The severity of hypogonadism symptoms and its risk factors among male employees of Tehran University of Medical Sciences

Abstract

Objectives

The current study was conducted to examine the severity of hypogonadism symptoms and their risk factors among the male employees of Tehran University of Medical Sciences (TUMS).

Methods

This cross-sectional study was conducted on 80 male employees aged 40–60 years, with hypogonadism, at TUMS. The participants were selected through census sampling. The data collection tools included the demographic questionnaire and the Aging Male Symptoms (AMS) questionnaire. The participants first completed the demographic questionnaire and then the AMS questionnaire. SPSS statistical software version 22 (Chicago, IL) was used to analyze the data, and one-way ANOVA tests, Pearson’s correlation coefficient, and stepwise multivariate logistic regression were applied.

Results

Based on our findings, the mean overall score of hypogonadism symptoms was 41.71 ± 9.20. Based on Pearson’s correlation coefficient results, there was a statistically significant association between the severity of hypogonadism symptoms and age (p < .001). Furthermore, there were significant associations between the economic status, cigarette consumption and hours of sleep and the severity of hypogonadism symptoms (p < .001).

Conclusions

The current study’s results showed that certain factors can affect hypogonadism in males. Thus, it is important to reduce the severity of hypogonadism symptoms and to modify the factors related to this phenomenon.

Keywords:

• Hypogonadism
• andropause
• testosterone
• risk factors
• males

Introduction

One of the important issues of today’s world is hypogonadism, which has recently caught the attention of the medical community [1]. This important phenomenon occurs as a result of reduced androgen levels in men and plays an important role in their lives [2]. In fact, hypogonadism is a transient phase, passing from one phase to another new phase in life [3]. In addition to the physical issues, it affects social, sexual and psychological aspects too [4,5]. No significant age has been expressed for hypogonadism, but it usually occurs in middle age [6–8]. In fact, the hormone testosterone plays an important role in male health, and as a condition in which reduced testosterone levels are seen, hypogonadism is associated with an increased serum level of glucose, total cholesterol and lipoproteins [9]. Moreover, there is an inverse relationship between inflammatory markers such as highly sensitive C-reactive protein and reduced total testosterone levels [10]. From the age of 40 onwards, testosterone levels annually fall by 0.4–2.6% [1,11]. Reduced testosterone levels cause a wide range of symptoms, including, erectile dysfunction, Lower Urinary Tract Symptoms (LUTS), depression, sleep disorders, reduced libido, hair loss, irritability, psychological disorders, hot flushes, etc. [12–19]. Raised body fat percentage is another common symptom of hypogonadism, such that obese men and those with weak health are at greater risk of this urologic disorder [17,20]. The severity of hypogonadism symptoms may differ in different individuals. In the long run, these symptoms lead to diseases such as cardiovascular diseases, metabolic syndrome, osteoporosis, Alzheimer’s, sexual disorders, falls and early death [21–24]. In the USA, approximately 5 to 10 million [25], and in Iran, approximately 21.2% have been said to have this disorder among the general public [26]. The results of some studies also indicate the high prevalence of hypogonadism in patients with benign prostatic hypertrophy (BPH) [20], cardiac insufficiency [19], and type II diabetes [27]. Overall, based on an international study, a considerable number of males suffer from hypogonadism in which this disorder has not been diagnosed and treated [28]. In spite of the importance of its early diagnosis and treatment, unfortunately, there is little data in this field in the scientific literature [29]. Based on literature, cardiovascular risk factors such as body mass index (BMI), serum cholesterol and triglycerides can predict the incidence of urologic disorders in the following 25 years [30,31]. Nevertheless, the causes of hypogonadism have not been clearly stated yet either [32]. However, given the population transition in Iran, many biological, psychological and social factors will affect the incidence of hypogonadism in the future.

Various studies have been conducted with respect to the risk factors of hypogonadism. Only the impact of few of these factors has been recognized, and most of these factors still have room for debate. In this regard, some studies have addressed the impact of factors such as age, BMI, cigarette consumption, educational status, employment, income, marital status, diabetes, and signs of hypogonadism [1,33–37]. Despite the aforementioned studies, there are still many doubts regarding the impact of each of these personal traits on hypogonadism. Given the problems threatening male health, the risk factors must be identified and dealt with to neutralize their effects. By detecting these factors, and through preventive measures, males can be safeguarded against the possible complications of this phenomenon [38] and also reduce its associated healthcare costs. For example, many individuals with hypogonadism who have multiple associated diseases, increased waist circumference and obesity can benefit from lifestyle changes such as weight reduction as well as testosterone replacement therapy (TRT) [39]. Multiple studies have indicated that the injection of testosterone undecanoate has led to a significant reduction in waist circumference and visceral fat, and has been introduced as an appropriate treatment of hypogonadism [40]. Bearing in mind the significance of hypogonadism, the scarcity of data in this field in Iran, and the conflicting information present in earlier literature, we sought to estimate the prevalence of hypogonadism and its determinant factors in males employed at Tehran University of Medical Sciences (TUMS).

Materials and methods

This was a cross-sectional study. The statistical population consisted of all male employees aged 40–60 years employed at TUMS’ schools. The research sample included 80 individuals selected through census sampling. Among the 124 male employees falling in the desired age range, 115 were interested in participating in the study, of which 80 were eligible and were thus included. The inclusion criteria were age 40–60 years, consent to participate in the study, an AMS score of 27 or higher, absence of chronic diseases, psychological disorders and disabilities. The exclusion criteria were lack of inclination to participate in the study, having a chronic disease or psychological disorder over the course of the study, and incomplete filling of the AMS questionnaire [38]. Sampling was done after the necessary licenses were obtained. Sampling was such that, upon visiting TUMS schools, qualified individuals would be briefed on the research and would then be invited to participate in the study. Consenting individuals were included in the study upon completing the informed consent form. First, the demographic questionnaire and later on the AMS questionnaire were completed for the purpose of screening and assessment of severity of symptoms in the participants. Moreover, this study was approved by TUMS Ethics Board under code no. 26288.

Questionnaire

The data collection tool consisted of two sections. The first was the demographic questionnaire which comprised 11 questions on age, marital status, educational status, economic status, cigarette consumption, hours of sleep during the day and night, and medical disorders. The second section of the questionnaire is the AMS questionnaire, which is a beneficial tool for assessing the severity of age-associated symptoms, and is repeatedly used by urologists and endocrinologists to diagnose and follow-up male hypogonadism [11]. This tool contains 17 items in three physical (seven items), psychological (seven items), and sexual (five items) dimensions, and uses the Likert scale ranging from 1 to 5 (1 = none, 2 = mild, 3 = moderate, 4 = relatively severe, 5 = severe) based on the severity of symptoms. The scores of the dimensions range from 5 to 35. The overall AMS score is classified based on having no symptoms – with a score below 26, mild – at a score between 27 and 36, moderate – at a score between 37 and 49, and severe – at a score higher than 50 [41,42]. The validity and reliability of the AMS questionnaire has been approved in Iran with a Cronbach’s alpha of 0.7 [43].

Statistical analysis

Descriptive statistics (frequency, mean, standard deviation) and inferential statistics, including the independent t-test for comparing the mean scores of the hypogonadism dimensions in binomial variables, Pearson’s correlation for assessing the correlation between hypogonadism’s dimensions with age, and one-way ANOVA for comparing the mean scores of the hypogonadism dimensions for variables exceeding two states, were used. Eventually, those variables that had significant associations with the hypogonadism dimensions’ scores were entered into the stepwise multivariate regression. Data analysis was performed in SPSS Inc., Version 22 (Chicago, IL). The level of significance was considered at .05.

Results

The samples were 80 males, mostly of the 45–49-year-old age group that included 31 persons (38.8%). The demographic characteristics and severity of hypogonadism symptoms in the male employees are displayed in Table 1. Table 2 shows the mean hypogonadism score for the population under study in different dimensions of the AMS questionnaire.

Table 1. Demographic characteristics of male employees at Tehran University of Medical Sciences.

Variable	Number	Percent
Age (years)
40–44	24	30
45–49	31	38.8
50–59	25	31.3
Marital status
Married	66	82.5
Other (separated, widowed)	14	17.5
Educational status
High school diploma	40	50
Academic	40	50
Economic status evaluation^a
Average	35	43.8
Weak	45	56.3
Cigarette consumption
Yes	21	26.3
No	59	73.8
Cigarette consumption in the past
Yes	35	43.8
No	45	56.3
Number of hours of sleep
<4 hours	9	11.3
4–6 hours	30	37.5
7–9 hours	35	43.8
>9 hours	6	7.5
Severity of hypogonadism symptoms
Mild	26	32.5
Moderate	35	43.75
Severe	19	23.75

^aNone of the units under study evaluated their economic status as good.

Table 2. Central and peripheral indices related to the dimensions of severity of hypogonadism symptoms.

Severity of hypogonadism symptoms	Mean	Standard deviation
Physical symptoms	17.33	3.81
Psychological symptoms	12.50	3.75
Sexual symptoms	11.87	3.45
Overall hypogonadism score	41.71	9.20

Pearson’s correlation coefficient showed that overall, there were significant associations between age and severity of hypogonadism symptoms in all the subscales (p < .001) (Table 3).

Table 3. Correlation coefficients between age and severity of hypogonadism symptoms among male employees of Tehran University of Medical Sciences’ schools.

Age	Test result
Hypogonadism symptoms	Correlation coefficient	Level of significance
Physical symptoms	0.838	<.001
Psychological symptoms	0.756	<.001
Sexual symptoms	0.634	<.001
Overall hypogonadism score	0.894	<.001

The associations between the physical, psychological, sexual and overall hypogonadism scores and the male employees’ personal characteristics (education, economic status, cigarette consumption, number of hours of sleep) were examined using independent t-test and one-way ANOVA. The “educational status” variable was not significantly associated with the severity of hypogonadism symptoms in either of the dimensions (p > .05). However, the “economic status” (p < .001), cigarette consumption (p < .001), and the number of hours of sleep (p < .001) all had significant associations with the severity of hypogonadism symptoms (Table 4).

Table 4. Means and standard deviations of hypogonadism dimensions and personal traits among male employees of Tehran University of Medical Sciences’ schools, 2014.

Variables studied	Physical dimension	p Value	Psychological dimension	p Value	Sexual dimension	p Value	Overall hypogonadism score	p Value
Educational status
High school diploma	17.35 ± 3.89	.9	13 ± 3.67	.2	12.1 ± 3.25	.5	42.45 ± 8.9	.4
Academic	17.32 ± 3.78		12 ± 3.81		11.65 ± 3.67		40.97 ± 9.54
Economic status evaluation
Average	19.08 ± 3.14	<.001	14.06 ± 3.68	<.001	13.06 ± 3.27	<.001	46.75 ± 8.15	<.001
Weak	15.08 ± 3.42		10.48 ± 2.8		9.6 ± 2.20		35.22 ± 5.81
Cigarette consumption
Yes	19.52 ± 3.32	.002	14.42 ± 3.91	.005	14.28 ± 3.71	<.001	48.23 ± 9.31	<.001
No	16.55 ± 3.69		11.81 ± 3.48		11.01 ± 2.94		39.38 ± 8.03
Number of hours of sleep
<4 hours	22 ± 1.32	<.001	17.55 ± 3.53	<.001	15.11 ± 2.14	.009	54.66 ± 4.27	<.001
4–6 hours	17.6 ± 3.03		12.7 ± 2.8		12.06 ± 3.52		42.36 ± 7.45
7–9 hours	16.62 ± 3.62		11.45 ± 3.6		11.02 ± 3.25		39.28 ± 8.6
>9 hours	33.16 ± 4.53		10 ± 2.75		10 ± 3.34		33.16 ± 7.02

Eventually, those variables that had significant associations with the overall score and dimensions of hypogonadism (age, economic status, cigarette consumption, number of hours of sleep) were entered into the multivariate regression model in stepwise fashion to examine their associations simultaneously.

Table 5 shows that there is a significant association between the overall score of hypogonadism, and physical, psychological and sexual dimensions and age (p < .001). Moreover, there is a significant association between the physical dimension (p = .01), sexual dimension and overall hypogonadism score (p < .001) and the economic status. There were significant associations between the psychological dimension and number of hours of sleep (7 h or more) (p = .02), and between the overall hypogonadism score and the sexual dimension and cigarette consumption (p < .05).

Table 5. Results of stepwise regression for variables associated with hypogonadism among male employees of Tehran University of Medical Sciences’ schools, 2014.

Dependent variable	Predicting variable	Squared correlation coefficient	Model coefficient	β standard	T	Level of significance
Physical dimension	Constant coefficient	0.851	−10.82	–	−4.03	<.001
	Age		0.60	0.75	11.21	<.001
	Economic status (basis: weak)		−1.30	−0.17	−2.53	.01
Psychological dimension	Constant coefficient	0.774	−13.54	–	−4.70	<.001
	Age		0.56	0.71	9.58	<.001
	Number of hours of sleep exceeding seven hours		−1.25	−0.16	−2.25	.02
Sexual dimension	Constant coefficient	0.732	−1.08	–	−0.33	.74
	Age		0.28	0.39	4.23	<.001
	Economic status (basis: weak)		−2.40	−0.34	−3.92	<.001
	Cigarette consumption (basis: non-smoker)		1.64	0.21	2.50	.01
Overall hypogonadism score	Constant coefficient	0.931	−23.56	–	−5.002	<.001
	Age		1.40	0.73	14.56	<.001
	Economic status		−4.89	−0.26	−5.59	<.001
	Cigarette consumption (basis: non-smoker)		2.27	0.10	2.42	.01

Discussion

The current study has examined the association between demographic characteristics and severity of hypogonadism symptoms in male employees aged 40–60 years. Of the 80 participants, 26 (32.5%) had mild hypogonadism, 35 (43.75%) had moderate hypogonadism and 19 (23.75%) had severe hypogonadism. These results are not consistent with those of other studies. Xia et al. estimated the overall incidence of hypogonadism among middle–aged and elderly males aged over 45 years at 64.7%; mild, moderate, and severe hypogonadism were estimated at 58.1%, 30.9%, and 11%, respectively [44]. Khosravi conducted a study on apparently healthy males aged 40–65 years, and found that 31.5%, 16.4%, and 3.6% had mild, moderate, and severe hypogonadism, respectively, and their mean score was 28.8 [45]. In our study, however, the frequency of males with severe hypogonadism was greater, which may be attributed to the difference in sampling, sample size, population under study and diagnostic criteria of hypogonadism. Therefore, it is not far from expectation to have a difference in prevalence too.

Here, the mean overall hypogonadism score was 41.71 ± 9.20, which is higher compared to the results of some other studies. In studies performed elsewhere, different figures have been estimated, e.g. in Iran, this estimate was 33.81 ± 11.36 [7], in China it was 31.2 ± 6.8 [44], and in Bulgaria it was 32.06 ± 7.87 [35]. The tool used in these studies was the same as the one used here, i.e. the AMS questionnaire. The differences in the overall hypogonadism scores between these studies and ours can also be associated with the sample size and difference in sampling methods.

The results of the regression indicated that the overall score and the subscales of severity of hypogonadism were positively associated with age; that is to say, the severity of symptoms increased with an increase in the men’s age. In our study, age was recognized as the most important predictor of severity of hypogonadism symptoms in male employees. Overall, a direct association has been observed between an increase in age and hypogonadism [1,26,32,33,46–50], and the subscales of physical [32], psychological [51], and sexual [44,52,53] symptoms in various similar studies. Given the fact that the levels of testosterone decrease with age in men, this issue is understandable. Reduced levels of androgen may cause disorders in physical, psychological and sexual performance [54]. Nevertheless, in a study conducted by Khosravi in Iran, no significant association was observed between these variables [45]. The difference between that study and ours can be explained by the difference in population under study and the number of samples.

We also observed an inverse significant association between economic status and the overall hypogonadism score and its physical and sexual subscales, such that a weak economic status was associated with an increase in the overall hypogonadism, and physical and sexual subscale scores. This type of association had been reported in many researches [26,48,50,53]. In fact, a good economic status can help deal with the changes brought about by hypogonadism and facilitate the access to healthcare services.

The current study’s results indicated an inverse significant association between hours of sleep (7 h or more) and severity of psychological symptoms in male employees with hypogonadism, findings which are consistent with those of Hirokawa et al. [32]. In hypogonadism, sleep patterns change due to reduced levels of testosterone [55]. Reduced androgen causes an overall reduction in quality and effectiveness of sleep, which are correlated with reduced mental health and psychological disorders [56]. In the current study, a significant association was observed between cigarette consumption and severity of hypogonadism symptoms and the overall hypogonadism score, which is similar to the results of other research studies [26,45,48,57]. The effect of cigarette smoking has been indicated as a risk factor in many studies.

Moreover, consistent with the earlier studies conducted on Iranian males with hypogonadism [57], there was no significant association between educational status and the severity of hypogonadism symptoms, which is in fact contrary to the findings of other studies [26,46]. The reason behind this difference may be that all the samples had been chosen from an academic environment.

Limitations

Given the study is cross-sectional in nature, we cannot develop causal relationships. Here, the symptoms were self-reported and serum hormonal levels were not measured. To control these circumstances, we used the AMS questionnaire. Another limitation of this study was the small sample size, which limits the generalization of findings. Furthermore, we could not examine the men’s BMI in this study; therefore, we recommend examining this important factor in future studies. Since all the samples were aged between 40 and 60 years, we recommend conducting the study on different age groups.

Conclusions

Given the rise in hypogonadism prevalence and the association between this and certain demographic factors, we recommend the delivery of appropriate educational programs by healthcare personnel and policy makers. Raising awareness and educating men about these symptoms and how to deal with them, and the application of methods to reduce the complications of hypogonadism, such as healthy nutrition, quitting smoking and physical activity are very important.

Acknowledgements

The authors thank all those who helped to conduct this research. This article is part of a thesis for a Master’s degree in Midwifery – with a special interest in Sociology – in Tehran University of Medical Sciences, under ethics code 26288.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was funded by Tehran University of Medical Sciences and Health Services [26288].