone undecanoate or placebo for
24 weeks (n = 190). Levels of HbA1c were reduced in the
group treated with testosterone compared with those of
the placebo arm at 18 weeks and 30 weeks. The reduc­
tion in levels of HbA1c was greater in the group with
poorly controlled T2DM in whom the baseline level of
HbA1c was >7.5% (0.42% at 30 weeks and 0.72% after
a further 52 weeks of open label medication). In all of
the above TRT intervention studies, HbA1c was not the
primary outcome and hence more research is needed
in this area to understand the effects of testosterone on
glycaemic control.
The first study to investigate the hypothesis that
testos­t erone improves glycaemic control was con­
ducted by Boyanov and colleagues.118 They looked at

486  |  AUGUST 2013  |  VOLUME 9  www.nature.com/nrendo

© 2013 Macmillan Publishers Limited. All rights reserved

48 middle-aged men with T2DM, symptoms of andro­
gen deficiency and low levels of testosterone. This was
an open label study with 24 participants receiving tes­
tosterone un­decanoate orally and the other 24 receiving
no treatment for 3 months. Levels of HbA1c improved
significantly from 10.4% to 8.6%. Other parameters also
improved, such as body weight, waist:hip ratio and per­
centage body fat. However, the study was not blinded and
so did not include a placebo group.
Heufelder and co-workers looked at the effect of
transdermal testosterone with supervised diet and
exercise in patients with hypogonadism, the metabolic
syndrome and newly diagnosed T2DM.100 No glucose-
lowering agents were administered prior to or during the
study. Levels of HbA1c improved significantly (–0.8%,
P <0.001) in the group that received testosterone along
with the diet and exercise programme compared with
the group that just received the diet and exercise pro­
gramme. All the patients who received testosterone
attained levels of HbA1c <7.0%, and 87.5% achieved levels
of HbA1c <6.5%. HOMA-IR and levels of adiponectin
and high-sensitivity C‑reactive protein also improved.
However, a study from India did not show any notable
improvement in levels of HbA1c or HOMA-IR following
intramuscular administration of testosterone. This study
looked at 22 men with T2DM and participants were
very lean with a mean baseline BMI of 24 kg/m2, which
might have influenced the results.119 The TriUS (Testim
Registry In United States) study was a 12 month, multi­
centre, prospective observational study in 849 men with
hypogonadism who were receiving a 1% testosterone
gel.120 After 12 months of testosterone therapy, patients
with the metabolic syndrome (37% of patients had the
metabolic syndrome at baseline) showed a decrease in
fasting plasma levels of glucose, waist circumference
and blood pressure. IPASS (International Multicentre
Post-authorization Surveillance Study) was a large study
of 1,438 men with hypogonadism, of whom 14% had
T2DM, who were followed up for up to 12 months. The
participants were treated with injectable long-acting
testos­terone undecanoate. A sub-analysis of 60 men with
uncontrolled T2DM, as defined by levels of HbA1c >6.1%
(mean HbA1c 7.9%), demonstrated a mean fall of HbA1c
of 1.1% after 12 months.99 A meta-analysis has shown
that TRT was associated with a reduction of fasting
plasma levels of glucose, HOMA-IR, triglycerides and
waist circumference.121 In addition, an increase of HDL
cholesterol was also observed.
Weight loss and bariatric surgery
Lifestyle modifications that cause weight loss improve
levels of both free and total testosterone.122 Losing
10% of the starting body weight with diet and exercise
programmes can achieve a rise in total testosterone of
2–4 nmol/l, whereas bariatric surgery can increase levels
of total testosterone by up to 10 nmol/l.122 An RCT was
performed in which one group received a 4‑month
weight-loss programme with 10 weeks of a very low
energy diet and 17 behaviour modification visits and
the other group received no interventions. The weight
NATURE REVIEWS | ENDOCRINOLOGY VOLUME 9  |  AUGUST 2013  |  487
© 2013 Macmillan Publishers Limited. All rights reserved
REVIEWS
loss in the treated group was 21 kg at 10 weeks after start­
ing the very low energy diet. In the treatment group,
increases in the levels of SHBG, testosterone and HDL
cholesterol, as well as decreases in levels of insulin and
leptin, were maintained until the end of the 8‑month
follow-up period.123 Similarly, another study has shown
that weight loss, whether by diet or surgery, leads to sub­
stantial increases in levels of total testosterone, especially
in men with morbid obesity, proportional to the amount
of weight lost.122
Bariatric surgery that leads to considerable weight loss
also increases levels of endogenous testosterone. A study
in Salt Lake City, UT, USA, looked at 64 men with severe
obesity, of whom 22 had gastric bypass surgery and 42
patients were controls. After 2 years, patients who had
undergone a gastric bypass had a significantly decreased
BMI (−16.6 ± 1.2 versus −0.46 ± 0.51 kg/m 2 ) and
decreased levels of estradiol (−29.7 ± 8.8 pmol/l versus
5.9 ± 5.1 pmol/l), compared with the control group.
Patients who had undergone gastric bypass also had an
increase in levels of total testosterone (10.7 ± 1.65 nmol/l
versus 0.49 ± 0.53 nmol/l) and free testosterone (156.8 ±
17.7 pmol/l versus −1.38 ± 10.4 pmol/l), compared with
the control group. 124 In another prospective study,
20 men with morbid obesity were followed up for
24 months. Group A included 10 patients who under­
went lifestyle modifications (exercise and diet) for
4 months and then had gastric bypass surgery, whereas
Group B included 10 patients who received no inter­
ventions. BMI reductions were 24.7 kg/m2 (P <0.0001)
and 0.7 kg/m2 (P >0.05) for groups A and B, respec­
tively, after 24 months. Comparing groups A and B,
International Index of Erectile Function 5 sexual health
score and levels of total testosterone and free testos­
terone increased significantly in group A (P = 0.0224,
0.0043 and 0.0149, respectively).125
These studies confirm a beneficial effect of weight loss
and exercise on levels of testosterone. However, whether
the modest rise in total testosterone as described above
will ameliorate symptoms of hypogonadism and meta­
bolic imbalance is not clear; whether or not weight loss
is maintained is also unclear from these studies. Bariatric
surgery is more effective than lifestyle modifications at
increasing levels of testosterone but is not readily avail­
able, as access to the surgery is regulated by strict criteria
and the procedure is costly and not without surgical and
postsurgical risk. In our experience of routine clinical
practice, only a small proportion of patients will lose a
considerable amount of weight and maintain this weight
loss in the long term with lifestyle modifications.
Insulin-related metabolic pathways
The beneficial effects of testosterone on insulin sensi­
tivity observed clinically might be attributable to a
com­plex regulatory influence on insulin signalling and
glucose homeostasis in the major insulin-responsive
target tissues, such as skeletal muscle, liver and adipose
(Figure 2). Impaired insulin sensitivity in these three
tissues is charac­terized by defects in insulin-stimulated
glucose transport activity (particularly into skeletal
REVIEWS

T
Insulin +ve Glucose T
+ve
Insulin
receptor GLUT4

P
IRS1/2 Translocation T T
P +ve +ve
P P T HK2
PKC AKT +ve
Glycogen synthase
T G6P dehydrogenase
+ve G6P G6P Glycogen
T
+ve Glycogen
GLUT4 phosphorylase
vesicle
6-P-gluconolactone Fructose-6-P
T
T –ve
PFK +ve

6-P-gluconate Fructose-1,6-P
Pentose
phosphate Gluconeogenesis Glycolysis
shunt Krebs
Ribulose-5P Glyceraldehyde-3-P cycle
Oxidative
phosphorylation
PEP

PEP T UQCRB Citrate

Nucleotide PEPCK +ve
synthesis
Oxaloacetate Pyruvate
kinase Acetyl-coenzyme A

Pyruvate Pyruvate Pyruvate

dehydrogenase

Figure 2 | Potential mechanism of testosterone action on cellular insulin sensitivity and glucose homeostasis.
Testosterone increases insulin receptor expression and IRS expression and phosphorylation, which enhances cellular
responsiveness to insulin. GLUT4 expression and membrane translocation is also raised in response to testosterone,
which increases cellular glucose uptake and utilization potentially via an increase in the phosphorylation of AKT and PKC.
Key enzymes in the glycolysis pathway are additionally influenced by testosterone, with HK2, PFK and (G6P) dehydrogenase
expression increased; this results in glucose utilization via the pentose phosphate shunt or pyruvate citric acid cycle.
Furthermore, the activity of glycogen synthase, the rate-limiting enzyme in glycogenesis, is increased by testosterone,
whereas glycogen phosphorylase activity is decreased to reduce glycogen breakdown and diminish cellular levels of free
glucose. Mitochondrial oxidative phosphorylation is increased by testosterone via upregulation of UQRCB, which is involved
in the activation of ubiquinol cytochrome c reductase and has a critical role in the biochemical generation of ATP. Dashed
arrows indicate pathways in which multiple steps are involved but not shown. Abbreviations: GLUT4, glucose transporter 4;
G6P, glucose‑6-phosphate; HK2, hexokinase 2; IRS, insulin receptor substrate; T +ve indicates targets or activity increased
by testosterone; T -ve indicates targets decreased by testosterone; P, phosphate; PEP, phosphoenolpyruvate; PEPCK,
phosphoenolpyruvatecarboxykinase; PFK, phosphofructokinase; PKC, protein kinase C; UQCRB, ubiquinol cytochrome c
reductase-binding protein.

muscle), impaired insulin-mediated inhibition of glucose
production in the liver and stimulation of glycogen syn­
thesis in the liver, and a reduced ability of insulin to
inhibit lipolysis in adipose tissue.126 In addition, fat depo­
sition in nonadipose tissue, including skeletal muscle
and the liver occurs as a ‘spillover’ effect of dissociated
fatty acid release from adipose tissue surplus to energy
requirements in other organs.127 In turn, this lipid accu­
mulation contributes to impaired insulin responsiveness
and abnormalities in glucose control. Interestingly, levels
of fat in the liver and muscle correlate more strongly with
insulin sensitivity than levels of abdominal fat in rats.128
Indeed, free fatty acids decrease hepatic insulin bind­
ing, increase hepatic gluconeogenesis and increase
hepatic insulin resistance.129 Build-up of triglycerides
and lipids in muscle also impairs insulin signalling,
which leads to decreased insulin sensitivity. Ultimately,
these effects lead to peripheral hyperinsulinaemia, sys­
temic insulin resistance and hepatic steatosis. There­
fore, a reduction in the size and number of adipocytes
by testos­terone would reduce the release of free fatty
acids and, in turn, insulin resistance. Moreover, a lack of
testos­terone action decreases the activity of key enzymes
in the regulation of hepatic fatty acid synthesis in animal
models, including sterol regulatory element binding
protein‑1c, stearoyl‑CoA desaturase 1, acetyl CoA car­
boxylase, fatty acid synthase and peroxisome prolifera­or
activated receptor‑γ.128,130
Insulin-stimulated uptake of glucose into muscle
and adipose tissue is largely mediated by glucose

488  |  AUGUST 2013  |  VOLUME 9  www.nature.com/nrendo

© 2013 Macmillan Publishers Limited. All rights reserved

transporter type 4 (GLUT4). GLUT4 translocates from
cyto­plasmic vesicles to the cell membrane in response
to insulin via signalling through the insulin receptor,
subsequent binding of insulin receptor substrate (IRS) 1
and activation of intracellular signalling pathways. 131
Thus, di­minished expression of GLUT4 correlates with
decreased insulin responsiveness, and defects at the
level of expression of the insulin receptor, IRS‑1 and
GLUT4 have been observed in patients with T2DM.132
Testosterone increased the expression of GLUT4 in
cultured skeletal muscle cells, hepatocytes and adipo­
cytes,133–135 as well as augmenting GLUT4 membrane
translocation and promoting glucose uptake in adipose
and skeletal muscle tissue.134
Similarly, testosterone treatment increased the expres­
sion of insulin receptors in the Chang human adult liver
and human larynx carcinoma cell line (HEp‑2), which
resulted in enhanced insulin binding and responsive­
ness through raised utilization of glucose compared
with the basal response.136,137 Testosterone administra­
tion in orchidectomized adult male rats increased insulin
receptor and IRS‑1 mRNA and protein expression in
liver tissue and was associated with a normalization of
the castration-induced impairment of glucose oxida­
tion.138 Supporting the effects on insulin receptor signal­
ling, IRS‑1 was upregulated in cultured adipocytes and
skeletal muscle cells following testosterone treatment,133
as was IRS‑2 in cells isolated from male human skeletal
muscle biopsy samples.139 Serine phosphorylation of
IRS‑1, which is known to attenuate insulin signalling by
inhibiting tyrosine phosphorylation, was raised in cas­
trated mice, with testosterone treatment increasing this
effect.138 Increased phosphorylation of AKT and protein
kinase C, as key steps in the insulin receptor signalling
pathways for regulation of GLUT4 trans­location, was also
shown upon testosterone treatment of skeletal muscle
cells.134 These effects were blocked by the 5α-reductase
inhibitor, finasteride, which suggests that local conver­
sion of testosterone to dihydro­testosterone and activation
of the androgen receptor might be important for glucose
uptake, at least in isolated rat skeletal muscle cells.
In addition to insulin signalling and glucose uptake,
experiments have shown that testosterone influences
key enzymes involved in glycolysis. Indeed, testos­terone
increased the activity of phosphofructokinase and hex­o­
kinase in cultured rat skeletal muscle cells and increased
hexokinase activity in castrated rats.134,140 Preliminary
work in the testicular feminized mouse, whereby
affected animals present low endogenous testos­terone
levels and a nonfunctional androgen receptor, has also
demonstrated that expression of hexokinase 2 was
reduced in skeletal muscle tissue of testicular feminized
mice compared with wild-type mice.141 Testosterone
treatment did not alter the expression of hexokinase 2,
which suggests an action that is dependent on the
androgen receptor. An increase in glycogen synthase
activity in skeletal muscle is apparent in castrated male
rats supplemented with testosterone, diminishing the
raised blood levels of glucose seen in untreated control
rats. 142 Concurrently, testosterone administration
NATURE REVIEWS | ENDOCRINOLOGY VOLUME 9  |  AUGUST 2013  |  489
© 2013 Macmillan Publishers Limited. All rights reserved
REVIEWS
returned the enhanced glycogen phosphorylase activ­
ity in castrated rats to a normal level, thus reducing gly­
cogen breakdown and the subsequent rise in levels of
free glucose. Indeed, castration is followed by decreased
levels of glycogen in rat perineal and levator ani muscles
and the administration of testosterone induces a con­
siderable increase in glyco­gen content.140,143,144 In addi­
tion, glucose‑6-­phosphate dehydrogenase activity, the
rate limiting enzyme in the pentose phos­phate pathway,
is increased in the rat levator ani muscle fo­l lowing
adminis­tration of testosterone propionate.145
Regulation of cellular fuel metabolism is impor­
tant for maintaining homeostatic energy balance and
can affect whole-body metabolic homeostasis and the
emergence of metabolic disorders. The mitochondria
have a central role in fuel utilization and energy pro­
duction, with dis­ordered mitochondrial function at the
cellular level linked to the pathophysiology of T2DM.
Evidence suggests that an association exists between
serum levels of testosterone and mitochondrial func­
tion, with testosterone deficiency directly contributing
to ineffi­cient energy utilization in cases of increased
insulin resistance.41,49
An inverse correlation exists between levels of testos­
terone and adverse mitochondrial function in men
with varying degrees of glucose control. 41 Low levels
of testos­terone were associated with decreased expres­
sion of genes involved in the mitochondrial oxidative
phosphorylation pathway in skeletal muscle biopsy
samples. Of these genes, those that encode ubiqui­
nol cytochrome c reductase binding protein and the
transcription factor proteasome proliferator activated
receptor‑γ co-­activator 1α (PGC‑1α) had the largest
expression difference between normal and diabetic
muscle and was correlated with levels of testosterone
and insulin resistance. 41 PGC‑1α downregulation in
skeletal muscle is considered to be the mechanism
that causes ­testosterone-deficiency-induced insulin
resistance, potentially via a subsequent reduction
of key mito­c hondrial transcriptional factors (for
example, transcription factor A, mitochondrial and
nuclear respiratory factor‑1) and signalling molecules
(such as, AKT) to decrease oxidative phosphorylation
and mitochondrial biogenesis. 146,147 Similarly, genes
involved in oxidative phosphorylation and ubiquinone
pathways are downregulated in young male mice fol­
lowing orchidectomy, an effect that was reversed by
testosterone treatment.148
In elderly (28 months old) male mice, testosterone
treatment in combination with physical exercise training
increased expression of the genes that encode carnitine
palmitoyltransferase‑1β and pyruvate dehydrogenase
kinase 4 in the mitochondria to improve fatty acid oxida­
tion and favour fatty acid utilization as the mito­chondrial
fuel.149 Indeed, testosterone treatment in female rats
increases skeletal muscle levels of fatty acid binding
protein, which has an important role in the delivery of
fatty acids to the mitochondria for oxidation.150 By regu­
lating mitochondrial function and efficient fuel metabo­
lism, testosterone might protect against a cellular energy
REVIEWS

imbalance that in turn leads to chronically raised levels Conclusions

of glucose and accumulation of lipids that can mediate
insulin resistance.
Use of TRT
Certain studies have shown improvements in angina
symptoms following TRT151–153 as a result of the effect
of testosterone on coronary vasodilatation 154,155 and
improvements in exercise capacity and symptoms in
men with heart failure.156,157 Testosterone therapy also
improves sexual function, especially erectile dysfunc­
tion.158 Furthermore, numerous studies have also shown
that testosterone has profound effects on improvement
in mood and cognition.159–162
However, a diagnosis of late-onset hypogonadism
should be based on international and/or national guide­
lines and recommendations.163,164 A decision to initiate
TRT should take into account the benefits versus risks
of potential adverse effects in individual patients. TRT
is contraindicated in the presence of metastatic prostate
carcinoma, breast cancer, prostate nodules and raised
levels of prostate specific antigen that have not been
investigated and prostate cancer excluded, severe lower
urinary tract symptoms associated with benign prostatic
hypertrophy, severe uncontrolled heart failure and levels
of haematocrit >50%. The incidence of adverse effects is
low when testosterone is replaced to achieve levels, by
titration, within the normal range. The most common
adverse effect attributable to TRT is secon­dary poly­
cythaemia. This symptom can be treated by dose reduc­
tion, venesection or switching the mode of testosterone
delivery. No evidence indicates that TRT increases the
risk of prostate carcinoma; however, as this condition can
occur in the general population of men >40 years, annual
assessment is advised.165,166
Epidemiological studies have established an associa­
tion between hypogonadism in men and an increased
risk of cardiovascular events and metabolic disorders.
Studies have also shown increased mortality in men
with hypogonadism, especially mortality as a result
of cardio­vascular disease. Short-term interventional
studies have shown beneficial effects of testosterone
therapy on various cardio­vascular risk factors; these
include improvements in insulin resistance and glycae­
mic control, as well as a decrease in visceral fat mass and
reduced levels of circulating inflammatory cytokines
and markers, an increase in vasodilatation and vaso­
reactivity, improvement in endothelial function (includ­
ing the number of endo­thelial progenitor cells), and a
decrease in total levels of cholesterol.10
It is imperative that TRT should be monitored carefully
with regular assessment of haematocrit, prostate specific
antigen and testosterone levels at 3, 6 and 12 months and
then annually. Further research is required in this impor­
tant field of health, including larger and longer-term
RCTs to evaluate fully the beneficial effects and risks of
TRT over time.
Review criteria
A search for original and review articles that focus on
testosterone, hypogonadism, metabolic syndrome and
type 2 diabetes mellitus was performed in MEDLINE.
The key search terms were “testosterone”, “androgen”,
“hypogonadism”, “obesity”, “metabolic syndrome”,
“diabetes”, “body composition”, “insulin resistance” and
“glycaemic control”. We also searched the reference lists
of the identified articles for further papers. Articles were
restricted to English language and no date restrictions
were applied.

1. World Health Organization. Fact sheet No317,
cardiovascular diseases [online], http://www.
who.int/mediacentre/factsheets/fs317/en/
(2011).
2. British Heart Foundation. Coronary heart disease
statistics in England 2012 [online], http://www.
bhf.org.uk/plugins/PublicationsSearchResults/
DownloadFile.aspx?docid=e3b705eb‑ceb3‑
42e2‑937d‑45ec48f6a797&version=‑1&title
=England+CHD+Statistics+Factsheet+2012&
resource=FactsheetEngland (2012).
3. American Heart Association. Men and
cardiovascular diseases [online], http://www.
heart.org/idc/groups/heart-public/@wcm/
@sop/@smd/documents/downloadable/
ucm_319573.pdf (2012).
4. Stellato, R. K., Feldman, H. A., Hamdy, O.,
Horton, E. S. & McKinlay, J. B. Testosterone, sex
hormone-binding globulin, and the development of
type 2 diabetes in middle-aged men: prospective
results from the Massachusetts male aging
study. Diabetes Care 23, 490–494 (2000).
5. Haffner, S. M., Shaten, J., Stern, M. P.,
Smith, G. D. & Kuller, L. Low levels of sex
hormone-binding globulin and testosterone
predict the development of non‑insulin‑
dependent diabetes mellitus in men. MRFIT
Research Group. Multiple Risk Factor
Intervention Trial. Am. J. Epidemiol. 143,
889–897 (1996).
6. Oh, J. Y., Barrett-Connor, E., Wedick, N. M.,
Wingard, D. L. & Rancho Bernardo, S.
Endogenous sex hormones and the development
of type 2 diabetes in older men and women:
the Rancho Bernardo study. Diabetes Care 25,
55–60 (2002).
7. Laaksonen, D. E. et al. Testosterone and sex
hormone-binding globulin predict the metabolic
syndrome and diabetes in middle-aged men.
Diabetes Care 27, 1036–1041 (2004).
8. Selvin, E. et al. Androgens and diabetes in men:
results from the Third National Health and
Nutrition Examination Survey (NHANES III).
Diabetes Care 30, 234–238 (2007).
9. Kupelian, V. et al. Low sex hormone-binding
globulin, total testosterone, and symptomatic
androgen deficiency are associated with
development of the metabolic syndrome in
nonobese men. J. Clin. Endocrinol. Metab. 91,
843–850 (2006).
10. Jones, T. H. Testosterone deficiency: a risk
factor for cardiovascular disease? Trends
Endocrinol. Metab. 21, 496–503 (2010).
11. Kelly, D. M. & Jones, T. H. Testosterone:
a vascular hormone in health and disease.
J. Endocrinol. 217, R47–R71 (2013).
12. Jones, T. H. Effects of testosterone on
type 2 diabetes and components of the
metabolic syndrome. J. Diabetes 2, 146–156
(2010).
13. Kapoor, D., Aldred, H., Clark, S., Channer, K. S. &
Jones, T. H. Clinical and biochemical
assessment of hypogonadism in men with type 2
diabetes: correlations with bioavailable
testosterone and visceral adiposity. Diabetes
Care 30, 911–917 (2007).
14. Ding, E. L., Song, Y., Malik, V. S. & Liu, S. Sex
differences of endogenous sex hormones and
risk of type 2 diabetes: a systematic review and
meta-analysis. JAMA 295, 1288–1299 (2006).
15. Hofstra, J. et al. High prevalence of
hypogonadotropic hypogonadism in men referred
for obesity treatment. Neth. J. Med. 66, 103–109
(2008).
16. Dhindsa, S. et al. Frequent occurrence of
hypogonadotropic hypogonadism in type 2
diabetes. J. Clin. Endocrinol. Metab. 89,
5462–5468 (2004).
17. Vermeulen, A., Verdonck, L. & Kaufman, J. M.
A critical evaluation of simple methods for the
estimation of free testosterone in serum. J. Clin.
Endocrinol. Metab. 84, 3666–3672 (1999).
18. Couillard, C. et al. Contribution of body fatness
and adipose tissue distribution to the age
variation in plasma steroid hormone
concentrations in men: the HERITAGE Family
Study. J. Clin. Endocrinol. Metab. 85, 1026–1031
(2000).
19. Svartberg, J., von Mühlen, D., Sundsfjord, J. &
Jorde, R. Waist circumference and testosterone

490  |  AUGUST 2013  |  VOLUME 9  www.nature.com/nrendo

© 2013 Macmillan Publishers Limited. All rights reserved

levels in community dwelling men. The Tromsø
study. Eur. J. Epidemiol. 19, 657–663 (2004).
20. Blouin, K. et al. Contribution of age and declining
androgen levels to features of the metabolic
syndrome in men. Metabolism 54, 1034–1040
(2005).
21. Singh, S. K., Goyal, R. & Pratyush, D. D. Is
hypoandrogenemia a component of metabolic
syndrome in males? Exp. Clin. Endocrinol.
Diabetes 119, 30–35 (2011).
22. Grossmann, M. et al. Low testosterone levels
are common and associated with insulin
resistance in men with diabetes. J. Clin.
Endocrinol. Metab. 93, 1834–1840 (2008).
23. Biswas, M., Hampton, D., Newcombe, R. G. &
Rees, D. A. Total and free testosterone
concentrations are strongly influenced by age
and central obesity in men with type 1 and
type 2 diabetes but correlate weakly with
symptoms of androgen deficiency and diabetes-
related quality of life. Clin. Endocrinol. 76,
665–673 (2012).
24. Ogbera, O. A., Sonny, C., Olufemi, F. & Wale, A.
Hypogonadism and subnormal total testosterone
levels in men with type 2 diabetes mellitus. J. Coll.
Physicians Surg. Pak. 21, 517–521 (2011).
25. Corona, G. et al. Type 2 diabetes mellitus and
testosterone: a meta-analysis study. Int.
J. Androl. 34, 528–540 (2011).
26. Wang, C. et al. Low testosterone associated with
obesity and the metabolic syndrome contributes
to sexual dysfunction and cardiovascular
disease risk in men with type 2 diabetes.
Diabetes Care 34, 1669–1675 (2011).
27. Laaksonen, D. E. et al. The metabolic syndrome
and smoking in relation to hypogonadism in
middle-aged men: a prospective cohort study.
J. Clin. Endocrinol. Metab. 90, 712–719 (2005).
28. Bojesen, A., Host, C. & Gravholt, C. H.
Klinefelter’s syndrome, type 2 diabetes and the
metabolic syndrome: the impact of body
composition. Mol. Hum. Reprod. 16, 396–401
(2010).
29. Barrett-Connor, E. Lower endogenous androgen
levels and dyslipidemia in men with
non‑insulin‑dependent diabetes mellitus. Ann.
Intern. Med. 117, 807–811 (1992).
30. de Ronde, W. et al. Calculation of bioavailable
and free testosterone in men: a comparison of 5
published algorithms. Clin. Chem. 52,
1777–1784 (2006).
31. Morris, P. D., Malkin, C. J., Channer, K. S. &
Jones, T. H. A mathematical comparison of
techniques to predict biologically available
testosterone in a cohort of 1072 men. Eur.
J. Endocrinol. 151, 241–249 (2004).
32. Kupelian, V. et al. Low sex hormone-binding
globulin, total testosterone, and symptomatic
androgen deficiency are associated with
development of the metabolic syndrome in
nonobese men. J. Clin. Endocrinol. Metab. 91,
843–850 (2006).
33. Peiris, A. N. et al. Relationship of insulin
secretory pulses to sex hormone-binding
globulin in normal men. J. Clin. Endocrinol.
Metab. 76, 279–282 (1993).
34. Birkeland, K. I., Hanssen, K. F., Torjesen, P. A. &
Vaaler, S. Level of sex hormone-binding globulin
is positively correlated with insulin sensitivity in
men with type 2 diabetes. J. Clin. Endocrinol.
Metab. 76, 275–275 (1993).
35. Stanworth, R. D., Kapoor, D., Channer, K. S. &
Jones, T. H. Statin therapy is associated with
lower total but not bioavailable or free
testosterone in men with type 2 diabetes.
Diabetes Care 32, 541–546 (2009).
36. Kapoor, D., Channer, K. S. & Jones, T. H.
Rosiglitazone increases bioactive testosterone
NATURE REVIEWS | ENDOCRINOLOGY VOLUME 9  |  AUGUST 2013  |  491
and reduces waist circumference in hypogonadal
men with type 2 diabetes. Diab. Vasc. Dis. Res. 5,
135–137 (2008).
37. Feldman, H. A. et al. Age trends in the level 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).
38. Vierhapper, H. & Nowotny, P. Reduced production
rates of testosterone and dihydrotestosterone in
healthy men treated with rosiglitazone.
Metabolism 52, 230–232 (2003).
39. Ginsberg, H. N. Insulin resistance and
cardiovascular disease. J. Clin. Invest. 106,
453–458 (2000).
40. Yeap, B. B. et al. Lower serum testosterone
is independently associated with insulin
resistance in non-diabetic older men: the Health
In Men Study. Eur. J. Endocrinol. 161, 591–598
(2009).
41. Pitteloud, N. et al. Relationship between
testosterone levels, insulin sensitivity, and
mitochondrial function in men. Diabetes Care 28,
1636–1642 (2005).
42. Mårin, P. et al. The effects of testosterone
treatment on body composition and metabolism
in middle-aged obese men. Int. J. Obes. Relat.
Metab. Disord. 16, 991 (1992).
43. Kapoor, D., Goodwin, E., Channer, K. S. &
Jones, T. H. Testosterone replacement therapy
improves insulin resistance, glycaemic control,
visceral adiposity and hypercholesterolaemia in
hypogonadal men with type 2 diabetes. Eur.
J. Endocrinol. 154, 899–906 (2006).
44. Marin, P. Testosterone and regional fat
distribution. Obes. Res. 3 (Suppl. 4), 609S–612S
(1995).
45. Simon, D. et al. Androgen therapy improves insulin
sensitivity and decreases leptin level in healthy
adult men with low plasma total testosterone:
a 3‑month randomized placebo-controlled trial.
Diabetes Care 24, 2149–2151 (2001).
46. Naharci, M. I., Pinar, M., Bolu, E. & Olgun, A. Effect
of testosterone on insulin sensitivity in men with
idiopathic hypogonadotropic hypogonadism.
Endocr. Pract. 13, 629–635 (2007).
47. Jones, T. H. et al. Testosterone replacement in
hypogonadal men with type 2 diabetes and/or
metabolic syndrome (the TIMES2 study).
Diabetes Care 34, 828–837 (2011).
48. Lebovitz, H. E. & Banerji, M. A. Insulin resistance
and its treatment by thiazolidinediones. Recent
Prog. Horm. Res. 56, 265–294 (2001).
49. Yialamas, M. A. et al. Acute sex steroid
withdrawal reduces insulin sensitivity in healthy
men with idiopathic hypogonadotropic
hypogonadism. J. Clin. Endocrinol. Metab. 92,
4254–4259 (2007).
50. Boden, G. & Shulman, G. I. Free fatty acids in
obesity and type 2 diabetes: defining their role
in the development of insulin resistance and
beta-cell dysfunction. Eur. J. Clin. Invest. 32
(Suppl. 3), 14–23 (2002).
51. McGarry, J. D. Banting lecture 2001: dysregulation
of fatty acid metabolism in the etiology of type 2
diabetes. Diabetes 51, 7–18 (2002).
52. Savage, D. B., Petersen, K. F. & Shulman, G. I.
Mechanisms of insulin resistance in humans
and possible links with inflammation.
Hypertension 45, 828–833 (2005).
53. Jacob, S. et al. Association of increased
intramyocellular lipid content with insulin
resistance in lean nondiabetic offspring of
type 2 diabetic subjects. Diabetes 48,
1113–1119 (1999).
54. Petersen, K. F. et al. 13C/31P NMR studies on
the mechanism of insulin resistance in obesity.
Diabetes 47, 381–386 (1998).
© 2013 Macmillan Publishers Limited. All rights reserved
REVIEWS
55. Unger, R. H. & Orci, L. Lipotoxic diseases of
nonadipose tissues in obesity. Int. J. Obes. Relat.
Metab. Disord. 24 (Suppl. 4), S28–S32 (2000).
56. Hoyos, C. M. et al. Body compositional and
cardiometabolic effects of testosterone therapy
in obese men with severe obstructive sleep
apnoea: a randomised placebo-controlled trial.
Eur. J. Endocrinol. 167, 531–541 (2012).
57. Marin, P., Oden, B. & Bjorntorp, P. Assimilation
and mobilization of triglycerides in subcutaneous
abdominal and femoral adipose tissue in vivo in
men: effects of androgens. J. Clin. Endocrinol.
Metab. 80, 239–243 (1995).
58. Hotamisligil, G. S. Inflammatory pathways and
insulin action. Int. J. Obes. Relat. Metab. Disord.
27 (Suppl. 3), S53–S55 (2003).
59. Malkin, C. J. et al. The effect of testosterone
replacement on endogenous inflammatory
cytokines and lipid profiles in hypogonadal men.
J. Clin. Endocrinol. Metab. 89, 3313–3318 (2004).
60. Guay, A. T., Bansal, S. & Heatley, G. J. Effect of
raising endogenous testosterone levels in
impotent men with secondary hypogonadism:
double blind placebo-controlled trial with
clomiphene citrate. J. Clin. Endocrinol. Metab. 80,
3546–3552 (1995).
61. Guay, A. T., Jacobson, J., Perez, J. B.,
Hodge, M. B. & Velasquez, E. Clomiphene
increases free testosterone levels in men with
both secondary hypogonadism and erectile
dysfunction: who does and does not benefit? Int.
J. Impot. Res. 15, 156–165 (2003).
62. Jones, T. H. & Kennedy, R. L. Cytokines and
hypothalamic-pituitary function. Cytokine 5,
531–538 (1993).
63. Mantzoros, C. S. The role of leptin in human
obesity and disease: a review of current
evidence. Ann. Int. Med. 130, 671 (1999).
64. Isidori, A. M. et al. Leptin and androgens in male
obesity: evidence for leptin contribution to
reduced androgen levels. J. Clin. Endocrinol.
Metab. 84, 3673–3680 (1999).
65. Herbison, A. E. Multimodal influence of estrogen
upon gonadotropin-releasing hormone neurons.
Endocr. Rev. 19, 302–330 (1998).
66. Smith, J. T., Clifton, D. K. & Steiner, R. A.
Regulation of the neuroendocrine reproductive
axis by kisspeptin-GPR54 signaling.
Reproduction 131, 623–630 (2006).
67. George, J. T., Millar, R. P. & Anderson, R. A.
Hypothesis: kisspeptin mediates male
hypogonadism in obesity and type 2 diabetes.
Neuroendocrinology 91, 302–307 (2010).
68. Iwasa, T. et al. Decreased expression of
kisspeptin mediates acute immune/
inflammatory stress-induced suppression of
gonadotropin secretion in female rat.
J. Endocrinol. Invest. 31, 656 (2008).
69. Singh, R., Artaza, J. N., Taylor, W. E., Gonzalez-
Cadavid, N. F. & Bhasin, S. Androgens stimulate
myogenic differentiation and inhibit
adipogenesis in C3H 10T1/2 pluripotent cells
through an androgen receptor-mediated pathway.
Endocrinology 144, 5081–5088 (2003).
70. Singh, R. et al. Testosterone inhibits adipogenic
differentiation in 3T3‑L1 cells: nuclear
translocation of androgen receptor complex with
beta-catenin and T‑cell factor 4 may bypass
canonical Wnt signaling to down-regulate
adipogenic transcription factors. Endocrinology
147, 141–154 (2006).
71. Singh, A. B. et al. The effects of varying doses
of T on insulin sensitivity, plasma lipids,
apolipoproteins, and C‑reactive protein in healthy
young men. J. Clin. Endocrinol. Metab. 87,
136–143 (2002).
72. Stanworth, R. D., Kapoor, D., Channer, K. S. &
Jones, T. H. Androgen receptor CAG repeat
REVIEWS
polymorphism is associated with serum
testosterone levels, obesity and serum leptin in
men with type 2 diabetes. Eur. J. Endocrinol.
159, 739–746 (2008).
73. Jones, T. H. Testosterone associations with
erectile dysfunction, diabetes, and the metabolic
syndrome. Eur. Urol. Suppl. 6, 847–857 (2007).
74. Cohen, P. G. The hypogonadal–obesity cycle: role
of aromatase in modulating the testosterone–
estradiol shunt—a major factor in the genesis of
morbid obesity. Med. Hypotheses 52, 49–51
(1999).
75. Barud, W., Palusinski, R., Beltowski, J. &
Wojcicka, G. Inverse relationship between total
testosterone and anti-oxidized low density
lipoprotein antibody levels in ageing males.
Atherosclerosis 164, 283–288 (2002).
76. Simon, D. et al. Association between plasma
total testosterone and cardiovascular risk
factors in healthy adult men: The Telecom Study.
J. Clin. Endocrinol. Metab. 82, 682–685 (1997).
77. Makinen, J. I. et al. Endogenous testosterone
and serum lipids in middle-aged men.
Atherosclerosis 197, 688–693 (2008).
78. Barrett-Connor, E. & Khaw, K. T. Endogenous sex
hormones and cardiovascular disease in men. A
prospective population-based study. Circulation
78, 539–545 (1988).
79. Haffner, S. M., Mykkanen, L., Valdez, R. A. &
Katz, M. S. Relationship of sex hormones to
lipids and lipoproteins in nondiabetic men.
J. Clin. Endocrinol. Metab. 77, 1610–1615
(1993).
80. Isidori, A. M. et al. Effects of testosterone on
sexual function in men: results of a meta-
analysis. Clin. Endocrinol. 63, 381–394 (2005).
81. Permpongkosol, S., Tantirangsee, N.
& Ratana-olarn, K. Treatment of 161 men with
symptomatic late onset hypogonadism with long-
acting parenteral testosterone undecanoate:
effects on body composition, lipids, and
psychosexual complaints. J. Sex. Med. 7,
3765–3774 (2010).
82. Kalinchenko, S. Y. et al. Effects of testosterone
supplementation on markers of the metabolic
syndrome and inflammation in hypogonadal men
with the metabolic syndrome: the double-blinded
placebo-controlled Moscow study. Clin.
Endocrinol. 73, 602–612 (2010).
83. Van Pottelbergh, I., Braeckman, L.,
De Bacquer, D., De Backer, G. & Kaufman, J. M.
Differential contribution of testosterone and
estradiol in the determination of cholesterol and
lipoprotein profile in healthy middle-aged men.
Atherosclerosis 166, 95–102 (2003).
84. Stanworth, R. D., Kapoor, D., Channer, K. S. &
Jones, T. H. Dyslipidaemia is associated with
testosterone, oestradiol and androgen receptor
CAG repeat polymorphism in men with type 2
diabetes. Clin. Endocrinol. 74, 624–630
(2011).
85. Isidori, A. M. et al. Effects of testosterone on
body composition, bone metabolism and serum
lipid profile in middle-aged men: a meta-analysis.
Clin. Endocrinol. 63, 280–293 (2005).
86. Kirkland, R. T. et al. Decrease in plasma high-
density lipoprotein cholesterol levels at puberty
in boys with delayed adolescence. Correlation
with plasma testosterone levels. JAMA 257,
502–507 (1987).
87. Zmuda, J. M. et al. The effect of testosterone
aromatization on high-density lipoprotein
cholesterol level and postheparin lipolytic
activity. Metabolism 42, 446–450 (1993).
88. Kekki, M. Lipoprotein-lipase action determining
plasma high density lipoprotein cholesterol level
in adult normolipaemics. Atherosclerosis 37,
143–150 (1980).
492  |  AUGUST 2013  |  VOLUME 9  www.nature.com/nrendo
89. Langer, C. et al. Testosterone up-regulates
scavenger receptor BI and stimulates
cholesterol efflux from macrophages. Biochem.
Biophys. Res. Commun. 296, 1051–1057
(2002).
90. Bagatell, C. J., Heiman, J. R., Matsumoto, A. M.,
Rivier, J. E. & Bremner, W. J. Metabolic and
behavioral effects of high-dose, exogenous
testosterone in healthy men. J. Clin. Endocrinol.
Metab. 79, 561–567 (1994).
91. Rossouw, J. E. et al. Risks and benefits of
estrogen plus progestin in healthy
postmenopausal women: principal results from
the Women’s Health Initiative randomized
controlled trial. JAMA 288, 321–333 (2002).
92. Zgliczynski, S. et al. Effect of testosterone
replacement therapy on lipids and lipoproteins in
hypogonadal and elderly men. Atherosclerosis
121, 35–43 (1996).
93. Uyanik, B. S., Ari, Z., Gumus, B., Yigitoglu, M. R.
& Arslan, T. Beneficial effects of testosterone
undecanoate on the lipoprotein profiles in
healthy elderly men. A placebo controlled study.
Jpn Heart J. 38, 73–82 (1997).
94. Nettleship, J. E., Jones, T. H., Channer, K. S. &
Jones, R. D. Physiological testosterone
replacement therapy attenuates fatty streak
formation and improves high-density lipoprotein
cholesterol in the Tfm mouse: an effect that is
independent of the classic androgen receptor.
Circulation 116, 2427–2434 (2007).
95. Scott, R. et al. Effects of fenofibrate treatment
on cardiovascular disease risk in 9,795
individuals with type 2 diabetes and various
components of the metabolic syndrome. The
Fenofibrate Intervention and Event Lowering in
Diabetes (FIELD) study. Diabetes Care 32,
493–498 (2009).
96. Jeppesen, J., Hein, H. O., Suadicani, P. &
Gyntelberg, F. Triglyceride concentration and
ischemic heart disease: an eight-year follow-up
in the Copenhagen Male Study. Circulation 97,
1029–1036 (1998).
97. Hokanson, J. E. & Austin, M. A. Plasma
triglyceride level is a risk factor for
cardiovascular disease independent of high-
density lipoprotein cholesterol level: a
metaanalysis of population-based prospective
studies. J. Cardiovasc. Risk 3, 213–219 (1996).
98. Alexandersen, P., Haarbo, J., Byrjalsen, I.,
Lawaetz, H. & Christiansen, C. Natural
androgens inhibit male atherosclerosis: a study
in castrated, cholesterol-fed rabbits. Circ. Res.
84, 813–819 (1999).
99. Zitzmann, M. et al. IPASS: a study on the
tolerability and effectiveness of injectable
testosterone undecanoate for the treatment of
male hypogonadism in a worldwide sample of
1,438 men. J. Sex. Med. 10, 579–588 (2013).
100. Heufelder, A. E., Saad, F., Bunck, M. C. &
Gooren, L. Fifty‑two‑week treatment with diet and
exercise plus transdermal testosterone reverses
the metabolic syndrome and improves glycemic
control in men with newly diagnosed type 2
diabetes and subnormal plasma testosterone.
J. Androl. 30, 726–733 (2009).
101. Agledahl, I., Hansen, J. B. & Svartberg, J. Impact
of testosterone treatment on postprandial
triglyceride metabolism in elderly men with
subnormal testosterone levels. Scand. J. Clin.
Lab. Invest. 68, 641–648 (2008).
102. Rosengren, A., Wilhelmsen, L., Eriksson, E.,
Risberg, B. & Wedel, H. Lipoprotein (a) and
coronary heart disease: a prospective case-
control study in a general population sample of
middle aged men. BMJ 301, 1248–1251 (1990).
103. Zmuda, J. M., Thompson, P. D., Dickenson, R. &
Bausserman, L. L. Testosterone decreases
© 2013 Macmillan Publishers Limited. All rights reserved
lipoprotein(a) in men. Am. J. Cardiol. 77,
1244–1247 (1996).
104. Ohlsson, C. et al. High serum testosterone is
associated with reduced risk of cardiovascular
events in elderly men: The MrOS (Osteoporotic
Fractures in Men) study in Sweden. J. Am. Coll.
Cardiol. 58, 1674–1681 (2011).
105. Corona, G. et al. Hypogonadism as a risk factor for
cardiovascular mortality in men: a meta-analytic
study. Eur. J. Endocrinol. 165, 687–701 (2011).
106. Ruige, J. B., Mahmoud, A. M., De Bacquer, D. &
Kaufman, J.‑M. Endogenous testosterone and
cardiovascular disease in healthy men: a meta-
analysis. Heart 97, 870–875 (2011).
107. Araujo, A. B. et al. Endogenous testosterone and
mortality in men: a systematic review and meta-
analysis. J. Clin. Endocrinol. Metab. 96,
3007–3019 (2011).
108. Jones, R. D., Nettleship, J. E., Kapoor, D.,
Jones, H. T. & Channer, K. S. Testosterone and
atherosclerosis in aging men. Am. J. Cardiovasc.
Drugs 5, 141–154 (2005).
109. Chew, K. K. et al. Erectile dysfunction as a
predictor for subsequent atherosclerotic
cardiovascular events: findings from a linked-
data study. J. Sex. Med. 7, 192–202 (2010).
110. Jackson, G. et al. Cardiovascular aspects of
sexual medicine. J. Sex. Med. 7, 1608–1626
(2010).
111. Araujo, A. B. et al. Erectile dysfunction and
mortality. J. Sex. Med. 6, 2445–2454 (2009).
112. Shores, M. M. et al. Low testosterone is
associated with decreased function and
increased mortality risk: a preliminary study of
men in a geriatric rehabilitation unit. J. Am.
Geriatr. Soc. 52, 2077–2081 (2004).
113. Shores, M. M., Matsumoto, A. M., Sloan, K. L. &
Kivlahan, D. R. Low serum testosterone and
mortality in male veterans. Arch. Intern. Med.
166, 1660–1665 (2006).
114. Khaw, K. T. et al. Endogenous testosterone and
mortality due to all causes, cardiovascular
disease, and cancer in men: European
prospective investigation into cancer in Norfolk
(EPIC-Norfolk) Prospective Population Study.
Circulation 116, 2694–2701 (2007).
115. Malkin, C. J. et al. Low serum testosterone and
increased mortality in men with coronary heart
disease. Heart 96, 1821–1825 (2010).
116. Muraleedharan, V., Marsh, H. & Jones, H. in
Society of Endocrinology, BES P163
(Birmingham, UK, 2011).
117. Hackett, G., Cole, N., Deshpande, A., Hall, A. &
Wilkinson, P. The BLAST study: treating
hypogonadism in type 2 diabetes with long
acting testosterone undecanoate versus
placebo significantly improves HbA1c, waist
circumference, aging male symptom scores and
all sexual function domains of the IIEF. Results
continue to improve for 12 to 18 months.
Presented at the European Society of Sexual
Medicine meeting, Milan (2011).
118. Boyanov, M. A., Boneva, Z. & Christov, V. G.
Testosterone supplementation in men with
type 2 diabetes, visceral obesity and partial
androgen deficiency. Aging Male 6, 1–7 (2003).
119. Gopal, R. A. et al. Treatment of hypogonadism
with testosterone in patients with type 2
diabetes mellitus. Endocr. Prac. 16, 570–576
(2010).
120. Bhattacharya, R. et al. Effect of 12 months of
testosterone replacement therapy on metabolic
syndrome components in hypogonadal men:
data from the Testim Registry in the US (TRiUS).
BMC Endoc. Disord. 11, 18 (2011).
121. Corona, G. et al. Testosterone and metabolic
syndrome: a meta-analysis study. J. Sex. Med. 8,
272–283 (2011).

122. Grossmann, M. Low testosterone in men with
type 2 diabetes: significance and treatment.
J. Clin. Endocrinol. Metab. 96, 2341–2353 (2011).
123. Kaukua, J., Pekkarinen, T., Sane, T. &
Mustajoki, P. Sex hormones and sexual function
in obese men losing weight. Obes. Res. 11,
689–694 (2003).
124. Hammoud, A. et al. Effect of Roux‑en‑Y gastric
bypass surgery on the sex steroids and quality
of life in obese men. J. Clin. Endocrinol. Metab.
94, 1329–1332 (2009).
125. Reis, L. O. et al. Erectile dysfunction and
hormonal imbalance in morbidly obese male is
reversed after gastric bypass surgery:
a prospective randomized controlled trial. Int.
J. Androl. 33, 736–744 (2010).
126. Kelly, D. M. & Jones, T. H. Testosterone:
a metabolic hormone in health and disease.
J. Endocrinol. 217, R25–R45 (2013).
127. Yu, Y. H. & Ginsberg, H. N. Adipocyte signaling
and lipid homeostasis sequelae of insulin-
resistant adipose tissue. Circ. Res. 96,
1042–1052 (2005).
128. Lim, S. et al. Fat in liver/muscle correlates more
strongly with insulin sensitivity in rats than
abdominal fat. Obesity 17, 188–195 (2012).
129. Lam, T. K. T., Van de Werve, G. & Giacca, A. Free
fatty acids increase basal hepatic glucose
production and induce hepatic insulin resistance
at different sites. Am. J. Physiol. Endocrinol.
Metab. 284, E281–E290 (2003).
130. Kelly, D. M. et al. Testosterone increases hepatic
liver X receptor and ApoE expression and
improves lipid metabolism in the testicular
feminized mouse: a potential protective
mechanism against atherosclerosis and fatty liver
disease. Endoc. Rev. 33, OR22–5 (2012).
131. Bryant, N. J., Govers, R. & James, D. E. Regulated
transport of the glucose transporter GLUT4. Nat.
Rev. Mol. Cell Biol. 3, 267–277 (2002).
132. Pessin, J. E. & Saltiel, A. R. Signaling pathways
in insulin action: molecular targets of insulin
resistance. J. Clin. Invest. 106, 165–170 (2000).
133. Chen, X., Li, X., Huang, H., Li, X. & Lin, J. F.
Effects of testosterone on insulin receptor
substrate‑1 and glucose transporter 4
expression in cells sensitive to insulin [Chinese].
Zhonghua Yi Xue Za Zhi 86, 1474–1477 (2006).
134. Sato, K., Iemitsu, M., Aizawa, K. & Ajisaka, R.
Testosterone and DHEA activate the glucose
metabolism-related signaling pathway in skeletal
muscle. Am. J. Physiol. Endocrinol. Metab. 294,
E961–E968 (2008).
135. Muthusamy, T., Murugesan, P. &
Balasubramanian, K. Sex steroids deficiency
impairs glucose transporter 4 expression and its
translocation through defective Akt
phosphorylation in target tissues of adult male
rat. Metabolism 58, 1581–1592 (2009).
136. Sesti, G. et al. Androgens increase insulin
receptor mRNA levels, insulin binding, and insulin
responsiveness in HEp‑2 larynx carcinoma cells.
Mol. Cell. Endocrinol. 86, 111–118 (1992).
137. Parthasarathy, C., Renuka, V. N. &
Balasubramanian, K. Sex steroids enhance
insulin receptors and glucose oxidation in Chang
liver cells. Clin. Chim. Acta 399, 49–53 (2009).
138. Muthusamy, T., Murugesan, P., Srinivasan, C. &
Balasubramanian, K. Sex steroids influence
glucose oxidation through modulation of insulin
receptor expression and IRS‑1 serine
NATURE REVIEWS | ENDOCRINOLOGY VOLUME 9  |  AUGUST 2013  |  493
phosphorylation in target tissues of adult male
rat. Mol. Cell. Biochem. 352, 35–45 (2011).
139. Salehzadeh, F., Rune, A., Osler, M. & Al-Khalili, L.
Testosterone or 17β-estradiol exposure reveals
sex-specific effects on glucose and lipid
metabolism in human myotubes. J. Endocrinol.
210, 219–229 (2011).
140. Bergamini, E., Bombara, G. & Pellegrino, C. The
effect of testosterone on glycogen metabolism
in rat levator ani muscle. Biochim. Biophys. Acta
177, 220–234 (1969).
141. McLaren, D., Kelly, D., Akhtar, S., Channer, K. &
Jones, T. Low testosterone is associated with
decreased expression of glut‑4 and hexokinase 2
in muscle of the testicular feminised mouse.
Endocrine Abstracts 29, P559 (2012).
142. Ramamani, A., Aruldhas, M. M. &
Govindarajulu, P. Differential response of rat
skeletal muscle glycogen metabolism to
testosterone and estradiol. Can. J. Physiol.
Pharmacol. 77, 300–304 (1999).
143. Leonard, S. L. The effect of castration and
testosterone propionate injection on glycogen
storage in skeletal muscle. Endocrinol. 51,
293–297 (1952).
144. Apostolakis, M., Matzelt, D. & Voigt, K. D. The
effect of testosterone propionate on glycolytic
and transamination enzyme activities in the
liver, biceps muscle and levator ani muscle in
rats [German]. Biochem. Z. 337, 414 (1963).
145. Max, S. R. Androgen-estrogen synergy in rat
levator ani muscle: glucose‑6‑phosphate
dehydrogenase. Mol. Cell. Endocrinol. 38,
103–107 (1984).
146. Mauvais-Jarvis, F. Estrogen and androgen
receptors: regulators of fuel homeostasis and
emerging targets for diabetes and obesity.
Trends Endocrinol. Metabol. 22, 24–33 (2011).
147. Traish, A. M., Abdallah, B. & Yu, G. Androgen
deficiency and mitochondrial dysfunction:
implications for fatigue, muscle dysfunction,
insulin resistance, diabetes, and cardiovascular
disease. Horm. Mol. Biol. Clin. Investig. 8,
431–444 (2011).
148. Ibebunjo, C., Eash, J. K., Li, C., Ma, Q. &
Glass, D. J. Voluntary running, skeletal muscle
gene expression, and signaling inversely
regulated by orchidectomy and testosterone
replacement. Am. J. Physiol. Endocrinol. Metab.
300, E327–E340 (2011).
149. Guo, W. et al. testosterone plus low-intensity
physical training in late life improves functional
performance, skeletal muscle mitochondrial
biogenesis, and mitochondrial quality control in
male mice. PloS ONE 7, e51180 (2012).
150. van Breda, E. et al. Modulation of fatty‑acid‑
binding protein content of rat heart and skeletal
muscle by endurance training and testosterone
treatment. Pflugers Arch. 421, 274–279 (1992).
151. Wu, S. Z. & Weng, X. Z. Therapeutic effects of an
androgenic preparation on myocardial ischemia
and cardiac function in 62 elderly male coronary
heart disease patients. Chin. Med. J. (Engl.) 106,
415–418 (1993).
152. English, K. M., Steeds, R. P., Jones, T. H.,
Diver, M. J. & Channer, K. S. Low-dose
transdermal testosterone therapy improves
angina threshold in men with chronic stable
angina: A randomized, double-blind, placebo-
controlled study. Circulation 102, 1906–1911
(2000).
© 2013 Macmillan Publishers Limited. All rights reserved
REVIEWS
153. Malkin, C. J. et al. Testosterone replacement in
hypogonadal men with angina improves
ischaemic threshold and quality of life. Heart 90,
871–876 (2004).
154. English, K. M., Jones, R. D., Jones, T. H.,
Morice, A. H. & Channer, K. S. Testosterone acts
as a coronary vasodilator by a calcium
antagonistic action. J. Endocrinol. Invest. 25,
455–458 (2002).
155. Webb, C. M., McNeill, J. G., Hayward, C. S.,
de Zeigler, D. & Collins, P. Effects of testosterone
on coronary vasomotor regulation in men with
coronary heart disease. Circulation 100,
1690–1696 (1999).
156. Malkin, C. J. et al. Testosterone therapy in men
with moderate severity heart failure: a double-
blind randomized placebo controlled trial. Eur.
Heart J. 27, 57–64 (2006).
157. Pugh, P. J., Jones, R. D., West, J. N., Jones, T. H.
& Channer, K. S. Testosterone treatment for men
with chronic heart failure. Heart 90, 446–447
(2004).
158. Jain, P., Rademaker, A. W. & McVary, K. T.
Testosterone supplementation for erectile
dysfunction: results of a meta-analysis. J. Urol.
164, 371–375 (2000).
159. Cherrier, M. M. et al. Testosterone
supplementation improves spatial and verbal
memory in healthy older men. Neurology 57,
80–88 (2001).
160. Janowsky, J. S., Oviatt, S. K. & Orwoll, E. S.
Testosterone influences spatial cognition in older
men. Behav. Neurosci. 108, 325–332 (1994).
161. Cherrier, M. M. et al. The role of aromatization in
testosterone supplementation: effects on
cognition in older men. Neurology 64, 290–296
(2005).
162. Wang, C. et al. Testosterone replacement
therapy improves mood in hypogonadal men
—a clinical research center study. J. Clin.
Endocrinol. Metab. 81, 3578–3583 (1996).
163. Wang, C. et al. ISA, ISSAM, EAU, EAA and ASA
recommendations: investigation, treatment and
monitoring of late-onset hypogonadism in males.
Int. J. Impot. Res. 21, 1–8 (2008).
164. Bhasin, S. et al. Testosterone therapy in men with
androgen deficiency syndromes: an Endocrine
Society clinical practice guideline. J. Clin.
Endocrinol. Metab. 95, 2536–2559 (2010).
165. Fernandez-Balsells, M. M. et al. Clinical review 1:
Adverse effects of testosterone therapy in adult
men: a systematic review and meta-analysis.
J. Clin. Endocrinol. Metab. 95, 2560–2575
(2010).
166. Fenely, M. R. & Carruthers, M. Is testosterone
treatment good for the prostate? Study of safety
during long-term treatment. J. Sex. Med. 9,
2138–2149 (2012).
167. Aversa, A. et al. Effects of testosterone
undecanoate on cardiovascular risk factors and
atherosclerosis in middle-aged men with late-
onset hypogonadism and metabolic syndrome:
results from a 24-month, randomized, double-
blind, placebo-controlled study. J. Sex. Med. 7,
3495–3503 (2010).
Author contributions
All authors researched data for the article,
contributed to discussion of the content and wrote
the article. P. M. Rao and T. H. Jones reviewed and
edited the manuscript before submission.