Retrospective observational study finds hypogonadism prevalent in men with sexual dysfunction and related to a range of chronic illnesses

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Hypogonadism in men with erectile dysfunction may be related to a host of chronic illnesses. Guay A, Seftel AD, Traish A. Int J Impot Res 2010; 22(1):9-19 [Erratum in: Int J Impot Res 2010; 22(3):210].

This retrospective, observational study evaluated the prevalence of hypogonadism among men with sexual dysfunction, and examined its association with medical and psychological factors. The study involved 990 men (90% Caucasian) who attended an endocrinology specialist centre for sexual function as a new consultation between July 1995 and July 1997.1 To identify medical and psychological conditions, patients underwent a detailed clinical evaluation and their medical history was examined. A diagnosis of hypogonadism was made based on a total testosterone level of <300 ng/dL (<10.4 nmol/L) accompanied by three or more signs/symptoms of hypogonadism. Primary hypogonadism was identified when low testosterone levels were accompanied by normal levels of luteinizing hormone (≥9 IU/L). Associations between conditions (medical and psychological) and hypogonadism were examined using the Mantel−Haenszel2-test.

The mean age of the men was 57.4 years and all had sexual dysfunction. Overall, 359 men (36.3%) had hypogonadism, most of whom were diagnosed with secondary hypogonadism (301 men). The men in this study had a high prevalence of chronic medical and/or psychological conditions, including; diabetes mellitus (23.1%), hypertension (35.8%), atherosclerotic coronary artery disease (19.9%), work-related stress (27.5%) and anxiety/depression (21.0%), and 28.2% of men were on multiple medications.

Key Points1

  • The prevalence of hypogonadism among men with sexual dysfunction and common medical causes of ED ranged from 30.8−64.3% (Figure 1)
  • Hypogonadism was prevalent among men who used alcohol excessively or who smoked (31.6% and 27.1%, respectively)
  • The prevalence of hypogonadism was also substantial among men receiving medication for anxiety or depression (37.0%) and in men with work-related stress (42.6%)
  • The highest prevalence of hypogonadism was observed in men in their 50’s and 60’s
  • A significant association between the medical or psychiatric causes of ED and hypogonadism was limited to hypertension (p=0.025), tobacco abuse (p=0.0059), sleep apnea (p=0.0001) and work stress (p=0.041)
  • Sleep apnea (odds ratio [OR] 3.34; 95% confidence interval [CI] 1.75, 6.37) and work stress (OR 1.36; 95% CI 1.01, 1.84) in particular were positively associated with hypogonadism.

What is known

Low testosterone levels, common in older men,2 are associated with a range of chronic illnesses including diabetes mellitus,3 vascular disease and the metabolic syndrome.4-7 To date, diabetes has been the most closely studied comorbid chronic illness, and 30−40% of men with diabetes are expected to have lower testosterone levels.3

Hypogonadism is also common in men with ED, with a prevalence of 36% according to the initial published results from this study.8 This high prevalence rate is reflected in other observational studies of men who attended healthcare centres.9,10 Guay and coworkers also identified a significant cardiovascular risk in these men with ED, a finding confirmed in subsequent studies.11-13

What this study adds

The results of this study confirm the association between hypogonadism and a range of chronic illnesses, and indicate that men with these conditions should have their testosterone levels checked, particularly when symptoms of sexual dysfunction are also present.

The prevalence of hypogonadism is widely accepted to increase with age, but in this study, the highest prevalence was in men aged 40−60 years of age, which may reflect referral bias and a high proportion of men reporting work-related stress. Indeed, there was a stronger association between hypogonadism and work-related stress than the more established association between hypogonadism and anxiety/depression. Perhaps surprisingly, the study identified a strong association between hypogonadism and sleep apnea.

Population studies have shown that lifestyle and health factors, in addition to age, have an impact on testosterone levels.14-16 The authors of this study hypothesize that chronic illness and stress may suppress the activity of the central hypothalamic−pituitary axis, leading to secondary hypogonadism. Further prospective studies are warranted to determine to what extent health-related lifestyle modifications may be able to correct low testosterone levels in these men.

Figure 1: Prevalence of hypogonadism in men with sexual dysfunction and specific medical or psychological conditions

References

1. Guay A, Seftel AD, Traish A. Hypogonadism in men with erectile dysfunction may be related to a host of chronic illnesses. Int J Impot Res 2010; 22(1):9-19 [Erratum in Int J Impot Res 2010; 22(3):210].
2. Seftel AD. Male hypogonadism. Part 1: epidemiology of hypogonadism. Int J Impot Res 2006; 18(2):115-120.
3. Ding EL, Song Y, Malik VS, Liu S. Sex differences of endogenous sex hormones and risk of type 2 diabetes: a systematic review and meta-analysis. JAMA 2006; 295(11):1288-1299.
4. Laaksonen DE, Niskanen L, Punnonen K, et al. Testosterone and sex hormone-binding globulin predict the metabolic syndrome and diabetes in middle-aged men. Diabetes Care 2004; 27(5):1036-1041.
5. Muller M, Grobbee DF, den Tonkelaar I, et al. Endogenous sex hormones and metabolic syndrome in aging men. J Clin Endocrinol Metab 2005; 90(5):2618-2623.
6. Corona G, Mannucci E, Schulman C, et al. Psychobiologic correlates of the metabolic syndrome and associated sexual dysunction. Eur Urol 2006; 50(3):595-604.
7. Jackson G. The metabolic syndrome and erectile dysfunction: multiple vascular risk factors and hypogonadism. Eur Urol 2006; 50(3):426-427.
8. Guay AT, Velasquez E, Perez JB. Characterization of patients in a medical endocrine-based center for male sexual dysfunction. Endocr Pract 1999; 5(6):314-321.
9. Mulligan T, Frick MF, Zuraw QC, Stemhagen A, McWhirter C. Prevalence of hypogonadism in males aged at least 45 years: the HIM study. Int J Clin Pract 2006; 60(7):762-769.
10. Makhlouf AA, Mohamed MA, Seftel AD, Neiderberger C. Hypogonadism is associated with overt depression symptoms in men with erectile dysfunction. Int J Impot Res 2008; 20(2):157-161.
11. Walczak MK, Lokhandwala N, Hodge MB, Guay AT. Prevalence of cardiovascular risk factors in erectile dysfunction. J Gend Specif Med 2002; 5(6):19-24.
12. Guay A, Jacobson J. The relationship between testosterone levels, the metabolic syndrome (by two criteria), and insulin resistance in a population of men with organic erectile dysfunction. J Sex Med 2007; 4(4 Pt 1):1046-1055.
13. Seftel AD, Sun P, Swindle R. The prevalence of hypertension, hyperlipidemia, diabetes mellitus and depression in men with erectile dysfunction. J Urol 2004; 171(6 Pt 1):2341-2345.
14. Hall SA, Esche GR, Araujo AB, et al. Correlates of low testosterone and symptomatic androgen deficiency in a population-based sample. J Clin Endocrinol Metab 2008; 93(10):3870-3877.
15. Travison TG, Araujo AB, Kupelian V, et al. The relative contributions of aging, health, and lifestyle factors to serum testosterone decline in men. J Clin Endocrinol Metab 2007; 92(2):549-555.
16. Wu FC, Tajar A, Pye SR, et al. Hypothalamic-pituitary- testicular axis disruptions in older men are differentially linked to age and modifiable risk factors: the European Male Aging Study. J Clin Endocrinol Metab 2008; 93(7):2737-2745.

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Last updated: 2018
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