Endocrine Care

Xu Xiaolin et al. Effect of Testosterone Synthesis … Horm Metab Res 2018; 00: 00–00

Effect of Testosterone Synthesis and Conversion on Serum

Testosterone Levels in Obese Men

Authors
Xiaolin Xu1, 2 * , Lei Wang3 * , Dandan Luo1, Meijie Zhang1, Shuhong Chen1, 4, Yupeng Wang1, Dongmei Zheng1, Li Feng1,
Ling Gao1, 5, Chunxiao Yu1, Qingbo Guan1

Affiliations
1 Department of Endocrinology, Shandong Academy of
Clinical Medicine, Jinan, Shandong, China
2 Department of Rheumatology and Immunology,
Dongying People’s Hospital, Shandong, China
3 Department of Gastrointestinal Surgery, Jinan Central
Hospital Shandong, China
4 Department of Endocrinology, Linyi People’s Hospital,
China
Tel.: + 86/156/10119 937, Fax: + 86/531/87037 758
doctorguanqingbo@163.com
Abs tr ac t
Obesity is associated with decreased testosterone levels in
males. Testosterone is synthesized by testosterone synthetic

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enzymes, which are stimulated by luteinizing hormone (LH).
Linyi, Shandong, China
Testosterone can also be converted to estradiol via the aro-
5 Scientific Center, Shandong Provincial Hospital, Jinan,
matase. The objective of this study was to examine the factors
Shandong, China
related to testosterone synthesis and conversion, and to sys-
Key words tematically evaluate the key processes that influence testos-
aromatase, male, obesity, StAR, testosterone terone levels in male obesity. Three hundred and two male
subjects (aged 25–45 years old) were divided according to BMI
Received 16.02.2018 into normal weight (18.5–23.9 kg/m 2 ), overweight (24–
Accepted 04.07.2018 27.9 kg/m2), and obese ( ≥ 28 kg/m2) groups; or divided follow-
ing WHR into non-abdominal obesity and abdominal obesity
Bibliography
groups (WHR:  ≥ 0.9). Male C57BL/6 mice were divided into
DOI https://doi.org/10.1055/a-0658-7712
normal diet (ND) and high-fat diet (HFD)-induced obesity
Published online: 2018
group. Serum sex hormones and aromatase levels were meas-
Horm Metab Res
ured using ELISAs. Testosterone synthetic enzymes in the tes-
© Georg Thieme Verlag KG Stuttgart · New York
tes were measured by qRT-PCR. The testosterone levels in
ISSN 0018-5043
obese men and abdominal obesity men were lower than nor-
Correspondence mal men. In abdominal obesity men serum LH levels were de-
Chunxiao Yu creased and associated with testosterone levels after multivar-
Shandong Provincial Hospital Affiliated to Shandong iate regression analysis. Serum aromatase levels were increased
University in abdominal obesity males. In mice, compared to the ND
324 Jingwu Road group, the HFD group had decreased steroidogenic acute reg-
Chunxiao Yu ulatory protein (StAR). However, aromatase levels in subcuta-
Jinan neous adipose tissue were higher in the ND group than HFD
250021 Shandong group. In conclusion, according to this study decreased testic-
China ular synthesis function and the conversion of testosterone may
Tel.: + 86/156/10119 937, Fax: + 86/531/87037 758 explain the reduction in testosterone levels in male obesity,
yuchx08@163.com and the decrease of testicular synthesis may change first.

Qingbo Guan
Shandong Provincial Hospital Affiliated to Shandong
University
324 Jingwu Road
Chunxiao Yu
Jinan
250021 Shandong

* These authors contributed equally to this work.

Xu X et al. Testosterone Synthesis and Conversion … Horm Metab Res

 Endocrine Care
Introduction
Currently, overweight status and obesity have reached epidemic pro-
portions globally [1]. These conditions are associated with cardiovas-
cular disease, metabolic syndrome, sleep apnea, and other factors
[2, 3]. Recently, an increasing number of studies have indicated that
obesity is one of the main reasons for male infertility. Some studies
have reported that serum testosterone and sex hormone-binding
globulin (SHBG) levels decrease significantly with increasing body
mass index (BMI) [4–6]. Testosterone, as the main androgen in males,
is responsible for normal testicular development, maintaining sec-
ondary sexual characteristics, spermatogenesis, and contributing to
the sex drive [7, 8]. Furthermore, testosterone plays an important role
in maintaining male normal fertility. Therefore, a systematic study of
the effects and mechanism of obesity on testosterone is essential to
deepen the understanding of obesity-induced male infertility.
Two testosterone metabolic processes, synthesis and conver-
sion, are involved in the regulation of testosterone levels. The bio-
synthesis of testosterone occurs in testicular Leydig cells and is
mainly controlled by the hypothalamic-pituitary-testis (HPT) axis,
which releases gonadotropin releasing hormone (GnRH) to stimu-
late luteinizing hormone (LH) [9, 10]. At the level of the hypothal-
amus, LH secretion is under negative feedback control by testos-
terone, which consequently decreases the frequency of LH pulsa-
tile release [9, 10]. Testosterone synthesis in Leydig cells is
controlled by steroidogenic acute regulatory protein (StAR) and
testosterone synthetic enzymes, including cytochrome P450 cho-
lesterol-side-chain cleavage enzyme (P450scc) and 3β-hydroxyster-
oid dehydrogenase (3β-HSD) [11, 12]. StAR is the rate-limiting step
in the synthesis of testosterone. It transfers cholesterol from the
outer mitochondrial membrane to the inner mitochondrial mem-
brane. The process is influenced by LH, which acts via cAMP to
transfer cholesterol into the mitochondria to regulate testosterone
production [13]. Recently, Yi et al. reported that obesity regulated
StAR in the testis via the leptin-JAK-STAT pathway [14], suggesting
that impaired testosterone synthesis might be one important pro-
cess through which obesity affects testosterone levels.
Testosterone conversion to estradiol (E2) via the enzyme aro-
matase is another important pathway for testosterone metabolism
[15]. In humans, aromatase is expressed in a number of tissues in-
cluding ovarian, testes, brain, bone, skin, and adipose tissues
[16, 17]. In men, the majority of estrogens are produced in extrag-
landular tissues as a result of the aromatization of circulating an-
drogens [18], particularly in white adipose tissue (WAT) [19]. As
WAT mass increases, aromatase may induce more peripheral con-
version of androgens to estrogens [10, 20]. In addition, the in-
creased levels of E2 feedback negatively to suppress the HPT axis,
further reducing the secretion of testosterone [2, 21]. However,
the data on E2 levels in male obesity are still controversial. There-
fore, it is unclear whether the increased conversion of testosterone
in obesity leads to decreased testosterone levels.
The synthesis and conversion of testosterone play important
roles in maintaining testosterone levels. In this study, to systemat-
ically analyze the reasons for the reduction in testosterone levels
in male obesity, we examined testicular synthesis function and tes-
tosterone conversion simultaneously using clinical research and
animal experiments. These findings will provide new therapy tar-
gets for obesity-associated hypogonadism.
Subjects and Methods
Study 1: Human study
Data were obtained from an epidemiological investigation of phys-
ical examinations performed in Shandong Provincial Hospital in
China from August 2015 to November 2015. All subjects had lived
in one community (Feicuijun in Ji’nan, China) for more than 5 years.
A total of 1531 people participated in the investigation. The study
was approved by the Shandong Provincial Hospital Ethics Commit-
tee. The procedures and purposes of this study were explained to
the subjects prior to completion of the questionnaires and a fasting
blood draw. All subjects provided informed consent. Height and
weight were measured in centimeters and kilograms, respectively,
and BMI was calculated by dividing the weight (kilograms) by the
square of the height (meters2). Waist circumference and hip circum-
ference were measured in centimeters, and WHR was calculated by
dividing the waist circumference (centimeters) by the hip circumfer-
ence (centimeters). The inclusion criteria consisted of being male
and aged between 25 and 45 years. The exclusion criteria consisted
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of individuals with a history of gonadal disease, cancer or endocrine
diseases, suffering from acute or chronic infections, serious cardio-
vascular or cerebrovascular disease, liver, pancreas, kidney or other
chronic parenchymal diseases, or using lipid-lowering drugs, aro-
matase inhibitors or steroid hormone drugs. According to the study
criteria, 302 men were included, and the subjects were divided based
on BMI or WHR separately, including three groups based on BMI: a
normal weight group with 96 men (BMI: 18.5–23.9 kg/m2), an over-
weight group with 125 men (BMI: 24–27.9 kg/m2), and an obese
group with 81 men (BMI:  ≥ 28 kg/m2); two groups based on WHR: a
non-abdominal obesity group with 137 men (WHR: < 0.9) and an ab-
dominal obesity group with 158 men (WHR:  ≥ 0.9) (▶Fig. 1).
Hormonal and biochemical analysis
Blood samples were collected after overnight fasting, and serum
samples were centrifuged, fractionated, and stored at –80  °C for
subsequent analysis. The triglyceride (TG), total cholesterol (TC),
high-density lipoprotein cholesterol (HDL), low-density lipoprotein
cholesterol (LDL), and fasting plasma glucose (FPG) levels were
measured using the BECKMAN Chemistry Analyzer AU5800 System
195 (Beckman Coulter, Tokyo, Japan). Total testosterone, E2, SHBG,
LH, follicle-stimulating hormone (FSH), and fasting insulin (FINS)
levels were determined in serum using an electrochemilumines-
cence immunoassay (Cobas8000; Roche, Basel, Switzerland). The
homeostasis model assessment of insulin resistance (HOMA-IR)
was calculated using fasting glucose levels and FINS values with the
following equation: fasting glucose (mmol/l) × FINS (μIU/ml])/22.5.
The free testosterone index (FTI) was calculated with the following
formula: testosterone (ng/ml) × 347/SHBG (nmol/l) [22].
Enzyme-linked immunosorbent assay (ELISA)
ELISA kits for human aromatase (ARO) (Uscn Life Science & Tech-
nology Co, Ltd., Wuhan, China) were used to determine serum aro-
matase levels according the manufacturer’s protocol.
Study 2: Animal study
All animal protocols and procedures were approved by the Institu-
tional Animal Care and Use Committee of Shandong University
Xu X et al. Testosterone Synthesis and Conversion … Horm Metab Res

▶Fig. 1 Flowchart of the enrollment process.
(Ji’nan, China). Male (3-week old) C57BL/6 mice were purchased from
Vital River Laboratory Animal Technology Co Ltd. (Beijing, China).
After being adapted to the housing conditions for 1 week, the mice
were divided into 2 groups and given the following different treat-
ments: the normal diet (ND) group received 100 % standard rodent
chow, 3.49 kcal/g (Keaoxieli Diets, Beijing, China); and the high-fat
diet (HFD)-induced obesity group received an HFD supplemented
with 60 kcal % fat, 5.24 kcal/g (D12492, Research Diets, USA). All mice
were adapted to a 12-h light/dark cycle at 22–25  °C for 12 weeks and
weighed every week. All mice were sacrificed at 16 weeks old.
Serum lipid and sex hormone measurements
The mouse serum samples were separated after centrifugation and
rapidly stored at –80  °C until analysis. The TG, TC, HDL, and LDL
values were measured using routine enzymatic methods with the
BECKMAN Chemistry Analyzer AU5800 System 195 (Beckman Coul-
ter, Tokyo, Japan). Total testosterone (Uscn Life Science & Technol-
ogy Co, Ltd, Wuhan, China), E2 (De Medi Tec, Germany), LH (LSBio,
Seattle, USA), FSH (Abnova, Taiwan), and ARO (CUSABIO, Wuhan,
Xu X et al. Testosterone Synthesis and Conversion … Horm Metab Res
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China) levels in serum were measured using an ELISA according to
the manufacturer’s protocols for each assay.
Quantitative real time polymerase chain reaction
(qRT-PCR)
Total RNA was extracted from mouse testes using the TRIzol reagent
and reverse transcribed with the Prime Script RT reagent kit (TaKaRa,
Otsu, Shiga, Japan). StAR, P450scc, 3β-HSD and LH receptor (LHR)
messenger RNA (mRNA) expression were measured with qRT-PCR,
with normalization to β-actin as the reference gene. qRT-PCR was per-
formed using a SYBR Premix Ex Taq II (TaKaRa) and a LightCycler480
instrument (Roche Diagnostics). The primers used were as follows (all
5′–3′): StAR (sense, ATG TTC CTC GCT ACG TTC AAG; antisense, CCC
AGT GCT CTC CAG TTG AG); P450scc (sense, AGG TCC TTC AAT GAG
ATC CCT T; antisense, TCC CTG TAA ATG GGG CCA TAC); 3β-HSD
(sense, AGC TCT GGA CAA AGT ATT CCG A; antisense, GCC TCC AAT
AGG TTC TGG GT); LHR (sense, CTC GCC CGA CTA TCT CTC AC; anti-
sense, ACG ACC TCA TTA AGT CCC CTG); and β-actin (sense, GGC TGT
ATT CCC CTC CAT CG; antisense, CCA GTT GGT AAC AAT GCC ATG T).
 Endocrine Care
Measurement of testosterone in the testis
For the detection of testosterone in the testis, testicular tissues
(20 mg) were homogenized by sonication in phosphate-buffered
solution (PBS, 200 μl), repeatedly frozen and thawed, then centri-
fuged. The supernatant was collected for intratesticular testoster-
one concentration assessment using an enzyme-linked immuno-
sorbent assay (ELISA) (Uscn Life Science & Technology Co., Ltd.,
Wuhan, China). Testosterone concentrations in testicular tissues
were normalized to protein concentrations, which were determined
using a BCA protein assay kit (Shenneng Bocai Biotechnology Co.,
Ltd., Shanghai, China). All procedures were carried out in accord-
ance with the instructions provided by the manufacturers.
Measurements of aromatase in subcutaneous
adipose tissues (SAT)
SAT was removed and immediately frozen in liquid nitrogen for aro-
matase measurements. Samples of SAT (50 mg) were excised from
the frozen sample on ice. The excised SAT was added to 50 μl of
phosphate-buffered saline (PBS) (pH 7.4) and homogenized. The
tissue homogenates were frozen overnight at –20  °C. After two
freeze-thaw cycles, the tissue homogenates were centrifuged using
a refrigerated centrifuge (parameters: revolution = 5000 g,
time = 5 min and temperature = 4  °C). The middle layer of the SAT
homogenate was separated and stored at –80  °C to determine the
total protein and aromatase levels. The aromatase levels were
measured by an ELISA (CUSABIO, Wuhan, China). The concentra-
tions of total protein in the adipose tissues were measured by BCA
protein assay kit (Bio-Rad, Hercules, CA, USA) to adjust for the level
of aromatase in adipose tissue. All methods were performed in ac-
cordance with the relevant guidelines and regulations.
Statistical analysis
The values are presented as the means (S.D.) or medians (interquar-
tile ranges) based on whether or not their distributions were skewed,
as judged by a histogram. In this study, one-way ANOVA and Kruskal–
Wallis H-test were used to compare variables among different body
weight groups; independent-samples T-test was used to compare
variables between two groups, and the parameters with skewed var-
iables were tested by a Mann–Whitney U-test. A monadic linear re-
gression analysis was performed to determine the role of BMI or WHR
as an independent factor associated with sex hormones in men ad-
justed for age. To further identify factors that affect the levels of total
testosterone, multivariate linear regression analysis was performed
using total testosterone as the dependent variable and age, WHR,
TC, FPG,FINS, LH, E2, and ARO as independent variables. All statisti-
cal analyses were performed using the SPSS Statistical Analysis Sys-
tem (version 22.0 for Windows, Chicago, IL, USA). Statistical signifi-
cance was defined with p-values < 0.05.
Results
Subject characteristics
The characteristics of the study subjects are listed in ▶Table 1, 2.
Normal weight men were younger than the overweight men and
obese men (31.75, 34.39, and 34.05 years, respectively; p = 0.004).
In addition to an increased BMI, the overweight and obese men
were insulin resistant and had higher FINS, TC, TG, and LDL levels and
significantly lower HDL levels than normal weight men (▶Table 1).
These results are consistent with the result of the data that divid-
ed based on WHR (▶Table 2).
Obese men had the lowest testosterone levels compared to
overweight and normal weight men (4.23, 4.84, and 6.28 ng/ml,
respectively; p = 0.000). Similarly, the SHBG level was lowest in
obese men compared to overweight and normal weight men
(26.47, 31.25, and 43.16 nmol/l, respectively; p = 0.000). The FTI
was increased in obese men compared to normal weight and over-
weight men (59.07, 57.12, and 52.21 %, respectively; p = 0.022).
Despite the increase in BMI, a decreased tendency of LH level and
an increased tendency of E2 and aromatase levels were observed;
however, there were no significant differences among the groups
(▶Table 1). According to WHR grouping, we further analyzed the
sex hormone levels of abdominal obesity male. Similarly, the testos-
terone levels and SHBG levels were decreased in abdominal obesity
group compared to non-abdominal obesity group (p = 0.000). No dif-
ferences were observed in FTI, serum E2 and FSH levels. However, the
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serum LH levels was lower in abdominal obesity group than non-ab-
dominal obesity group (p = 0.035). And aromatase levels was increased
in abdominal obesity group (p = 0.000) (▶Table 2).
The testosterone to estradiol (T/E2) ratio is commonly defined
as a marker of aromatase [23, 24], and the LH/T ratio can serve as
a surrogate marker of testicular function [25, 26]. In our study, the
T/E2 ratio was significantly decreased in obesity, and the LH/T ratio
was significantly increased in obese men (▶Table 1, 2).
BMI and WHR are associated with sex hormones
To explore the relationship between BMI and sex hormones, we
used BMI as an independent variable in the unary linear regression
analysis. After adjusting for age, BMI was significantly, positively
and linearly related to FTI (β = 0.169, p = 0.003) values, negatively
and linearly related to total testosterone (β =  − 0.454, p = 0.000),
SHBG (β =  − 0.438, p = 0.000), LH (β =  − 0.145, p = 0.014) and the
T/E2 ratio (β =  − 0.384, p = 0.000) (▶ Table 3). Despite that the
serum E2 and aromatase were not significantly related to an in-
crease in BMI, the levels tended to increase with increased BMI
(▶ Table 3).
We also investigated the relationship between WHR and sex hor-
mones, and used WHR as an independent variable in the unary lin-
ear regression analysis. As shown in ▶ Table 4, after adjusting for
age, WHR was significantly, positively and linearly related to FTI
(β = 0.174, p = 0.004) values, negatively and linearly related to total
testosterone (β =  − 0.488, p = 0.000), SHBG (β =  − 0.460, p = 0.000),
and aromatase (β = 0.255, p = 0.000). The result of the relationship
between WHR and total testosterone, FTI, SHBG was similar to BMI,
but the aromatase levels was significantly related to an increase in
WHR. These findings indicated that aromatase may causes more
testosterone conversion in abdominal obesity men.
Total testosterone levels are associated with sex
hormones and metabolic parameters
To identify potential mechanisms of the reduction of serum total
testosterone levels in obese men, a multivariate linear regression
analysis was performed using total testosterone as the dependent
variable. The regression analysis revealed that WHR (β =  − 0.364,
Xu X et al. Testosterone Synthesis and Conversion … Horm Metab Res
 ▶Table 1 Clinical and laboratory characteristics of the different groups in the human population.

Characteristics Normal (n = 96) Overweight(n = 125) Obesity (n = 81) p-Value

Age, years, mean (SD) 31.75(6.14) 34.39(6.12) 34.05(6.12) 0.004

BMI, kg/m2, mean (SD) 21.83(1.44) 25.93(1.10) 30.44(2.40) 0.000
TC, mmol/l, mean (SD) 4.74(0.77) 5.17(0.82) 5.21(0.93) 0.000
HDL, mmol/l, mean (SD) 1.27(0.21) 1.14(0.23) 1.04(0.22) 0.000
LDL, mmol/l, mean (SD) 2.91(0.64) 3.25(0.61) 3.30(0.63) 0.000
TG, mmol/l, median (IQR) 1.03(0.62) 1.50(1.10) 2.02(1.65) 0.000
FPG, mmol/l, mean (SD) 5.45(0.58) 5.49(1.65) 5.52(0.61) 0.920
FINS, μIU/ml, mean (SD) 8.24(3.69) 11.87(5.16) 16.33(6.87) 0.000
HOMA-IR, mean (SD) 1.96(0.87) 2.87(1.46) 4.00(1.71) 0.000
Sex hormones
Total testosterone, ng/ml, mean (SD) 6.28(2.01) 4.84(1.42) 4.23(1.39) 0.000
FTI,  %, mean (SD) 52.21(18.07) 57.12(15.44) 59.07(18.67) 0.022
SHBG, nmol/l, mean (SD) 43.16(18.73) 31.25(12.80) 26.47(9.95) 0.000
E2, pg/ml, mean (SD) 29.51(9.63) 30.06(10.48) 31.51(9.27) 0.391
FSH, mIU/ml, mean (SD) 4.83(2.10) 5.18(2.60) 4.88(2.58) 0.514

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LH, mIU/ml, mean (SD) 5.30(1.91) 5.03(2.16) 4.65(1.85) 0.100
T/E2, mean (SD) 0.231(0.117) 0.175(0.777) 0.147(0.68) 0.000
LH/T, mean (SD) 0.908(0.389) 1.098(0.551) 1.18(0.569) 0.001
Aromatase, ng/ml, mean (SD) 4.86(1.88) 5.11(1.94) 5.22(1.47) 0.423

BMI: Body mass index; TC: Total cholesterol; HDL: High-density lipoprotein cholesterol; LDL: Low-density lipoprotein cholesterol; TG: Triglycerides;
FPG: Fasting plasma glucose concentration; FINS: Fasting insulin concentration; HOMA-IR: Homeostatic model assessment of insulin resistance; FTI:
Free testosterone index; SHBG: Sex hormone-binding globulin; E2: Estradiol; FSH: Follicle-stimulating hormone; LH: Luteinizing hormone.

▶Table 2 Clinical and laboratory characteristics of the different groups in the human population.

Characteristics Non-abdominal Obesity (n = 137) Abdominal Obesity (n = 158) p-Value

Age, years, mean (SD) 31.21(6.10) 35.45(5.70) 0.000

BMI, kg/m2, mean (SD) 23.67(2.83) 27.75(3.25) 0.000
WHR, mean (SD) 0.84(0.04) 0.95(0.03) 0.000
TC, mmol/l, mean (SD) 4.80(0.79) 5.25(0.87) 0.000
HDL, mmol/l, mean (SD) 1.24(0.22) 1.08(0.23) 0.000
LDL, mmol/l, mean (SD) 2.96(0.64) 3.32(0.61) 0.000
TG, mmol/l, median (IQR) 1.13(0.73) 1.82(0.56) 0.000
FPG, mmol/l, mean (SD) 5.35(0.51) 5.59(1.50) 0.066
FINS, μIU/ml, mean (SD) 9.55(4.40) 14.11(6.66) 0.000
HOMA-IR, mean (SD) 2.30(1.14) 3.51(1.96) 0.000
Sex hormones
Total testosterone, ng/ml, mean (SD) 6.00(1.84) 4.37(1.42) 0.000
FTI,  %, mean (SD) 56.64(17.70) 55.96(17.29) 0.743
SHBG, nmol/l, mean (SD) 39.23(17.93) 28.64(11.55) 0.000
E2, pg/ml, mean (SD) 30.07(9.92) 30.82(9.77) 0.512
FSH, mIU/ml, mean (SD) 4.80(2.15) 5.12(2.69) 0.255
LH, mIU/ml, mean (SD) 5.24(1.87) 4.75(2.05) 0.035
T/E2, mean (SD) 0.22(0.10) 0.15(0.08) 0.000
LH/T, mean (SD) 0.92(0.35) 1.17(0.61) 0.000
Aromatase, ng/ml, mean (SD) 3.64(1.44) 4.86(1.56) 0.000

For abbreviations, see ▶ Table 1.

Xu X et al. Testosterone Synthesis and Conversion … Horm Metab Res

 Endocrine Care

▶Table 3 BMI as the independent factor associated with sex hor- ▶Table 4 WHR as the independent factor associated with sex hor-
mones and metabolic variables, adjusted for age. mones and metabolic variables, adjusted for age.

Variables Unstandardized Standardized t p-Value Variables Unstandardized Standardized t p-Value

Coefficients B Coefficients β Coefficients B Coefficients β

TC 0.044 0.190 3.363 0.001 TC 3.577 0.265 4.426 0.000

HDL − 0.023 − 0.350 − 6.390 0.000 HDL − 1.269 − 0.341 − 5.725 0.000
LDL 0.035 0.201 3.579 0.000 LDL 2.989 0.293 4.950 0.000
FINS 0.946 0.569 11.652 0.000 FINS 48.25 0.500 8.896 0.000
HOMA-IR 0.239 0.510 10.002 0.000 HOMA-IR 12.23 0.448 7.784 0.000
TT − 0.224 − 0.454 − 8.785 0.000 TT − 14.003 − 0.488 − 8.834 0.000
FTI 0.797 0.169 3.012 0.003 FTI 47.72 0.174 2.892 0.004
SHBG − 1.877 − 0.438 − 8.209 0.000 SHBG − 113.86 − 0.460 − 8.018 0.000
E2 0.302 0.112 1.915 0.056 E2 10.47 0.068 1.074 0.284
FSH − 0.007 − 0.010 − 0.181 0.857 FSH 2.316 0.060 0.970 0.333
LH − 0.079 − 0.145 − 2.478 0.014 LH − 3.172 − 0.102 − 1.618 0.107
T/E2 − 0.010 − 0.384 − 7.073 0.000 ARO 6.388 0.255 4.058 0.000

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ARO 0.034 0.067 1.106 0.270
TT: Total testosterone; ARO: Aromatase.
TT: Total testosterone; ARO: Aromatase.

▶Table 5 Linear regression analysis of the variables associated with serum total testosterone levels in males.

Variables Unstandardized Coefficients B Standardized Coefficients β t p-Value 95%CI

Age − 0.015 − 0.052 − 0.988 0.324 − 0.046 to  − 0.015

WHR − 10.40 − 0.364 − 6.074 0.000 − 13.77 to  − 7.029

TC − 0.028 − 0.013 − 0.258 0.797 − 0.243 to 0.186
FPG − 0.106 − 0.061 − 1.260 0.209 − 0.270 to 0.059
FINS − 0.061 − 0.203 − 3.711 0.000 − 0.094 to  − 0.029
LH 0.176 0.188 3.875 0.000 0.086 to 0.265
E2 0.058 0.306 6.403 0.000 0.040 to 0.076
ARO − 0.014 − 0.012 − 0.242 0.809 − 0.124 to  − 0.097

In the multiple linear regression analysis with total testosterone as the dependent variable, values included are age, WHR, FINS, metabolic parame-
ters, SHBG, FTI, LH, E2, and ARO.

p = 0.000), FINS (β =  − 0.203, p = 0.000), LH (β = 0.188, p = 0.000)
and E2 (β = 0.306, p = 0.000) were independently associated with
the total testosterone levels (▶ Table 5). Serum aromatase levels
showed no associations with total testosterone levels.
The high-fat diet increased the body weight and
serum lipid profiles in mouse
In this study, the body weights of the mice in the HFD group signif-
icantly increased and were obviously higher than those in the ND
group during the 12-week feeding period (▶Fig. 2a). The ratio of
epididymal adipose tissue (EAT) weight to the body weight in-
creased in the HFD group compared to those in the ND group, but
the ratio of testicular weight to the body weight decreased in the
HFD group, and these differences were statistically significant.
However, there was no significant difference in testicular weight
between the two groups (▶ Fig. 2b–f). To observe the effects of
the high-fat diet induced obesity on circulating lipid and glucose
profiles, serum TG, TC, HDL, LDL, and FPG levels in mice were ex-
amined. As shown in ▶Fig. 2g, h, at the 12th week, the level of TC,
HDL, LDL, and FPG significantly increased of the mouse in the HFD
group compared with those in the ND group. There was no differ-
ence in TG between two groups.
The high-fat diet altered the mouse sex hormone
levels in serum
To observe the mouse sex hormone levels in serum following the
high-fat diet induced obesity, the levels of serum total testoster-
one, E2, LH, and FSH were measured. As shown in ▶Fig. 3, the level

Xu X et al. Testosterone Synthesis and Conversion … Horm Metab Res

 Downloaded by: Washington University. Copyrighted material.
▶Fig. 2 Description of the mouse model of obesity established after 12 weeks on an HFD. a: Comparison of the time-dependent increases in body
weight between the ND and HFD groups; BW: Body weight. b–f: Comparison of the shape, EAT, testes, the ratio of EAT weight to body weight, testic-
ular weight, the ratio of testicular weight to body weight in the mice in the ND and HFD groups; EAT: Epididymal adipose tissue, TW: Testicular
weight. g: Comparison of the serum lipid levels between the ND and HFD groups; TG: Triglycerides, TC: Total cholesterol, LDL: Low-density lipopro-
tein, HDL: High-density lipoprotein. h: Comparison of FPG in mice between ND and HFD groups; FPG: Fasting plasma glucose. Data are the
means ± SD. * p < 0.05, *  * p < 0.01, or *  *  * p < 0.001.

of testosterone decreased in the HFD group, and the serum E2 lev-
els were higher in the HFD group mice than those in the ND group
mice. However, no differences in serum LH and FSH levels were ob-
served between the groups.
The high-fat diet altered the expression of
testosterone synthesis enzymes and aromatase
To further identify the effect of high-fat diet on the testosterone syn-
thesis and conversion in mice, the testosterone concentration, the
expression of testicular synthesis enzymes and LH receptor in the
testis were analyzed. We detected the levels of aromatase in the
serum and SAT. The result shows that intratesticular testosterone
levels was decreased in the HFD group, and this result is consistent
with the results of serum testosterone levels (▶Fig. 4a). The key pro-
tein in the process of testosterone synthesis is StAR, and it is the
rate-limiting step of testosterone synthesis. In this study, compared
to the ND group mice, mice that received an HFD showed a signifi-
cant decrease in the mRNA expression of StAR in the testes. No dif-
ferences were observed in the mRNA expression of P450scc, 3β-HSD
and LH receptor (▶Fig. 4b). We further observed the expression of
aromatase. As the results showed, the aromatase levels per milligram
SAT were decreased in the HFD group compared to those in the ND
group. No differences in serum aromatase levels were observed be-
tween the groups (▶Fig. 4c, d). These results suggest that obesity
may inhibit the testosterone synthesis in the testes.

Xu X et al. Testosterone Synthesis and Conversion … Horm Metab Res

 Endocrine Care
Discussion
In recent years, the effect of obesity on male reproduction has re-
ceived more attention in clinical and basic research studies. In this
study, we confirmed that serum testosterone levels was decreased
in both obese male humans and mice, and we investigated it
▶Fig. 3 Comparison of the sex hormones in the mice in the ND and
HFD groups; T: Testosterone; E2: Estradiol; FSH: Follicle-stimulating
hormone; LH: Luteinizing hormone. Data are the means ± SD. *
p < 0.05, *  * p < 0.01, or *  *  * p < 0.001.
▶Fig. 4 The expression of intra-testicular testosterone, StAR, P450scc, 3β-HSD, LH receptor, and aromatase in the ND and HFD groups. a: Compari-
son of the testosterone content in testis. b: The expressions of StAR, P450scc, 3β-HSD, and LH receptor in the testicular tissues of the experimental
groups were evaluated by qRT-PCR, and the mRNA expression is shown relative to β-actin expression. c, d: The expression of aromatase levels in
serum and subcutaneous adipose tissues. Data are the means ± SD. * p < 0.05, *  *  * p < 0.001.
through two kinds of grouping, BMI and WHR, fully analyzed the
reason of decreased testosterone levels in obesity, especially ab-
dominal obesity in males, which may be due to decreased testos-
terone synthesis in the testes and increased conversion of testos-
terone in fat.
Testosterone is present in the serum as free or unbound testos-
terone, SHBG-bound testosterone and albumin-bound testoster-
one. In lean men, approximately 50 % of testosterone is bound to
albumin and other proteins, 44 % is bound to SHBG and 2 % is un-
bound [5]. The fraction of testosterone that is free or albu-
min-bound is considered bioavailable testosterone, and SHBG-
bound testosterone may be bioavailable in some target tissues
[27]. The section of testosterone bound to SHBG is proportional to
the serum SHBG levels [28]. In the human study, we observed that
after adjusting for age, BMI and WHR were positively related to the
TC, LDL, FINS, and HOMA-IR values, suggesting that obesity can re-
sult in dyslipidemia and insulin resistance. Correspondingly, total
testosterone and SHBG levels were significantly inversely correlat-
ed, whereas FTI was positively correlated with increased BMI and
Downloaded by: Washington University. Copyrighted material.
WHR, suggesting that male obesity can cause testosterone defi-
ciency accompanied by decreased SHBG and elevated free testos-
terone levels.
Studies have demonstrated that dyslipidemia might be involved
in the obesity-induced decrease in testosterone, and the high-fat
diet is the main cause of obesity and lipid metabolism disorders
[29, 30]. To further analyze the role and mechanism of decreased
testosterone secondary to HFD-induced obesity, we constructed
an HFD-induced obesity animal model. Consistent with the de-
clined serum testosterone levels in the male obesity, the serum tes-
tosterone and intratesticular testosterone levels in the mouse
HFD-induced obesity group were also decreased. Intriguingly, the
decrease in serum testosterone in the obese human group was
more significant than that in the HFD-induced obesity mouse
group. Differences in the species and HFD ingredients may partly
contribute to this observation. The mice were given a high triglyc-
eride diet containing 60 % kcal % fat, whereas the characteristics of
a human high-energy diet usually include high saturated fat,
Xu X et al. Testosterone Synthesis and Conversion … Horm Metab Res
trans-fatty acids and excessive sugar intake. Therefore, this result
suggests that a high-saturated fat diet can result in low testoster-
one levels, and high intake of trans-fatty acids and sugar may ag-
gravate this phenomenon.
The synthesis of testosterone occurs in the testicular Leydig cells
and is regulated by neuroendocrine feedback including LH [31] and
a series of steroidogenic enzymes in the testes. The human study
showed that after adjusting for age, the LH levels was significantly,
inversely correlated with BMI, and men with abdominal obesity had
lower LH levels, suggesting that male obesity might cause neuroen-
docrine dysfunction. Using a multivariate regression analysis, we
identified that total testosterone levels were associated with LH
levels. This finding suggests that pituitary-gonadal axis dysfunc-
tion might be involved in the decrease in testosterone levels in
obese males. The LH/T ratio is a surrogate marker of testicular func-
tion, and the results indicated that the LH/T ratio was increased in
obese males, suggesting that testicular function was decreased
[32]. To explore the changes in testosterone biosynthesis in the
testicular Leydig cells, we detected steroidogenic enzymes and LH
receptor in the mouse model. The key enzymes involved in testos-
terone biosynthesis include StAR, which is the rate-limiting step in
the steroidogenic pathway that transfers cholesterol to the inner
membrane of the mitochondria; P450scc, which converts choles-
terol to pregnenolone within the mitochondria [33]; and 3β-HSD,
which converts pregnenolone into progesterone [31]. Our study
found that the mRNA expression of StAR was significantly de-
creased, which was accompanied by a decrease in testosterone in
the obesity group. However, the mRNA expression of P450scc, 3β-
HSD and LH receptor was not different between the groups. These
findings suggest that the inhibition of StAR expression may be the
primary reason for the decrease in testosterone levels during tes-
tosterone synthesis.
In males, an androgen/estrogen balance is necessary for repro-
duction and normal sexual development [34]. The final and
rate-limiting step in the synthesis of estrogens is catalyzed by the
cytochrome P450 aromatase enzyme, which converts testoster-
one and androstenedione to E2 and estrone, respectively [35, 36].
An increase in aromatase activity may lead to higher levels of E2 and
a reduction in testosterone levels [37]. SAT highly expresses aro-
matase [38–40]. The expression of aromatase in male obesity is
still a controversial issue, with some studies reporting that aro-
matase expression in adipose tissue is higher and causes more tes-
tosterone to be converted into E2, whereas other studies have re-
ported no changes [41]. In our human study, based on BMI, serum
aromatase and E 2 levels tended to be increased, although the
change was not statistically significant, possibly due to the limited
sample size. However, the serum aromatase levels was increased
in men with abdominal obesity, it means abdominal obesity may
causes more testosterone converts to E2. These results demon-
strate that WHR is more representative of male abdominal obesity
and is a better way to detect obesity than BMI. In the future, we will
continue to improve and perfect the data on bioelectrical imped-
ance analysis, and verify the underlying mechanisms of aromatase
conversion in adipose tissue. The T/E2 ratio decrease may be attrib-
uted to the conversion of more testosterone to E2 by aromatase or
because the testosterone levels were more significantly decreased
[23, 24]. However, a further multivariate regression analysis did not
Xu X et al. Testosterone Synthesis and Conversion … Horm Metab Res
show a link between the serum aromatase and testosterone levels.
Given the function of aromatase in converting testosterone to E2
in abdominal obesity, testosterone conversion may be one of the
mechanisms contributing to male subfertility and testosterone re-
duction. To identify the role of testosterone conversion in the tes-
tosterone reduction in male obesity, the levels of aromatase in the
serum and SAT were analyzed in the animal model. No differences
in serum aromatase levels were observed in the mouse study. We
further measured the aromatase levels in the SAT of mice, and the
results showed that the aromatase levels per milligram SAT were
lower in the HFD group than those in the ND group, but the serum
E2 levels in the HFD group were slightly higher than those in the ND
group. Although there exists the inconsistency in the elevated E2
levels in the serum and the decreased aromatase levels in the per
milligram SAT, the increased amount of fat mass in the HFD group
which could result in the increased levels of total aromatase can ex-
plain the phenomenon. In animal experiments, we have found a
decrease in testosterone and an increase in E2, and the enzyme of
testosterone synthesis was decreased. We hypothesized that the
Downloaded by: Washington University. Copyrighted material.
decrease in testosterone synthesis enzyme may occur in the early
stages of obesity, the changes in the expression of aromatase will
occur later. A long period of animal feeding time will be needed for
further observation.
In conclusion, our epidemiological and animal experimental in-
vestigations demonstrated that male obesity can result in de-
creased testosterone levels. Decreased testicular synthesis and the
conversion of testosterone may explain the decreased testoster-
one levels observed in this study, and the decrease of testicular syn-
thesis may change first. Further experimental studies are required
to unravel the molecular mechanism for the observed associations
between obesity and the testosterone synthesis-related protein
StAR.
Acknowledgements
This work was supported by the National Natural Science Founda-
tion of China (81641030, 81471078, 81770860 and 81170764),
State Drug Administration of TCM Clinical Research Base Construc-
tion Business Research Projects No.JDZX2012007.
Conflict of Interest
The authors declare that they have no conflict of interest.
References
[1] Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C,
Mullany EC, Biryukov S, Abbafati C, Abera SF, Abraham JP, Abu-Rmeileh
NM, Achoki T, AlBuhairan FS, Alemu ZA, Alfonso R, Ali MK, Ali R,
Guzman NA, Ammar W, Anwari P, Banerjee A, Barquera S, Basu S,
Bennett DA, Bhutta Z, Blore J, Cabral N, Nonato IC, Chang JC,
Chowdhury R, Courville KJ, Criqui MH, Cundiff DK, Dabhadkar KC,
Dandona L, Davis A, Dayama A, Dharmaratne SD, Ding EL, Durrani AM,
Esteghamati A, Farzadfar F, Fay DF, Feigin VL, Flaxman A, Forouzanfar
MH, Goto A, Green MA, Gupta R, Hafezi-Nejad N, Hankey GJ,
Harewood HC, Havmoeller R, Hay S, Hernandez L, Husseini A, Idrisov
BT, Ikeda N, Islami F, Jahangir E, Jassal SK, Jee SH, Jeffreys M, Jonas JB,
 Endocrine Care
Kabagambe EK, Khalifa SE, Kengne AP, Khader YS, Khang YH, Kim D,
Kimokoti RW, Kinge JM, Kokubo Y, Kosen S, Kwan G, Lai T, Leinsalu M,
Li Y, Liang X, Liu S, Logroscino G, Lotufo PA, Lu Y, Ma J, Mainoo NK,
Mensah GA, Merriman TR, Mokdad AH, Moschandreas J, Naghavi M,
Naheed A, Nand D, Narayan KM, Nelson EL, Neuhouser ML, Nisar MI,
Ohkubo T, Oti SO, Pedroza A, Prabhakaran D, Roy N, Sampson U, Seo
H, Sepanlou SG, Shibuya K, Shiri R, Shiue I, Singh GM, Singh JA,
Skirbekk V, Stapelberg NJ, Sturua L, Sykes BL, Tobias M, Tran BX,
Trasande L, Toyoshima H, van de Vijver S, Vasankari TJ, Veerman JL,
Velasquez-Melendez G, Vlassov VV, Vollset SE, Vos T, Wang C, Wang X,
Weiderpass E, Werdecker A, Wright JL, Yang YC, Yatsuya H, Yoon J,
Yoon SJ, Zhao Y, Zhou M, Zhu S, Lopez AD, Murray CJ, Gakidou E.
Global, regional, and national prevalence of overweight and obesity in
children and adults during 1980-2013: a systematic analysis for the
Global Burden of Disease Study 2013. Lancet 2014; 384: 766–781
[2] Fui MN, Dupuis P, Grossmann M. Lowered testosterone in male
obesity: mechanisms, morbidity and management. Asian J Androl
2014; 16: 223–231
[3] Armamento-Villareal R, Aguirre LE, Qualls C, Villareal DT. Effect of
Lifestyle Intervention on the Hormonal Profile of Frail, Obese Older
Men. J Nutr Health Aging 2016; 20: 334–340
[4] Belanger C, Luu-The V, Dupont P, Tchernof A. Adipose tissue intracrinol-
ogy: potential importance of local androgen/estrogen metabolism in
the regulation of adiposity. Horm Metab Res 2002; 34: 737–745
[5] Abate N, Haffner SM, Garg A, Peshock RM, Grundy SM. Sex steroid
hormones, upper body obesity, and insulin resistance. J Clin Endocrinol
Metab 2002; 87: 4522–4527
[6] Colangelo LA, Ouyang P, Liu K, KoppP Golden SH, Dobs AS, Szklo M,
Vaidya D, Cushman M, Gapstur SM. Association of endogenous sex
hormones with diabetes and impaired fasting glucose in men:
multi-ethnic study of atherosclerosis. Diabetes Care 2009; 32:
1049–1051
[7] Sinclair M, Grossmann M, Gow PJ, Angus PW. Testosterone in men with
advanced liver disease: abnormalities and implications. J Gastroenterol
Hepatol 2015; 30: 244–251
[8] Niederberger C. Re: A Randomized Prospective Double-Blind
Comparison Trial of Clomiphene Citrate and Anastrozole in Raising
Testosterone in Hypogonadal Infertile Men. J Urol 2016; 195 (4 Pt 1):
1075–1077
[9] Kloner RA, Carson C 3rd, Dobs A, Kopecky S, Mohler ER 3rd.
Testosterone and Cardiovascular Disease. J Am Coll Cardiol 2016; 67:
545–557
[10] Pintana H, Chattipakorn N, Chattipakorn S. Testosterone deficiency,
insulin-resistant obesity and cognitive function. Metab Brain Dis 2015;
30: 853–876
[11] Sun J, Cao Y, Zhang X, Zhao Q, Bao E, Lv Y. Melamine negatively affects
testosterone synthesis in mice. Res Vet Sci 2016; 109: 135–141
[12] Zhao YT, Qi YW, Hu CY, Chen SH, Liu Y. Advanced glycation end
products inhibit testosterone secretion by rat Leydig cells by inducing
oxidative stress and endoplasmic reticulum stress. Int J Mol Med 2016;
38: 659–665
[13] Diemer T, Allen JA, Hales KIH, Hales DB. Reactive oxygen disrupts
mitochondria in MA-10 tumor Leydig cells and inhibits steroidogenic
acute regulatory (StAR) protein and steroidogenesis. Endocrinology
2003; 144: 2882–2891
[14] Yi X, Gao H, Chen D, Tang D, Huang W, Li T, Ma T, Chang B. Effects of
obesity and exercise on testicular leptin signal transduction and
testosterone biosynthesis in male mice. Am J Physiol Regul Integr
Comp Physiol 2017; 312: R501–R510
[15] Page ST. Physiologic role and regulation of intratesticular sex steroids.
Curr Opin Endocrinol Diabetes Obes 2011; 18: 217–223
[16] Puche C, Jose M, Cabero A, Meseguer A. Expression and enzymatic
activity of the P450c17 gene in human adipose tissue. Eur J Endocrinol
2002; 146: 223–229
[17] McInnes KJ, Brown KA, Knower KC, Chand AL, Clyne CD, Simpson ER.
Characterisation of aromatase expression in the human adipocyte cell
line SGBS. Breast Cancer Res Treat 2008; 112: 429–435
[18] Czajka-Oraniec I, Simpson ER. Aromatase research and its clinical
significance. Endokrynol Pol 2010; 61: 126–134
[19] Stokes VJ, Anderson RA, George JT. How does obesity affect fertility in
men – and what are the treatment options? Clin Endocrinol (Oxf)
2015; 82: 633–638
[20] Cohen PG. Aromatase, adiposity, aging and disease. The hypogonad-
al-metabolic-atherogenic-disease and aging connection. Med
Hypotheses 2001; 56: 702–708
[21] Raven G, de Jong FH, Kaufman Jm, de Ronde W. In men, peripheral
estradiol levels directly reflect the action of estrogens at the
hypothalamo-pituitary level to inhibit gonadotropin secretion. J Clin
Endocrinol Metab 2006; 91: 3324–3328
[22] Lambrinoudaki I, Georgiopoulos GA, Athanasouli F, Armeni E, Rizos D,
Augoulea A, Chatzidou S, Koutli E, Makris N, Kanakakis I, Stamate-
lopoulos K. Free androgen index as a determinant of arterial stiffness
in menopause: a mediation analysis. Menopause 2017; 24: 635–644
[23] Schulte DM, Hahn M, Oberhauser F, Malchau G, Schubert M, Heppner C,
Muller N, Gudelhofer H, Faust M, Krone W, Laudes M. Caloric
restriction increases serum testosterone concentrations in obese male
Downloaded by: Washington University. Copyrighted material.
subjects by two distinct mechanisms. Horm Metab Res 2014; 46:
283–286
[24] Dhindsa S, Furlanetto R, Vora M, Ghanim H, Chaudhuri A, Dandona P.
Low estradiol concentrations in men with subnormal testosterone
concentrations and type 2 diabetes. Diabetes Care 2011; 34:
1854–1859
[25] Bandak M, Aksglaede L, Juul A, Rorth M, Daugaard G. The pitui-
tary-Leydig cell axis before and after orchiectomy in patients with
stage I testicular cancer. Eur J Cancer 2011; 47: 2585–2591
[26] Rannikko A, Petas A, Raivio T, Janne OA, Rannikko S, Adlercreutz H.
The effects of short-term oral phytoestrogen supplementation on the
hypothalamic-pituitary-testicular axis in prostate cancer patients.
Prostate 2006; 66: 1086–1091
[27] Morley JE, Patrick P, Perry HM 3rd. Evaluation of assays available to
measure free testosterone. Metabolism 2002; 51: 554–559
[28] Hayashi T, Yamada T. Association of bioavailable estradiol levels and
testosterone levels with serum albumin levels in elderly men. Aging
Male 2008; 11: 63–70
[29] Zhang N, Zhang H, Zhang X, Zhang B, Wang F, Wang C, Zhao M, Yu C,
Gao L, Zhao J, Guan Q. The relationship between endogenous
testosterone and lipid profile in middle-aged and elderly Chinese men.
Eur J Endocrinol 2014; 170: 487–494
[30] Waxman A. World Health, WHO global strategy on diet, physical
activity and health. Food Nutr Bull 2004; 25: 292–302
[31] Taibi N, Dupont J, Bouguermouh Z, Froment P, Rame C, Anane A,
Amirat Z, Khammar F. Expression of adenosine 5'-monophosphate-Ac-
tivated protein kinase (AMPK) in ovine testis (Ovis aries): In vivo
regulation by nutritional state. Anim Reprod Sci 2017; 178: 9–22
[32] Wang HJ, Wang Q, Lv ZM, Wang CL, Li CP, Rong YL. Resveratrol
appears to protect against oxidative stress and steroidogenesis
collapse in mice fed high-calorie and high-cholesterol diet. Andrologia
2015; 47: 59–65
[33] Miller WL. Steroid hormone synthesis in mitochondria. Mol Cell
Endocrinol 2013; 379: 62–73
[34] Xu X, Sun M, Ye J, Luo D, Su X, Zheng D, Feng L, Gao L, Yu C, Guan Q.
The Effect of Aromatase on the Reproductive Function of Obese Males.
Horm Metab Res 2017; 49: 572–579
[35] Loves S, de Jong J, van Sorge A, Telting D, Tack CJ, Hermus A,
Westerterp K, de Boer H. Somatic and psychological effects of
low-dose aromatase inhibition in men with obesity-related hypogon-
adotropic hypotestosteronemia. Eur J Endocrinol 2013; 169: 705–714
Xu X et al. Testosterone Synthesis and Conversion … Horm Metab Res
[36] de Boer H, Verschoor L, Ruinemans-Koerts J, Jansen M. Letrozole
normalizes serum testosterone in severely obese men with hypogon-
adotropic hypogonadism. Diabetes Obes Metab 2005; 7: 211–215
[37] Lee HK, Lee JK, Cho B. The role of androgen in the adipose tissue of
males. World J Mens Health 2013; 31: 136–140
[38] Corbould AM, Bawden MJ, Lavranos TC, Rodgers RJ, Judd SJ. The effect
of obesity on the ratio of type 3 17beta-hydroxysteroid dehydroge-
nase mRNA to cytochrome P450 aromatase mRNA in subcutaneous
abdominal and intra-abdominal adipose tissue of women. Int J Obes
Relat Metab Disord 2002; 26: 165–175
Xu X et al. Testosterone Synthesis and Conversion … Horm Metab Res
[39] Hammoud AO, Griffin J, Meikle AW, Gibson M, Peterson CM, Carrell DT.
Association of aromatase (TTTAn) repeat polymorphism length and
the relationship between obesity and decreased sperm concentration.
Hum Reprod 2010; 25: 3146–33151
[40] Bekaert M, Van Nieuwenhove Y, Calders P, Cuvelier CA, Batens AH,
Kaufman JM, Ouwens DM, Ruige JB. Determinants of testosterone
levels in human male obesity. Endocrine 2015; 50: 202–211
[41] Clyne CD, Speed CJ, Zhou J, Simpson ER. Liver receptor homologue-1
(LRH-1) regulates expression of aromatase in preadipocytes. J Biol
Chem 2002; 277: 20591–20597
Downloaded by: Washington University. Copyrighted material.