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Abstract

Andropause is a syndrome that usually occurs during men’s midlife. It is associated with clinical short-term and long-term effects, as well as some physiological and psychological symptoms due to subnormal levels of testosterone serum. The objective of this study was to identify the factors that significantly contribute to the prevalence of symptoms that may be related to androgen deficiency. The study used a cross-sectional structured questionnaire and a sample of 214 Kuwaiti men aged 40 years and older. The questionnaire consisted of the sociodemographic characteristics of the participants and the Androgen Deficiency of the Aging Male Scale of Andropausal Symptoms. The results of the study indicate that Kuwaiti men who were 40 to 49 years old reported fewer symptoms than did Kuwaiti men aged 50 years and older, including deterioration in their ability to play sports, easily falling asleep after dinner, anger, and hot flushes (p < .05); and Kuwaiti men aged 50 years and older reported experiencing decrease in muscle strength, decrease in sport performance, sweating, loss of height, decreased libido, as well as falling asleep after dinner. For those aged 40 to 49 years, lower education levels, marital status, and employment status were significantly associated with the men’s symptoms (p < .05). On the other hand, in the case of respondents aged 50 years and older, only education level was significantly associated with their symptoms (p < .05). This is a preliminary study that reports the prevalence of aging male symptoms among Kuwaiti men. The findings will offer insight into the necessary health care provisions to educate, treat, and provide information related to andropause for the general public.

Keywords

andropause symptoms Kuwaiti men testosterone aging

Introduction

Universally, menopause is defined as the end of women’s menstruation associated with biological, hormonal, and psychological changes in a woman’s body due to oocyte depletion in the ovaries. These changes affect women’s well-being in their midlife due to the loss of bone mineral density, increased body weight, and mood swings (Daig et al., 2003; Korenman, 2000; Mathews, 1992; Obermeyer, 2000). Comparable to these changes in women, men experience biological, psychological, and endocrinological changes at midlife, such as impaired cognitive function, decreased libido, erectile dysfunction, osteoporosis, decrease in strength, fatigue, irritability, hot flushes, decreased lean body mass, increased visceral fat, and decreased body hair caused by hypogonadism and reduction in total testosterone levels (Araujo et al., 2004; Goel, Sinha, Dalela, Sankhwar, & Singh, 2009; Tenover, 1998; Wespes & Schulman, 2002). These symptoms that middle-aged to older men experience are explained as resulting from male menopause, male climacteric, and/or viropause and androgen deficiency (Perheentupa & Huhtaniemi, 2007).

The Endocrine Society defines “androgen deficiency” in men as a “clinical syndrome that results from failure of the testes to produce physiologic levels of testosterone” (Bhasin, 2006). The prevalence and intensity of androgen deficiency syndrome can vary among men depending on their age, presence of chronic disease, and variations in androgen sensitivity. Researchers use different terms to refer to androgen deficiency syndrome, such as “androgen deficiency of the aging male” (ADAM) or “late-onset hypogonadism” (LOH). Men who were diagnosed with LOH have reported experiencing abnormal reduction in their levels of testosterone due to hypothalamic-pituitary disorder or testicular disease that are usually recognized through a clinical and biochemical laboratory analysis of blood (Kelleher, 2004; Tsujimura et al., 2005). Health care providers usually recommend testosterone-replacement therapy as a treatment for androgen deficiency, which could help men overcome the negative effects of the declining testosterone levels on their quality of life (Jankowska et al., 2006; Maggi, 2007), cardiovascular risk factors, and bone mineral density (Kupelian, 2006).

Andropause is becoming a global health concern as the world’s population of aging males increases. About a third of men in their 60s and more than 80% of men aged 80 or older experience physical and psychological changes referred to as “the andropause syndrome” (Adebajo et al., 2007). Schieszer (2004) stated that about four to five million American men who were diagnosed with subnormal serum testosterone levels were treated to improve their impotence. Morales (2003) stated that 1 in 200 men have abnormally low levels of testosterone and therefore are candidates for androgen supplementation therapy. There are many components (fertility, sexuality, and endocrinology) that affect male reproductive health and well-being. Each component is influenced by men’s life history, cultural behavior and values, as well as heredity (Couillard, Gagnon, & Bergeron, 2000; Handelsman & Liu, 2005; Zmuda et al., 1997).

Cross-cultural research illustrates that the prevalence and intensity of andropausal symptoms are affected by men’s cultural beliefs about youth, masculinity, and ego. Because of the consequences of androgen deficiency on men’s sexual performance, many men may deny this event and regard the topic as a myth (Brand, 1993; Gray, 1997; Sun & Liu, 2007). Because of the variability of male reproductive systems, some men show a relatively normal reproductive function at an older age, whereas others develop significant impairments in testosterone production or erectile function as they age (Gruenewald & Matsumoto, 2003).

The phenomenon of male aging has been studied to investigate the relationship between the social and cultural backgrounds of the aging process and the awareness and knowledge of andropause in many countries in North America, Australia, Poland, France, Belgium, Nigeria, and China (Calvaresi & Bryan, 2003; Fatusi et al., 2003; Jankowska et al., 2006; Mak, De Backer, Kornitzer, & De Meyer, 2002; Myon, Martin, Taieb, & Heinemann, 2005; Sun & Liu, 2007). Psychological and sociodemographic factors also have been investigated, such as age, occupation, depression, education, marital status, and social environment, which may also contribute to andropausal symptoms (Ichioka et al., 2006; Jankowska et al., 2006; Kratzik et al., 2004; Myon et al., 2005; Tan & Philip, 1999; T’Sjoen, Goemaere, De Meyere, & Kaufman, 2004). A cross-cultural research on the prevalence and perception of andropause revealed many variations among middle-aged men. These variations can be attributed to the following factors: (a) differences in the translation of the andropausal symptoms scale to the native language where the research is administrated; (b) cross-cultural variation on identity, self-image, and youth of middle-aged men (Calvaresi & Bryan, 2003; Jankowska, Szklarska, Lopuszanska, & Medras, 2008; Zhibing, 2003); (c) inter- and intra-individual variability in hormonal levels (Novak, Brod, & Elbers, 2002); and (d) lifestyle habits, heredity, diet, chronic disease, and drug misuse (Adlercreutz, 1990; Cicero, 1992; Deslypere & Vermeulen, 1984; Turner & Wass, 1997; Vermeulen, 2000).

The current study is comparable to the study of Jankowska et al. (2008), who conducted research among Polish men to detect the intensity of age-related symptoms by using the Aging Males’ Symptoms scale to assess symptoms associated with the aging process. Also, the current study design is similar to Adebajo et al.’s (2007) study on reporting the severity of andropause symptoms among Nigerian men. Previous studies about measuring the prevalence of andropausal symptoms were not clinical and only used a structured questionnaire as an assessment tool to detect aging males’ symptoms, as did the current study. The purpose of the present study was to examine some sociocultural and anthropometric factors that significantly affect the prevalence of a number of symptoms possibly related to androgen deficiency among Kuwaiti men at midlife. The study attempted to answer the following research question: Is there a significant association between the prevalence of andropausal symptoms and sociodemographic factors? The findings provide insight into the health care provisions to educate, treat, and provide information related to andropause for the general public.

Research Design

This is a cross-sectional study that was conducted in 2011 in Kuwait. The sampling method is a nonprobability, convenience sampling. A structured questionnaire of 34 questions including Saint Louis University’s “Androgen Deficiency in the Aging Male” (ADAM) scale was translated to Arabic and distributed by qualified interviewers to 300 healthy Kuwaiti men between the ages of 40 and 70 after obtaining their verbal approval to participate in the study. Out of 300 distributed questionnaires, only 214 men agreed to participate in this study and were willing to fill out the questionnaire. This can be attributed to the sensitivity of the topic for Kuwaiti men who live in this conservative and traditional culture, where issues that concern men’s health status in relation to their sexual life (loss of libido, impotence, and erectile dysfunction) are considered embarrassing and taboo. For the purpose of statistical analysis, men’s age was divided into two groups (40-49 years and 50 years and older) because of the small sample size. The questionnaire consisted of two main parts: the first part included the personal characteristics of the participants (age, body mass index [BMI], educational level, marital status, employment status, medical history, smoking habit, and physical activity). For statistical analysis, the respondents’ educational levels were divided into three categories: low education (primary school), middle education (completed secondary school), and high education (completed university and above).

The second part included 14 signs/symptoms associated with testosterone deficiency: (a) vasomotor (hot flushes, sweating), (b) somatic (loss of height, decrease in strength, deterioration in ability to play sports, falling asleep after dinner, and fatigue/weakness), (c) sexual behavior (loss of sexual desire, erectile dysfunction), and (d) psychological disorders (inability to concentrate, irritability, depression, anger, and memory loss). The total number of symptoms experienced by each participant was calculated by adding the total number of “yes” responses (a score of 1 was assigned to a “yes” response and 0 to a “no” response). Data were analyzed using SPSS (SPSS Inc; Chicago, IL) for Windows version 13.0.1. T-test, Pearson’s chi-square test, simple logistic regression, and correlation analyses were used to examine differences between groups and to find significant correlations among any demographic factors (age, BMI, educational level, occupation, and marital status) and androgen deficiency (the total account of the andropausal symptoms).

Results

Of the 214 respondents, 143 were in the age group of 40 to 49 years, and 71 were 50 years and older. The mean age of the respondents was 48.07 years. About 75% of the respondents in the age group of 40 to 49 years had a BMI below 29, compared to 30.4% of those aged 50 years and older. Table 1 reports that more than half of the respondents in this study achieved middle education, and 70.6% of the respondents who achieved middle education were between 40 and 49 years old, whereas 29.4% were aged 50 years and older. About half of the respondents were currently working, 83.8% were 40 to 49 years old, and 16.2% were 50 years and older. Most (65.2%) of the respondents were married, were between 40 and 49 years old, and 34.8% were 50 years and older. Most of the respondents (84%) reported that they had never exercised, 59.5% were 40 to 49 years old, and 40.5% were 50 years and older. More than half of the respondents reported that they were unaware of the term andropause—the majority (63%) were between 40 and 49 years old, and 32% were 50 years and older.

Table 1.

Demographic and Lifestyle Factors According to Age Group.

Factors	40 to 49 years old		50 years and older
Factors	Number (N = 143)	Percentage	Number (N = 71)	Percentage
BMI (kg/m²)	143	66.8	71	33.2
Below 29	87	69.6	38	30.4
Above 30	47	67	23	32.9
Education
Low education	21	51	20	48.8
Middle education	108	70.6	45	29.4
High education	14	70	6	30
Marital status
Never married	14	87.5	2	12.5
Married	107	65.2	57	34.8
Divorced/separated	11	84.6	2	15.4
Widowed	10	62.5	6	37.5
Occupation
Government employed	83	83.8	16	16.2
Self-employed	32	80	8	20
Retired	24	33.8	47	66.2
Physical activity
Every day	31	75.6	10	24.4
Sometimes	48	75	16	25
Never	50	59.9	34	40.5
Used to	13	68.4	6	31.6

Note. Frequency for individual categories may not add up to the total N due to missing data.

The main andropausal symptoms reported by Kuwaiti men aged between 40 and 49 years included the following: noticeable deterioration in the ability to play sports (82 men, 57.3%), weakness/fatigue (56 men, 39.2%), irritability and anger (43 men, 30.1%), inability to concentrate (42 men, 29.4%), and anxiety (39 men, 27.3%). Of the 14 symptoms listed, only 18 men (12.6%) reported experiencing sweating, 21 men (14.7%) reported less strength in erections, 22 men (15.4%) reported depression, and 30 men (21%) said they had decreased libido.

Similar to the younger age group in the current study, the main andropausal symptoms that were reported by Kuwaiti men aged 50 years and older included the following: physical weakness, noticeable decrease in athletic performance (41 men, 57.7%), followed by inability to concentrate (40 men, 56.3%), irritability (38 men, 53.5%), decreased libido (31 men, 43.7%), and anxiety (26 men, 36.6%). A few respondents reported depression (9 men, 12.7%), hot flushes (12 men, 16.9%), and sweating (19 men, 26.8%; Table 2). Out of the 14 andropausal symptoms displayed in Table 2, 15 respondents in the age group of 40 to 49 years reported no symptoms compared to only 4 respondents aged 50 years and older who reported no symptoms.

Table 2.

The Prevalence of Andropausal Symptoms According to Age Group.

Symptoms	p	40 to 49 years		50 years and older
Symptoms	p	Number (N = 143)	Percentage (66.8)	Number (N = 71)	Percentage (33.2)
Decrease in muscle strength	<.001	35	24.5	35	49.3
Anxiety	.206	39	27.3	26	36.6
Fatigue/weakness	<.008	56	39.2	41	57.7
Loss of sex desire	<.001	30	21	31	43.7
Loss of height	<.002	19	13.3	22	31
Notice deterioration in ability to play sports	<.026	61	42.7	41	57.7
Depression	.683	22	15.4	9	12.7
Falling asleep after dinner	.058	27	18.9	22	31
Less strength in erections	<.002	21	14.7	24	33.8
Irritability	<.001	43	30.1	38	53.5
Anger	<.003	43	30.1	37	52.1
Hot flushes	.408	18	12.6	12	16.9
Sweating	.737	34	23.8	19	26.8
Inability to concentrate	<.0001	42	29.4	40	56.3

The current study findings identified that the majority of both age groups reported between 1 and 3 symptoms, and a few reported 13 or 14 symptoms. One fourth of the respondents in the age group of 40 to 49 years reported one andropausal symptom, 26 men (18.2%) reported two symptoms, and 19 men (13.3%) reported three symptoms. On the other hand, 10 (14.1%) respondents aged 50 years and older reported three symptoms, 9 (12.7%) reported two symptoms, and 8 (11.3%) reported one symptom.

Pearson’s correlation was applied to examine the association between each age group’s demographic characteristics and the 14 ADAM symptoms. Differences were considered significant at p < .05. Respondents aged 40 to 49 years and who accomplished lower education experienced falling asleep after dinner and having hot flushes (p < .05). Also there was a significant association between the respondents’ employment status and falling asleep after dinner, anger, and hot flushes (p < .05). Respondents’ marital status was significantly associated with feeling weak when they play a sport (p < .001). On the other hand, for respondents aged 50 years and older, only education level was significantly associated with experiencing body weakness and fatigue, loss in sex drive, noticeable deterioration in physical activity, falling asleep after dinner, and sweating (p < .05). The findings can be attributed to aging that is concurrent with increases in the incidence of chronic disease and lifestyle problems (Jankowska et al., 2006; Novak et al., 2002) and to inverse associations between androgen deficiency (serum bioavailable testosterone and free testosterone) and the incidence of andropausal symptoms associated with aging (Diamond, 1998; Jankowska et al., 2008; Kratzik et al., 2004; Morley, Perry, & Kevorkian, 2006). On the other hand, Jankowska et al. (2008) did not detect any significant relationships between men’s age and the prevalence of their andropausal symptoms.

Discussion

The findings of the current study are similar to those of Gladh, Rahgozar, Hammar, Fredriksson, and Spetz’s (2005) research conducted in Sweden; Fatusi et al.’s (2003) study conducted in the South Western part of Nigeria; and Tan and Philip’s (1999) study conducted in Texas. These studies revealed that andropausal symptoms (decreased libido, lack of energy, loss of height, and decrease in muscle strength) differed significantly between the respondents’ age groups. In the current study, respondents aged 50 years and older reported experiencing more andropausal symptoms than did younger respondents. These symptoms include decrease in muscle strength and in sport performance, loss of height, night sweating, falling asleep after dinner, and decreased libido.

The findings of the current study are comparable to those of several studies that also reported a significant association between middle-aged men’s experience of various andropausal symptoms (sexual, psychological, and somatic) and their marital status, education levels, and occupations (Adebajo et al., 2007; Gliksman, Lazarus, Wilson, & Leeder, 1995; Handelsman & Liu, 2005; Mathews, 1992; Nguyen, 1996; Obermeyer, 2000; Waite & Lehrer, 2003). Respondents aged 50 years and older who achieved lower education reported more symptoms (loss in sex drive, falling asleep after dinner, fatigue, deterioration in physical activity, and sweating) than those in the same age group with middle and higher educational levels. This finding also can be attributed to aging, since most of the respondents aged 50 years and older have accomplished lower education compared to the younger respondents. In addition, the previous andropausal symptoms that Kuwaiti men reported also can be related to the reduction in testosterone levels that men experience at midlife and to concurrent somatic disorders, mood disorders, aging, medication intake, pituitary tumors, and chronic diseases such as diabetes or anemia (Vance, 2003).

The current study cannot ascertain a causal connection between an average age-dependent decline in testosterone production and andropausal symptoms. Studies of men with androgen deficiency illustrated that most men are unlikely to recognize that they have low testosterone levels, and therefore they do not share their experiences with others (Heaton & Morales, 2001; Michael, 2003; Morales, 2003; Morley et al., 2000). In addition, many men feel uncomfortable and embarrassed to talk to their friends and their mates about their experience in sexual intimacy and performance (Pan, 1996; Sun & Liu, 2007).

The only conducted study that examines the level of awareness of andropause and the relationship between men’s perceptions and attitudes toward the andropause event among Kuwaiti men was conducted by Al-Sejari (2013). The study revealed that 36.0% of Kuwaiti men acknowledged having signs of andropause, 38.4% of Kuwaiti men reported believing that men do not go through andropause, 53.4% said that they do not know at what age men experience andropause, and 46.9% reported that they think that andropause is a sign of aging. Health care providers, the media, and the general public should emphasize on health education and enlighten the community about the aging process and hormonal changes (their etiology, symptom prevalence, and diagnosis) and how men can cope with and adjust to this midlife transition. Kuwaiti men need to be educated and receive more information about andropause from the media, health care providers, and health organizations. Additional information regarding andropausal signs, symptoms, screening, and treatment will help men accept this life change and cope with it and minimize any psychological and physiological discomfort by selecting the appropriate health care treatment. Epidemiological, cross-cultural, and clinical studies need to be conducted targeting men aged 40 and older from diverse ethnocultural groups to see if there are any differences in endogenous hormonal levels in men. Future studies in this area are needed to develop standards and guidelines to direct the diagnosis and management of andropause. Cross-cultural studies are also needed to observe whether there are variations in the definition and experiencing of aging and andropause.

There are a few limitations that should be considered when taking into account the current study findings. First, the majority of the respondents were in the age group of 40 to 49 years. This could affect the frequency of andropausal symptoms that Kuwaiti men reported having experienced with aging. Second, due to the sensitivity of the research topic, many men are uncomfortable participating in a study such as this and feel embarrassed to answer the questions in the questionnaire. They refer to this psychological and physiological transition as a “midlife crisis.” Third, this is the first research of its kind conducted in Kuwait that discusses and measures the prevalence and intensity of andropausal symptoms using a constructed questionnaire and clinical and laboratory research using both blood samples to assess androgen deficiency and the frequency of andropausal symptoms.

Conclusion

The results of this study revealed that andropause as a health condition is difficult to recognize by a majority of men because of the lack of knowledge of its etiology, pathophysiology, and management. Kuwaiti men attributed the decline in their health and well-being to chronic disease, fatigue, and aging rather than to endocrinological imbalance. Many men in this study reported that it was difficult for them to recognize that they were undergoing andropause because the symptoms vary in intensity from one man to another and do not appear simultaneously. The findings of this study showed that it is important to educate the public, especially men, about andropause. Future studies in this area are needed to develop standards and guidelines to direct the diagnosis and management of andropause among Kuwaiti men.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Prevalence of Andropausal Symptoms Among Kuwaiti Males

Abstract

Keywords

Introduction

Research Design

Results

Discussion

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

References