The Role of Testosterone Level in Women with Osteopenia

There is substantial data supporting the importance of both endogenous and exogenous estrogen in maintaining reproductive health and preventing chronic disease, androgens in women's health are rarely discussed. This is one of the first researches to investigate correlates of blood testosterone concentrations in women with osteopenia, in anticipation of the growing interest in the role of androgens in women's health. A 65 volunteer women were enrolled in the current study, they were divided into two groups, 35 postmenopausal women with osteopenia were in the first group, and the second group contained 30 postmenopausal women without osteopenia as a control. Blood samples were collected from all participants and analyzed for testosterone level, also demographic data were collected. The results showed that women with osteopenia have significantly low levels of testosterone as compared to control, the correlation analysis using postmenopausal women with osteopenia as a model showed a significant reversed correlation between testosterone and T score. Cluster analysis results illustrated that T-Score, testosterone and, duration of the postmenopausal were organized in one cluster, which means the three variables were associated with each other in most of the studied cases. The second cluster included t-score, testosterone and, BMI. Whereas the age factor contributed to the third cluster. Testosterone levels were significantly associated with osteopenia, which could indicate the development of osteoporosis in post-menopause women. Testosterone results were organized in one cluster with T-score and, duration of the postmenopausal. So the three variables were associated with each other in most studied cases.


Introduction
As a result of faster population, aging ,and the tendency for involution of bone and muscle tissues among older persons, the implications of these muscular and bone abnormalities are approaching pandemic status. 1,2 steopenia is a clinical term for a reduction in bone mineral density BMD that is below normal reference levels although not too low to be considered osteoporotic.Dualenergy x-ray absorptiometry DXA bone scans are used to determine BMD.The World Health Organization WHO defines a tscore between 1 and 2. 5

Abstract
There is substantial data supporting the importance of both endogenous and exogenous estrogen in maintaining reproductive health and preventing chronic disease, androgens in women's health are rarely discussed.This is one of the first researches to investigate correlates of blood testosterone concentrations in women with osteopenia, in anticipation of the growing interest in the role of androgens in women's health.A 65 volunteer women were enrolled in the current study, they were divided into two groups, 35 postmenopausal women with osteopenia were in the first group, and the second group contained 30 postmenopausal women without osteopenia as a control.Blood samples were collected from all participants and analyzed for testosterone level, also demographic data were collected.The results showed that women with osteopenia have significantly low levels of testosterone as compared to control, the correlation analysis using postmenopausal women with osteopenia as a model showed a significant reversed correlation between testosterone and T score.Cluster analysis results illustrated that T-Score, testosterone and, duration of the postmenopausal were organized in one cluster, which means the three variables were associated with each other in most of the studied cases.The second cluster included t-score, testosterone and, BMI.Whereas the age factor contributed to the third cluster.Testosterone levels were significantly associated with osteopenia, which could indicate the development of osteoporosis in post-menopause women.Testosterone results were organized in one cluster with T-score and, duration of the postmenopausal.So the three variables were associated with each other in most studied cases.and osteoporosis.Osteoporosis is diagnosed when the value is less than 2.5.BMD declines reflect an underlying change in bone microarchitecture, and osteopenia and osteoporosis are considered quantitative rather than qualitative bone mineralization disorders. 3,4 On osteoblasts, androgen receptors can be found.Reduced endogenous androgen levels have been linked to low bone mass and an increased risk of vertebral and hip fractures in both menstruation and postmenopausal women.5,6 Higher free testosterone levels in postmenopausal women, on the other hand, have been linked to a decreased incidence of hip fracture.7 Testosterone is involved in both reproductive and non-reproductive health in women.Age-related testosterone decrease begins before natural menopause 8,9 .During the late reproductive years, circulating testosterone drops the most 10 .Testosterone treatment enhances BMD and lean body mass while lowering fat mass in postmenopausal women, according to small studies 11, 12 . Furtermore, higher levels of endogenous testosterone in postmenopausal women are linked to a lower incidence of hip fracture 5,13 .This study aimed to examine total serum testosterone concentrations in relation to osteopenia in Iraqi women.

Materials and Methods
Patients: This study involved 65 females they were divided into two groups, the first group included 35 postmenopausal women with osteopenia, and the second group included 30 postmenopausal women without osteopenia.The age of the cases, as well as the controls, ranged from 50 to 70 years.Patients' blood samples were collected from outpatient clinics in Serdem private hospital, Iraq from June 2018 to August 2019.Collection of the samples: Blood was drawn from the cubital veins of the arms of both patients and healthy controls while they were fasting.by 10 ml syringe after centrifugation performed, serum was sent to the laboratory after being transferred to a separate tube for processing and performance of the biochemical tests.Blood samples are processed in two steps: first, they are centrifuged at 3000 x g for five minutes, and second, the level is determined using specialized chemical tests.
Selectivity of blood samples: Patients with parathyroid illness, liver disease, kidney disease, cigarette smoking, alcohol consumption, or those who had any overlapping doses were eliminated when blood samples were collected.The quantitative measurement of testosterone was done using the sandwich technique and the enzyme-linked immunosorbent assay (ELISA).This technique works by coupling an antibody or antigen to an enzyme used in the assay.The T-score percentage was calculated by DEXA.Statistical analysis: Statistical analysis program (SPSS 25) was used for analyzing the results.The general descriptive statistic was used to describe the main findings; independent T-test and Mann whitney test was used with an alpha level of 0.05 to compare groups, the correlation is done by using Spearman correlation, cluster analysis of multivariate have been used.

Results and Discussion
The results of BMI and Age for the studied groups were normally distributed so it described as mean ± SE Table .1, whereas Testosterone level was non normal distributed so it discussed as mean ranks Table .2. The authors have matched presented demographic factors age and DMI to study the real alteration on testosterone level in the studied population.The results showed that women with osteopenia have significantly low levels of testosterone as compared to control Table .2. The current study disagrees with Arpaci et.al 14 , the last study failed to demonstrate a statistically significant relationship between testosterone and BMD.Also, Wang et.al 15 found that total testosterone concentration below 500 ng/dl may have no effect on bone mineral density.Several factors are involved in the alteration of chemical parameters when making the case-control study.In the current study, the duration of menopause was analyzed in relation to testosterone level.The results showed no significant difference among the study group postmenopause.The decrement in testosterone levels could be due to declining adrenal function and ovarian within aging.Further classification of the studied population has been made according to the duration of menopause, the results are presented in Table .3. There are no significant alterations in testosterone level when compared all groups one another.The subjects were divided into three groups with duration 1-5, 5-10, 10-15 for both Osteopenia and control subjects.Low testosterone levels have nothing to do with the duration of postmenopausal as shown in the present study.Other researchers said that testosterone has nothing to do with sexual dysfunction postmenopausal 16 .Both findings are in the same line.

Groups
Correlation analysis using postmenopausal women with osteopenia as a model showed a significant reversed correlation between testosterone and T Score Table   To confirm the association among the studied variables Cluster analysis has been used.T-Score, testosterone and, duration of the postmenopausal were organized in one cluster, which means the three variables were associated with each other in most of the studied cases.The second cluster included t-score, testosterone and, BMI.Whereas the Age factor was contributed to the third cluster, the latter included t-score, testosterone, BMI, and Age (Fig. 1).During ageing, total and free testosterone levels decline 17 .There was no link between serum testosterone and age, according to Akatsu.In both premenopausal and postmenopausal women, age has a negative relationship with serum testosterone levels 18 .Current study do not showed any correlation to age with testosterone.Correlation analysis using postmenopausal women without osteopenia as a model showed a significant reversed correlation between Age and T score only Table .5. Cluster analysis showed that T-Score, testosterone and, duration of the postmenopausal were organized in one cluster, the three variables were associated with each other in most of the studied cases with or without osteopenia even though it was not correlated to each other in control subjects.The second cluster included t-score, and, BMI.Whereas the Age factor was contributed to the third cluster, the latter included BMI and Age Fig. 2. . 4.

Figure 1 .
Figure 1.Cluster analysis of variables used in the current study using osteopenia patients as a model.

Figure 2 .
Figure 2. Cluster analysis of variables used in the current study using control as a model