The Prevalence of Andropause and Its Relationship With Sexual Quality of Life Among Older Iranian Men

Abstract

Available evidence indicates insufficient knowledge about the status of andropause and sexual quality of life among Iranian older men. The study aimed to investigate the prevalence of andropause and its relationship with sexual quality among older adults. This descriptive-analytical study was conducted among 576 older people referred to urban health centers in Mashhad, Iran. The eligible samples were selected through the cluster sampling method. To collect data, the male andropause symptoms’ self-assessment questionnaire and the sexual quality of life-male were used. Forty-seven of the respondents (n = 271) were diagnosed with a “moderate” level of andropause. A strong negative correlation was identified between the sexual quality of life and the severity of andropause (r = −.366, p < .001). Sexual quality of life and andropause was also affected by age, marital status, health status, and exercise. Thirty-six percent of the changes in the quality of sexual life of older men were influenced by the independent variables (adjusted R² = .36; R² = .40; R = .63). The findings indicated that andropause has highly prevailed among the participants. There was a meaningful association between andropause and sexual quality of life among older men. Further studies are recommended to investigate sexual orientation qualitatively and to discover other factors influencing andropause among adult men.

Introduction

Along with the gradual but significant increase in the population and life expectancy of Iranian older men and the experts’ focus on improving or maintaining the older adults’ life quality, “andropause” is turning into a severe health problem that requires a great deal of attention to prevent possible difficulties (Afsharnia et al., 2016). Andropause, also known as testosterone deficiency syndrome or late-onset hypogonadism, refers to the symptoms that men experience as their testosterone production levels decrease with age (Rezaei et al., 2020). Lowered libido, lack of energy and interest, muscle and joint pain, muscle atrophy, impaired memory function, decreased mental focus and capacity to cope with stress, negative emotions, sleep disorders, hot flashes, prostatitis, gynecomastia, height loss, pubic hair loss, anxiety, accelerated osteoporosis, and frequent urination are some of the main symptoms of andropause (Rezaei et al., 2020). Although most of these symptoms are nonspecific, andropause may adversely affect men’s mental and physical health and quality of life (Fileborn et al., 2017).

Testosterone is the primary androgen in the blood, playing an essential role in stimulating body functions such as sexual function, blood formation, bone mineralization, muscle mass growth, and lipid and carbohydrate metabolism (Fabrazzo et al., 2021; Novák et al., 2002). As men get older, a gradual decline occurs in testosterone levels. In the fourth decade of life, testosterone levels decline by about 1% per year, and the symptoms associated with andropause begin to manifest throughout life. Bioavailable testosterone levels in a 75-year-old man are less than half of the healthy men aged 20 to 30 years (Novák et al., 2002; Brooke et al., 2014). Age-related diseases such as diabetes, heart disease, kidney disease, obesity, metabolic syndrome, and some medicines such as glucocorticoids, cigarettes, and alcohol also play a role in lowering testosterone levels (Rezaei et al., 2020). According to global statistics, over 480,000 older men annually experience menopause, gradually increasing in severity and frequency. Andropause symptoms range from mild to moderate and severe (Brooke et al., 2014; Cybulski et al., 2018).

According to mentioned, sexual quality is one of the main dimensions of life among older men that may be affected by andropause (Dogan et al., 2008; Fabrazzo et al., 2021). Andropause may be sexually threatening in some people. There is evidence that male sexual function reduces with age and the onset of andropause (Abootalebi et al., 2020; Cybulski et al., 2018; Dogan et al., 2008; Rezaei et al., 2020). Male sexual dysfunction can include a wide variety of problems, ranging from low libido, erectile dysfunction, premature ejaculation, and other issues. Although many men know that these issues are common, they can be difficult to talk about (Dogan et al., 2008). The onset of symptoms does not necessarily mean the inability of men to play a positive and influential role in sexual interactions (Fileborn et al., 2017). Sexual quality of life generally refers to the feeling of sexual attractiveness, sexual interest, participation in sexual activity, and perception of sexual function, but among men, it mainly includes sexual self-confidence, emotional health, and interpersonal relationships (Abootalebi et al., 2020). When sexual desire declines among men, they no longer reflect much tendency to have sexual intercourse, and this dissatisfaction in acute cases can threaten the family’s foundation (Brooke et al., 2014).

The study of people’s sexual affairs should start from the first level of the care system such as health centers, family physicians, geriatricians, endocrinologists, counselors, and psychologists (Zohreh et al., 2017). Men’s sexual life quality largely depends on their personality traits, emotions, perceptions, beliefs, and thoughts which are strongly influenced by knowledge, media, education, and personal experiences. Hence, therapists need to consider the underlying factors, especially the cultural context, to promote sexual health in any society (Tajar et al., 2012). A good sex life includes interacting with all physical, psychological, social, and emotional factors to create a clear mental understanding and strengthen the desire to participate in future sexual intercourse (Tajar et al., 2012). Considering the concurrence of symptoms and complications of andropause and the increased likelihood of sexual dysfunction among older men, it is essential to be concerned about sexual quality under the influence of this issue (Rezaei et al., 2020; Yadav et al., 2019).

As a developing country, Iran faces an overpopulation of the elderly, probably rising by 22% in 2050. This might cause an elderly tsunami in Iran (Ghanbari et al., 2015). Unfortunately, despite the increasing demand for health programs to improve the sexual quality of life among older people, there is only limited epidemiological information (Abootalebi et al., 2020; Haren et al., 2006; Asadollahi et al., 2013; Samipoor et al., 2017). Hence, appropriate strategies should be considered as soon as possible to maintain or improve male adults’ sexual life. Therefore, the present study aimed to investigate andropause prevalence among older men and its relationship with the quality of their sexual life.

Materials and Methods

Design of the Study

A descriptive-analytical (cross-sectional) approach was performed during 2021 to 2022 among older men referring to health centers in Mashhad, Iran.

Sampling

Using the sample size calculator, the number of 384 people was recommended. Applying the cluster sampling method and the design effect of 1.5 (Asadollahi et al., 2013), the sampling accuracy was improved, and finally, 576 older men (60 years old and above) were approached in the study. The age of 60 years and above, living in Mashhad for at least one recent year, informed written consent, and being blessed with consciousness and cognition to obtain accurate information were considered the inclusion criteria. The unwillingness to participate in the research at any time during the study and inappropriate responses were taken as the exclusion criteria. Based on inclusion and exclusion criteria, the participants were selected through cluster sampling using their profiles in five health centers: 85 samples from center A, 125 from center B, 90 from center C, 83 from center D, and 193 from center E. Family health records were reviewed at each center, and those families with eligible men were randomly approached.

Instruments

The characteristics of socio-demographic (age, marital status, education, employment, household living arrangements, substance abuse, history of disease, sexual dysfunction, income, exercise, number of children, health status of the older men, average number of times couples have sex per week, the spouse’s menopausal status, the spouse’s education, and awareness about sexual issues) were collected. Then, the Iranian male andropause symptoms self-assessment questionnaire (MASSQ) was used (Asadollahi et al., 2013). The questionnaire includes four subscales and 25 items, scored on a 5-point Likert-type scale (0–4). The questions evaluate andropause symptoms with cutting points for no andropause or mild andropause (less than 40), moderate andropause (between 41 and 84), and severe andropause (above 85). Finally, the sexual quality of life-male was applied to assess the relationship between male sexual dysfunction and quality of life (Zohreh et al., 2017). It consists of 11 items with a total score ranging from 11 to 66. Each item is scored using a 6-point Likert-type scale ranging from 1 as agree to 6 as disagree entirely. Higher scores indicate a better male sexual quality of life (Zohreh et al., 2017).

Data Analysis

Demographic-social information of the participants was reported by descriptive statistics like percentage, mean, and standard deviation. Correlation tests, independent t-tests, and one-way analysis of variance were used to find the relationship between variables. The role of predictors was also determined using inverse multiple linear regression.

Ethical Considerations

Informed consent was obtained from all the people who participated in the study. All procedures performed in the study were following the national ethical standards and the ethics committee of the university.

Findings

The mean age of the participants was 69 ± 7.35 years. Most of the respondents were married and had a primary level of education. About 40% of the participants suffered from erectile dysfunction. Furthermore, premature ejaculation and sexual dysfunction were prevalent in 20% of cases (see Table 1). Table 2 presents the mean scores (39±16.38) and levels of andropause. It was found that 47% of cases had significant signs and symptoms of andropause. Moreover, Table 3 summarizes mean scores of andropause syndrome according to socio-demographic characteristics among older Iranian men (n = 576). Marital status, educational levels, employment status, household living arrangements, age, chronic illness, health status, substance abuse, and exercise were significantly related to the score of andropause syndrome (p < .001).

Table 1.

Socio-Demographic Characteristics of the Respondents (n = 576).

Variables	Classifications		%	Variables	Classifications		%
Marital status	Not married	—	—	Living arrangements	Single	42	7.3
	Has a spouse	505	87.7		With wife	259	45
	Death of wife	55	9.5		With wife and children	244	42.4
	Divorce of spouse	16	2.8		With child	27	4.7
Educational levels	Illiterate	162	28.8	History of diseases	Yes	500	86.8
	Primary level	271	47		No	76	13.2
	College	107	18.6	Exercise	Yes	165	28.6
	University	32	5.6		No	411	71.4
Employment status	Employee	32	5.6	Sexual problems	Erection disorder	229	39.8
	Self-employed	189	32.8		Premature ejaculation	118	20.4
	Housewife	8	1.4		Relationship problem	119	20.7
	Unemployed	77	13.4		Sexual injury	—	—
	Retired	267	46.4		Divorce	12	2.1
	Voluntary work	—	—		None	211	36.7
Income adequacy	Enough	147	25.5
	Insufficient	424	74.5
Health status	Very good	24	4.2	Drug abuse	Liquor	16	2.8
	Good	164	28.5		Narcotics	64	11.1
	Medium	308	53.5		Cigarettes	112	19.4
	Bad	67	11.6		Hormone drugs	—	—
	Very bad	9	1.6		None	378	56.6
Age	Mean	69.5		Number of children	Mean	4.6

Table 2.

Mean Scores and Levels of Andropause Syndrome Among Older Iranian Men (n = 576).

Andropause level	Frequency	Percent
Low	305	53
Moderate	271	47
Severe	0	0
Total	576	100

Table 3.

Mean Scores of Andropause Syndrome According to Some Demographic Characteristics Among Older Iranian Men (n = 576).

Variables	Classification	%	Andropause mean scores	p	Variables	Classification	%	Andropause mean scores	p
Marital status	Not married	—	—	.000 ***	Living arrangement	Single	7.3	42.85	.001 **
	Has a spouse	87.7	43.39			With wife	45	37.19
	Death of wife	9.5	37.58			With wife and children	42.4	39.46
	Divorce of spouse	2.8	43.91			With child	4.7	48.45
Educational levels	Illiterate	28.8	44.11	.000 ***	Age	Mean	69.05	—	.000 ***
	Primary	47	37.38
	College	18.6	39.33		Number of children	Mean	4.61	—	0.768
	University	5.6	35.04
Employment status	Employee	5.6	26.06	.000 ***	Sexual problem	Erection disorder	—	44.70	.000 ***
	Self-employed	32.8	39.47			Premature ejaculation	39.8	32.73
	Housewife	1.4	45.50			Relationship problem	20.4	48.83
	Unemployed	13.4	40.81			Sexual injury	—	—
	Retired	46.4	37.13			Divorce	2.1	15.50
	Voluntary work	—	40.80			None	36.7	—
Health situation	Very good	4.2	25.50	.333	Income adequacy	Enough	25.5	41.08	.845
	Good	28.5	31.98
	Medium	53.5	41.35			Insufficient	74.5	43.88
	Bad	11.6	47.41
Health situation exercise	Very bad	1.6	61.77	.000 ***	Drug abuse	Liquor	2.8	17	.000 ***
	Yes	28.6	32.84			Narcotics	11.1	39.33
	No	71.4	41.41			Cigarettes	19.4	43.31
						Hormone	—	44.92
						None	56.6	—
				.000 ***	History of diseases	Yes	86.8	40.07	.000 ***
						No	13.2	44.76

p < 0/001 = *. p < 0/01 = **. p < 0/05= ***.

Table 4 provides the mean scores of the MASSQ. It was revealed that marital status, educational levels, employment status, living with the spouse and children, health status, substance abuse, age, other illnesses, sexual dysfunction, income level, exercise, number of children, frequency of weekly sexual intercourse, the spouse’s education level and awareness about sexual affairs, the period of the spouse’s presence at home was significantly associated with the sexual life quality among the older men participated in the study (p < .05). Finally, Table 5 shows the role of andropause and other independent variables as predictors of sexual life quality. Thirty-six percent of the changes in the quality of sexual life of older men were influenced by the independent variables (adjusted R² = .36; R² = .40; R = .63).

Table 4.

Relationship Between Andropause Syndrome and Quality of Sexual Life Among Older Iranian Men (n = 576).

Variable	M	SD	Maximum	Minimum
Andropause scores	39	16.38	82	0
Sexual quality of life scores	48/86	14.43	66	11
Test	Correlation	r = −.36 Pearson
	Univariate linear regression	r² = .128 p = .001 β = −.26

Table 5.

Evaluation of the Predictive Role of Andropause and Socio-Demographic Correlations Related to the Quality of Sexual Life of Elderly Men Based on Multiple Linear Regression Model.

Predictors	B	SE	Beta	T	P
Constant	26.17	11.72	—	2.23	.000
Andropause	−.57	.07	−.65	−8.23	.000
Age	.56	.11	.30	4.77	.000
Marital status	−6.12	1.92	−.20	−3.18	.002
Health condition	5.04	1.23	.28	4.08	.000
Exercise	−4.02	1.94	−.12	−2.06	.040
Model indicators	Adjusted R 2 = .36; R 2 = .40; R = .63

Discussion

This study aimed to determine the prevalence of andropause and quality of sexual life among older men and its relationship with socio-demographic variables. The results showed a moderate but significant inverse relationship between the two main variables (R = .36, p > 001). Thus, with acceptable confidence, it can be stated that as andropause rises in the elderly, their sexual life quality declines significantly. More precisely, about 13% of changes in sexual life quality scores are affected by andropause (r² = .13). Regarding the significant relationship between andropause and sexual quality of life, the present study results were consistent with several conducted among adult populations (Afsharnia et al., 2016; Novák et al., 2002). Nevertheless, our findings on the prevalence or severity of andropause were inconsistent to some extent with the results of other research (Hakimi et al., 2019; Tajar et al., 2012; Yadav et al., 2019) who reported more severe andropause (7.4% and 19%, respectively), while none of the older adults studied in the present study complained sever levels of andropause syndrome. The moderate degrees of andropause will become a critical concern among half of the participants since they might undergo severe andropause in the coming years if neglected. Public awareness, especially older men’s awareness about the signs and symptoms of andropause, helps the cases cope more effectively and manage their sexual health difficulties through appropriate treatments.

Regarding the variance in results, differences in the age range of the sample group and andropause diagnosis tools can justify the discrepancy between the findings. It is noteworthy that the present study stated mild levels of andropause symptoms among all of the men aged 60 years and older, while the study conducted in Rasht, Iran, reported that 23% of the older adults did not suffer any symptoms of andropause (Afsharnia et al., 2016). Therefore, it can be said that, unlike the symptoms of menopause among women, andropause occurs in men gradually. Hence, many men think that andropause is part of aging, and most of them are not able to diagnose androgen deficiency and therefore do not seek medical help (Novák et al., 2002; Rezaei et al., 2020). Furthermore, due to traditional culture, issues related to men’s sexual relations are considered shameful and taboo in this part of Iran. In such a culture, sexual intercourse is seen as a vital sign of masculinity, and most men with andropause symptoms are reluctant to expose the problem, and some may deny the existence of these changes (Rezaei et al., 2020; Yadav et al., 2019).

Multivariate linear regression indicated that the quality of sexual life and andropause was also affected by age, marital status, health status, and exercise. A significant negative relationship was observed between the sexual quality of life and the severity of andropause (r = −.366, p < .001). As the scores of andropause syndrome increased, sexual quality of life scores decreased (β = −.57). These results are also consistent with the previous studies (Afsharnia et al., 2016; Mousavi et al., 2018; Novák et al., 2002; Rezaei et al., 2020).

Conclusion

Our findings showed that andropause is highly prevalent among the participants. The study also confirmed the results of previous studies on the negative association of andropause with sexual life quality in older men. Further studies are recommended to evaluate the quality of QOL qualitatively and to discover other factors affecting andropause among adult men.