Prevalence of andropause among Iranian men and its relationship with quality of life

Abstract

Introduction

Andropause is a complicated process in men's life which can negatively affect their quality of life in both physical and psychological dimensions.

Objectives

The aim of this study was to determine the prevalence of andropause among Iranian men age 40–85 years and its relationship with quality of life.

Materials and methods

This was a cross-sectional study among 393 men attending ten urban healthcare centers in Ilam province in southwestern Iran. Study participants were recruited using proportional random sampling. The Male andropause symptoms self-assessment questionnaire (MASSQ) and SF-12 were used for data collection. Data were analyzed using SPSS version 22 (Chicago, IL).

Results

The mean (SD) of participants scores in MASSQ was 57.46 (17.56). Only 61 (15.5%) men were classified at “don't need testosterone” category based on MASSQ. There were significant associations between the eight aspects of HRQoL and the andropause severity (p < .001). Older age, lower education, having depression, coronary heart disease, and incontinence were associated with increased odds of andropause (p < .05).

Conclusion

This study confirmed findings of previous studies regarding andropause and its relationship with men’s quality of life. Future studies in this topic are needed to discover all the factors that may influence men andropause.

Keywords:

• Andropause
• men
• quality of life
• aging
• testosterone
• hypogonadism
• Iran

Introduction

Testosterone is the most important androgen of blood which is an important factor in stimulating multiple body functions such as sexual function, hematopoiesis, bone mineralization, muscle mass growth, lipid, and carbohydrate metabolism [1–4]. The gradual drop in testosterone level occurs as men age [5–7]. The testosterone levels drop about 1% a year starting around age 30 and continue throughout the life [8]. The bioavailable testosterone level of a 75 years old man is less than half of a healthy man between the ages of 20 and 30 [8,9].

Age-related comorbid disease such as diabetes, heart disease, renal disease, obesity, metabolic syndrome, and some medications such as glucocorticoids, cigarettes, and alcohol are also contribute to the decline in testosterone levels [1,3,5,10–13]. Previous studies showed that the death rates due to cardiovascular disease are higher for men who have testosterone levels lower than men at the same age with normal testosterone levels [10].

The age-related gradual decline in plasma testosterone levels associated with androgen deficiency symptoms is called andropause [8,9,14]. Andropause is a complicated process in men's life, with symptoms clearly occurring usually in the middle age and beyond [9,15–17]. Andropause is associated with severe physiological and psychological changes that can have a significant effect on the cycle of silent illnesses over a long period of time [8,11,18,19]. The findings of previous studies showed that with the increase in age and onset of andropause, the sexual function of men decreases [20–23].

Symptoms and problems associated with andropause initially started asymptomatic and did not show a clear clinical manifestation like female menopause in which decreases in estrogen happen suddenly [8,15,22,24,25]. So, it is difficult to determine an instant when testosterone levels fall under the threshold levels that affect body normal functioning [9,21,26]. However, men with decrease in testosterone level may experience a range of symptoms. Decrease in libido, lack of energy and interest to work, pain in muscles and joints, muscle atrophy, decreased memory performance, diminished mental focus and stress coping capacity, negative mood, sleep disturbances, hot flashes, prostate inflammation, gynecomastia, short stature, hair loss in pubic area, anxiety, accelerating osteoporosis, urinary frequency, and urinary stress incontinence are some of the main symptoms of andropause [3,4,8,10,11,27–31]. Although most of these symptoms are non-specific, but andropause can adversely affect both mental and physical health and quality of life of men [19].

Quality of life is a broad multidimensional concept that reflects person's perspective on the level of life satisfaction in different aspects, including housing, recreation, entertainment, environmental conditions, health, and work [8,19,32,33]. Having physical, psychological, sexual, social and emotional health will affect the quality of life of people [19,33]. Quality of life is considered as a valuable factor in assessing the health of people after the onset of illness in middle age [33,34].

Sexual function is one of the important dimensions of adult life [4,35]. Decline in Sexual function due to andropause can affect the people's physical and psychological dimensions of the quality of life [8,19]. The findings of a study aimed at determining the relationship between erectile dysfunction with quality of life of Egyptian men showed that the average score of quality of life in both mental and physical health of men with sexual dysfunction were significantly lower compared to men without reporting these disorders [36]. The results of some studies indicate that with the increase in age, libido decreased from 1% to 25% and erectile dysfunction increased from 1% to 39% in men 40 to 79 years, respectively [8,37–39].

Given the coincidence of menopausal and andropause symptoms and the increased likelihood of sexual problems in couples, attention to andropause is important because of its impact on other dimensions of couples’ life. According to the statistical center of Iran, 25.1% of the total population of the country is at age group of 25–40 years which in the next 20 years, these people will be in middle and older age groups [40]. So, appropriate strategies should be considered for the health and quality of life this population as early as possible. There are a limited number of studies about the prevalence of andropause among Iranian middle-age men and how this can affect their quality of life. So the aim of this study was to explore the prevalence of andropause among Iranian men age 40–85 years and its relationship with their quality of life.

Materials and methods

Study design

This is a cross-sectional study that was conducted in 2018 in Iran. The study setting was ten urban healthcare centers affiliated to Ilam University of Medical Sciences in Ilam city in southwest of Iran.

Study population

The study population was 393 men who were 40–85 years old, resident in Ilam city and were willingness to participate in the study.

Selection of study subjects

Study participants were recruited using random cluster sampling. First, Ilam city was divided into five geographical zone including West, East, North, South, and Center. Next, in each of those zones, we select two healthcare centers randomly. Because there were many number of household in each of health centers, proportional random sampling was used to recruit determined samples in each of healthcare center. The family health records in each center were reviewed and those families who had men satisfied the study requirements were recognized and those who were eligible for the study selected randomly and requested to participate in the study. Study sample size was calculated based on the prevalence of andropause in previous studies conducted in Iran [12,19]. So, using the following formula and 95% confidence interval the sample size was determined as 368 men: $$\left[n=\frac{z_{1-\alpha /2}{}^{2}p(1-p)}{d^2}=368\right]$$

Based on sample attrition rate of 15%, a sample of 425 eligible participants was randomly selected form ten healthcare centers in five geographical zone of Ilam city of those 410 men accepted to be enrolled. Finally, 17 incomplete questionnaires were excluded because of missing data. So the data of 393 men were gathered and analyzed.

Study instrument

The data collection tools consist of three sections. The first part was to collect socio-demographic and health status of men. Data were such as age, job, income, education level, wife menopause, weight and height, smoking and alcohol, and a history of diabetes, depression, incontinence, and heart disease. The second part was male andropause symptoms self-assessment questionnaire (MASSQ) which consist of 25 item regarding the disability and symptoms of andropause [41]. Each item was given a score from (none) to 5 (severe). The overall scores of this scale ranged from 25 to 125 which indicate no symptom to most severe symptom, respectively. The validity and reliability of this questionnaire among Iranian population was assessed by Asadollahi et al. [41]. Coefficients of Cronbach’s alpha (0.89) showed a good internal consistency.

The third part of instrument was a SF-12 to assess participant health related quality of life. This is a short form of SF-36 which widely been used in the world. This instrument includes 12 items in eight dimensions: physical functioning (two items), role limitation to physical problems (two items), bodily pain (one item), general health (one item), vitality (one item), social functioning (two item), role limitation due to emotional problems (two items), and perceived mental health (two items). The validity and reliability of this questionnaire among Iranian population was assessed by Montazeri et al. and showed satisfactory internal consistency (0.72–0.73) using Cronbach’s alpha [33].

Accuracy and clarity of MASSQ was verified by two expert translators in both Persian and English languages. The face/content validity of the MASSQ was assessed and confirmed by a panel consisting of 10 experts in sexual health. Moreover, to certify reliability of the final version of the questionnaire a pilot study was conducted on 25 men aged 40 years and over. Cronbach’s alpha coefficient value was 0.82.

Ethical issues and data collection

The study proposal was approved by the local-regional ethics committee of Ilam University of Medical Sciences prior to data collection. Then the first author referred to healthcare centers from December 2017 to January 2018. Next, the purpose of the study explained to participants and they were asked to fill the paper version of the research questionnaires and return those to researcher. Those participants who had trouble to personally fill out the questionnaire were asked to attend to a personal interview for data collection. Interviews were performed by a male interviewer in locations preferred by the subjects. Prior to the study, all participants provided informed consent for voluntary participation in the study.

Statistical analysis

Statistical analysis was performed using SPSS version 22 (SPSS, Chicago, IL). The demographic and health-related data of men were reported using descriptive statistics such as a percentage, mean and standard deviation. Pearson Chi-square test was used to find association between health-related problems of participants with andropause status. Independent T-test and analysis of variance (ANOVA) were used to examine the association between participants’ characteristics with mean of HRQoL and andropause score. The predictors of men andropause were determined using backward multiple linear regression. The input variables to the model (those that were significantly associated with andropause based on primary bivariate analysis) included age, level of education, income, spouse menopause, job, number of children, depression, coronary disease, and urinary incontinence.

Results

The mean (SD) of age of men and their wives was 59.86 (10.48) and 51.07 (9.86) years, respectively. Most of them were living with their spouses (98.7%) and 227 (57.8%) declared that their spouses were menopause. The mean (SD) of participants scores in MASSQ was 57.46 (17.56). The mean (SD) of participants quality of life in eight domains and their andropause status based on MASSQ was shown in Table 1. As shown in Table 1, the highest and the lowest QOL of participants were at RE and GH domains. Also based on MASSQ only 61 (15.5%) were classified at “don't need testosterone” category based on MASSQ.

Table 1. Mean (SD) of participants quality of life in eight aspects and their andropause status.

Variables	Subscales	Result
Subscales of quality of life (mean ± SD)	Physical function (PF)	67.36 ± 36.58
	Role physical (RP)	58.84 ± 33.62
	Bodily pain (BP)	68.51 ± 32.72
	General health (GH)	36.93 ± 25.36
	Vitality	59.41 ± 26.43
	Social function (SF)	70.48 ± 32.68
	Role emotional (RE)	79.38 ± 27.39
	Mental health (MH)	71.62 ± 23.58
	Total physical HRQoL	57.91 ± 24.80
	Total mental HRQoL	70.22 ± 21.37
Andropes types N (%)	Don't need testosterone	61 (15.5)
	May benefit from testosterone	303 (71.1)
	Certainly benefit from testosterone	29 (7.4)

Table 2 shows the mean (SD) of MASSQ scores according to some demographic characteristics of participants. As shown in this table, less than 12 years of education, spouse menopause, insufficient income, job status, having higher number of children, and older age were significantly related to higher MASSQ score (p < .001).

Table 2. Mean (SD) of MASSQ scores according to demographic characteristics of participants.

Variable	Category	Andropause score	p value
Level of education	≤12 years	61.23 ± 17.88	<.001
	>12 years	49.09 ± 13.53
Live with spouse	Yes	57.43 ± 17.61	.785
	No	59.60 ± 13.75
Spouse menopause	Yes	61.03 ± 17.42	<.001
	No	52.57 ± 16.58
Income	Income < expense	59.25 ± 17.14	.001
	Income ≥ expense	52.47 ± 17.81
Job	Non-governmental	55.74 ± 16.98	<.001
	Governmental	48.90 ± 18.36
	Retired	55.54 ± 15.34
	Unemployment	70.66 ± 16.45
Number of children	≤2	51.14 ± 18.24	<.001
	3–6	56.31 ± 17.00
	≥7	64.05 ± 16.52
Age groups	40–49	49.06 ± 18.47	<.001
	50–59	55.06 ± 16.42
	60–69	59.56 ± 16.69
	70–79	61.94 ± 14.94
	80–85	73.71 ± 17.34

The participants’ scores in eight domains of HRQoL according to MASSQ scores are shown in Table 3. As shown in Table 3, the mean scores of eight domains of HRQoL were significantly higher for those participants who classified at “don't need testosterone” based on MASSQ scores. The relationship between participants andropause status with some health-related problems showed in Table 4. As shown in Table 4, health-related conditions including depression, coronary disease, and urinary incontinence were significantly related to participants’ andropause status.

Table 3. Participants’ scores of HRQoL subscales according to their andropause status.

	Andropause
	Physical function	Role physical	Bodily pain	General health	Vitality	Social function	Role emotional	Mental health
QOL
Don't need testosterone	87.29 ± 24.41	82.37 ± 25.91	85.65 ± 29.74	59.18 ± 17.42	83.19 ± 18.66	95.90 ± 15.26	97.13 ± 9.51	90.16 ± 13.90
May benefit from testosterone	66.00 ± 36.55	57.26 ± 32.69	67.49 ± 31.50	34.91 ± 23.82	57.26 ± 24.09	68.39 ± 32.19	79.62 ± 25.51	70.99 ± 21.60
Certainly benefit from testosterone	39.65 ± 36.91	25.86 ± 22.39	43.10 ± 32.66	11.20 ± 20.68	31.89 ± 26.63	38.79 ± 28.01	39.65 ± 29.13	39.22 ± 22.34
p value	<.001	<.001	<.001	<.001	<.001	<.001	<.001	<.001

Table 4. Relationship between participants andropause status with some health-related problems.

	MASSQ range
	Don't need testosterone (%)	May benefit from testosterone (%)	Certainly benefit from testosterone (%)	p value
Diabetes
Yes	6 (12.5)	37 (77.1)	5 (10.4)	.605
No	55 (15.9)	266 (77.1)	24 (7.0)
Depression
Yes	0 (0.0)	60 (75.9)	19 (24.1	<.001
No	61 (19.4)	243 (77.4)	10 (3.2)
Coronary disease
Yes	17 (12.0)	109 (76.8)	16 (11.3)	.042
No	44 (17.5)	194 (77.3)	13 (5.2)
Blood pressure
Yes	14 (11.1)	99 (78.6)	13 (10.3)	.103
No	47 (17.6)	204 (76.4)	16 (6.0)
Overweight
Yes	35 (14.0)	195 (78.0)	20 (8.0)	.483
No	26 (18.2.0)	108 (75.5)	9 (6.3)
Smoking
Yes	7 (14.3)	40 (81.6)	2 (4.1)	.598
No	54 (15.7)	263 (76.5)	27 (7.8)
Urinary incontinence
Yes	0 (0)	7 (50.0)	7 (50.0)	<.001
No	61 (16.1)	296 (78.1)	22 (5.8)

Table 5 shows the input variables that were tested using backward linear regression analysis and recognized as statistically significant predictors of andropause among Iranian men. Briefly, the result revealed that andropause in men was determined by age, education, depression, coronary heart disease, and incontinence. In other words, older age, lower education, having depression, coronary heart disease, and incontinence were associated with increased odds of andropause.

Table 5. Predictors of andropause scores among Iranian men.

Variables	Unstandardized coefficient	SE	p value	Confidence interval 95%	Standardized coefficient
Age	0.414	0.076	<.001	0.266–0.563	0.248
Education	−6.981	1.711	<.001	−10.346 to −3.616	−0.184
Depression	14.716	1.856	<.001	11.049–18.383	0.336
Urinary incontinence	15.222	4.031	<.001	7.296–23.147	0.161
Coronary heart disease	3.827	1.557	.014	0.766–6.888	0.105

Dependent variables: total score of MASSQ.

Discussion

The study findings showed that the study participants had moderate level quality of life in most HRQOL subscales. Also most of them had mild to severe symptoms of andropause that is comparable to Samipoor et al. study in the north of Iran who reported 73.6% of the subjects experienced andropause [21]. The findings of current study are similar to those of Al-Sejari in Kuwait, Afsharnia et al. and Samipoor et al. in Iran, and Chen et al. in China which reported significant relationship between age and andropausal symptoms [16,19,20,21]. In our study, men in 40–49 years age group had lower andropausal score than other age groups. The study findings also showed that men with higher andropausal score had lower QOL in all subscales of HRQOL. These findings are also comparable with findings of other studies [42,43]. Sex is an important component of a good life and has a very important association with durable marital satisfaction. Decline in sexual desire and satisfaction have an important impact on overall quality of life of the individuals, which is consistent with our study findings [35].

The study findings also showed a significant association between participants andropausal score and some variable such as lower education, lower income, and unemployment. However, in logistic regression model, only the demographic variables including age and lower education were predictors of higher andropausal score. Al-Sejari in Kuwait also reported that men with lower education had more andropausal symptoms [20]. One explanation for this finding is that older participants had lower education compare to younger. Adebajo et al. also reported that increasing age, not working, and lack of formal education were significantly associated with andropausal symptoms experienced by Nigerian men [44].

In our study, men who categorized as “certainly benefit from testosterone” according to MASSQ had lower quality of life in all dimensions of SF-12 compared with those who categorized as “don't need testosterone”. This is comparable to Afsharnia et al. and Farahat et al. studies that also reported significant associations between the overall quality of life score and the andropause severity in Iranian and Egyptian men, respectively [19,36].

The study findings showed that chronic diseases including depression, coronary heart disease, and urinary incontinence were significantly associated with participants’ andropause symptoms. Also, in our logistic regression model, the estimated probability of higher andropausal scores was associated with depression, coronary heart disease, and urinary incontinence. Novak reported that andropausal symptoms are linked to health status of people [45]. Causal relationship between reduction of testosterone and development of chronic diseases such as urinary incontinence, depression, high blood pressure, and heart disease has been reported in some previous studies [10,11,27,37,43,46]. But whether testosterone replacement therapy can cease progression of such chronic conditions remains controversially discussed. For example, although studies revealed that there is a likely causal relationship between lower bioavailable testosterone level and increased risk of cardiovascular disease, the findings of a review study revealed that the clear beneficial of testosterone replacement therapy on the cardiovascular system of andropausal men has not been widely accepted [10]. These controversies are mainly due to lack of large, well-designed randomized placebo-controlled trials.

In our study, the men andropausal symptom was significantly associated with their spouse menopause. Menopause in women is often associated with physical, psychological and sexual changes, and their reluctance to engage in sexual relations [47]. Andropausal symptoms in men are often happen coinciding with the occurrence of menopausal symptoms in their wives. The coincidence of these changes in both men and their spouses can be associated with decreasing quality of life and exacerbation of andropausal symptoms in men [24], which confirms the results of this study.

We could not find any association between being overweight and andropausal symptoms. The findings of a review study showed that except for severe obesity bioavailable testosterone does not change substantially with body mass index [48]. Some studies reported an association between symptoms of a generalized decline of male hormones with increase abdominal fat and loss of muscle mass and tone [10,12,21,49]. Also, some research shows the positive effects of testosterone replacement therapy on improvement in lean body mass and decrease in fat [50–52].

Contrary to menopause symptoms in women, andropause occur gradually in men. Many men think andropause is part of aging and most of them are unable to identify that they have androgen deficiency, and, therefore, do not seek for medical assistance [8,22]. Also, due to traditional culture, in this part of Iran, issues regarding men sexual relations are considered embarrassing and taboo. In such a culture, sexual relations is perceived as strong sign of masculinity and most of men with andropausal symptoms are not willing of disclosure of this problem and some of them may deny the presence of these changes. In Samipoor et al.’s study [21], despite the high prevalence of andropause only 15% of participants were aware about andropause symptoms. Another study in Kuwait which is somewhat similar to Iranian culture showed that most of participants were unaware about the term male menopause or andropause and they think menopause occurs exclusively in women [20]. Also, in our study, lower education was a predictor for higher andropausal symptoms. These findings emphasized the need for provision of health education to increase the knowledge of andropause among men and general public. Iranian elder population is rising rapidly and it is expected that we encounter with more andropause cases in near future. The need for appropriate strategy to manage this health problem is apparent. Proper information regarding normal aging and hormonal change and how men can adapt successfully with those changes should be provided by mass media and healthcare providers. Public and older population awareness regarding the symptoms, diagnosis, and treatment of andropause will help older people maintain a healthy life and cope more efficiently with normal aging changes and manage their health discomfort through appropriate treatments.

Contrary to clear manifestation of female menopause due to dramatic drop in hormone levels, male andropause has wide range of symptoms that occur gradually. So, greater awareness and education is required among the health professionals. Finding of a study in Iran showed that the knowledge of general practitioner and nurses regarding andropause were poor [53]. So, designing in-service training programs to improve healthcare providers’ knowledge of andropause is required.

This study has also some limitations which should be considered when using the findings. First, this study was conducted in a city in southwest of Iran and it not represent variation of all the country population. In relation to future research, diverse cultural studies in other Iranian contexts are required. Next, the symptoms declared by our participants measured only using a validated questionnaire. In future research, replication of this study alongside measuring blood androgens will discover more beneficial information about andropause.

Conclusions

The present study highlights important concerns regarding sexual health and quality of life of middle age and older men in Iran. The study findings revealed high prevalence of andropause among study participants and men with higher andropausal symptoms had lower quality of life. The study findings also revealed some predictors of male andropause including higher age, lower education, depression, coronary heart disease, and urinary incontinence. Future studies in this topic are needed to discover all the factors that may influence men andropause that will be valuable for diagnosing and management of this problem.

Disclosure statement

No potential conflict of interest was reported by the authors.