© Borgis - Postępy Nauk Medycznych 11/2012, s. 843-847
*Michał Rabijewski, Lucyna Papierska, Jarosław Kozakowski, Wojciech Zgliczyński
Ocena przydatności klinicznej zaburzeń libido w rozpoznawaniu hipogonadyzmu późnego u mężczyzn
An assessment of clinical importance of low libido in the evaluation of men with late-onset hypogonadism**
Department of Endocrinology, Medical Centre of Postgraduate Education, Warsaw
Head of Department: prof. Wojciech Zgliczyński, MD, PhD
Cel pracy. Oceniano związki pomiędzy stężeniem testosteronu, libido oraz zaburzeniami wzwodu u mężczyzn z hipogonadyzmem późnym (LOH) oraz zaburzeniami seksualnymi.
Materiał i metody. Badano 334 mężczyzn > 50. roku życia z hipogonadyzmem późnym oraz zaburzeniami seksualnymi (obniżone libido i/lub zaburzenia wzwodu). Badani wypełniali ankiety oceniające funkcje erekcyjne (International Index of Erectile Function – IIEF-5) oraz libido (zmodyfikowany kwestionariusz Brief Sexual Function Inventory = BSFI). Oznaczano stężenia testosteronu całkowitego (TT).
Wyniki. Wiek pacjentów wynosił średnio 64 ± 9,2 lat (od 50 do 78 lat). W badanej grupie 51% miało niskie libido, 37% umiarkowane oraz 12% wysokie libido. Średnie stężenie testosteronu całkowitego wśród pacjentów z niskim, umiarkowanym oraz wysokim libido wynosiło odpowednio 2,4, 2,9 oraz 3,3 ng/mL, a róznice pomiędzy grupami były znamienne statystycznie (p < 0,01). Stwierdzono istotną ujemną korelację pomiędzy wskaźnikiem BSFI a stężeniem testosteronu całkowitego (r = -0,3481, p < 0,05) oraz wskaźnikiem BSFI a wiekiem chorych (r = -3382, p < 0,02). Wykazano również istotną ujemną korelację pomiędzy wskaźnikiem IIEF-5 a stężeniem testosteronu całkowitego (r = -0,3123, p < 0,002) oraz wskaźnikiem IIEF-5 a wiekiem chorych (r = -0,3463, p < 0,02). Wykazane korelacje były istotne po wytrąceniu wpływu wieku i wskaźnika masy ciała (BMI).
Wnioski. Zaburzenia wzwodu są bardziej specyficznym objawem hipogonadyzmu późnego u mężczyzn niż obniżone libido i korelują ujemnie ze stężeniem testosteronu całkowitego. Oznaczanie stężenia testosteronu całkowitego nie jest wystarczającym narzędziem diagnostycznym wszystkich zaburzeń seksualnych u mężczyzn.
Aim. We evaluated the relationship between total testosterone levels, libido and erecrile functions (ED) among men with sexual dysfunction and late-onset hypogonadism (LOH).
Material and methods. 334 men over 50 years with LOH and sexual dysfunctions (low libido and/or ED) were invited to complete the International Index of Erectile Function questionnaire (IIEF-5), as a diagnostic tool for ED and libido was assessed using modified the Brief Sexual Function Inventory questionnaire (BSFI). Serum total testosterone (TT) were measured. Linear regresion model were used to analyze the factors that are associated with sexual dysfunctions and testosterone levels.
Results. Mean patient age was 64 ± 9.2 years (range 50 to 78). Of the men 51% had low, 37% moderate and 12% high libido. Mean serum total testosterone levels among men with low, moderate and high libido were 2.4, 2.9 and 3.3 ng/mL respectively, and differences among means were statistically significant (p < 0.01). There was significant inverse relationship between BSFI score and total testosterone (r = -0.3481, p < 0.05) and BSFI score and age (r = -3382, p < 0.02). Moreover, there was significant inverse relationship between IIEF-5 score and total testosterone (r = -0.3123, p < 0.002) and IIEF-5 score and age (r = -0.3463, p < 0.02). These relationships were significant after adjustment for age and BMI.
Conclusions. Erectile dysfunctions are more specific symptom of late-onset hypogonadism than low libido and correlated negatively with testosterone levels. Total testosterone level is an inadequate measure of sexual dysfunctions in men over 50 years.
Accompanying the aging process are certain critical conditions that are often associated with decreased testosterone, such as decreased sense of well-being, depression, decreased libido and increased erectile dysfunction (ED) (1). Associated with aging decreasing of total testosterone (TT) levels is named Late-Onset Hypogonadism (LOH) (2). Testosterone is a major androgen which is essential for the development and maintenance of male sexual characteristics. However, the physiological role of TT in male sexual behavior is not well understood. Results of several studies about the relationship between TT and sexual behavior have been conflicting or not significant. Probably, the most specific symptoms of this process are ED. However, testosterone deficiency is linked to multiple causes of metabolic syndrome as well as ED and may be a central factor in the pathology of ED (3). Moreover, there is wide individual variability in the threshold of serum TT below which impairment of sexual function becomes evident (4, 5). Testosterone enhance libido in some patient but a causal relationship between altered androgen levels, ED and libido is still discussed (6). Nevertheless, measurement of serum TT level has become standard clinical practice in the evaluation of ED and especially decreased libido.
Moreover, management of LOH is difficult because there is not wide accepted low limit of normal TT levels. Guidelines from the Endocrine Society have defined LOH as a TT level of less than 200 ng/dL. These low levels must occur in conjunction with one or more of the signs and symptoms of hypogonadism (6). In contrast, the American Society of Andrology has stated that symptomatic men with reliable TT levels less than 300 ng/dL should be considered hypogonadal (7) and in recommendations of The International Society for the Study of the Aging Male symptomatic, aged men with reliable TT levels less than 350 ng/dL can be considered hypogonadal (2).
We used modified the Brief Sexual Function Inventory (BSFI) as a validated instrument for assessing libido (8) and the International Index of Erectile Function questionnaire (IIEF-5) as tool to assessing ED to evaluate the relationship between libido, ED and TT levels and clinical importance of low libido in the evaluation of men with LOH.
MATERIAL AND METHODS
Our study included 334 men treated in Department of Endocrinology, Medical Centre for Postgraduate Education in Warsaw with a primary complaint of LOH. LOH was defined as as a TT level of less than 350 ng/dL in conjunction with one or more of the signs and symptoms of hypogonadism like low sex drive (libido), ED or lack of nocturnal erections. We excluded patients with obvious preexisting conditions that strongly contribute to sexual dysfunction, such as diabetes mellitus, renal failure or a history of surgery in the pelvic cavity and, especially patients with insufficiency of hypophysis and primary hypogonadism. Men were also excluded from analysis due to recent or current hormone replacement therapy at the time of evaluation, noncompletion of the questionnaire and unavailable or missing testosterone results. Obesity is defined as a body-mass index (the weight in kilograms divided by the square of the height in meters) of 30 or more. Hyperlipidemia was considered to be present if the participant reported having received the diagnosis or if he was receiving medication for the condition.
Patient age was over 50 years (from 50 to 78 years; mean age 64 ± 9.2 years). Erectile function was assessed according to the International Index of Erectile Function (IIEF-5). Possible scores on the IIEF-5 are 1 to 25 and erectile dysfunction was classified into 5 categories based on the scores, namely severe – 1 to 7, moderate – 8 to 11, mild to moderate – 12 to 16, mild – 17 to 21 and none – 22 to 25. Libido (sexual drive) was assessed according to the Brief Sexual Function Inventory questionnaire (BSFI) and scores were categorized as low – 0 to 3, moderate – 4 to 4 or high – 6 to 8.
Blood samples were collected between 8:00 and 9:00 a.m. Endocrinological data including luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin (PRL) – using Immulite 2000; DPC United States kids, TT – using Coat-a-Coat; Siemens United States kids – were evaluated. TT, LH and FSH were measured by radioimmunoassay and prolactin was measured by chemiluminescent immunometric assay.
Statistical analysis was performed using Statistica software. The p values were calculated with the use of Fisher’s exact test and Student’s t-test. Plus-minus values are means ±SD. All relationships were assessed by linear univariate and multivariate regression analysis to determine factors which affected the testosterone levels and to reduce bias in a cross-sectional study.
A total of 334 men with LOH and sexual dysfunctions were evaluated in the study. Mean patient age was 64 ± 9.2 years (range 50 to 78). All men had their TT, LH, FSH and PRL levels checked at least once. Of the 334 men, 8% had TT levels < 200 ng/dL, 22% – 200-250 ng/dL, 32% – 250-300 ng/dL and 37% – 300-350 ng/dL. Mean TT concentration was 3.05 ± 0.25 ng/mL. Mean LH and FSH levels were just below high limits of normal range and mean prolactin levels were in normal range. Hormones levels are shown in table 1.
Table 1. Mean hormones levels and percentage of patients in four cutpoints of TT levels and in all patients.
| ||Total testosterone levels|
|< 200 ng/dL||200-250 ng/dL||250-300 ng/dL||300-350 ng/dL||All patients|
|No. pts. (%)||29 (8)||72 (22)||109 (33)||124 (37)||334 (100)|
|Total testosterone (ng/dL)||1.64 ± 0.2||2.35 ± 0.19||2.73 ± 0.22||3.26 ± 0.21||3.05 ± 0.25|
|LH (IU/L)||7.2 ± 0.75||6.5 ± 0.6||6.1 ± 0.6||6.4 ± 0.8||6.6 ± 1.2|
|FSH (IU/L)||7.4 ± 1.1||7.1 ± 0.8||6.5 ± 0.9||6.7 ± 0.7||6.8 ± 0.9|
|Prolactin (ng/mL)||14 ± 3.7||12.1 ± 2.9||15.3 ± 3.7||12.3 ± 3.8||12.3 ± 3.5|
Of the men 51% had low, 37% moderate and 12% high libido according to BSFI questionnaire (fig. 1a). Mean serum TT levels among men with low, moderate and high libido were 2.4 ± 0.3, 2.9 ± 0.4 and 3.3 ± 0.5 ng/mL respectively, and differences among means were statistically significant (p < 0.01) (tab. 2). LInear regression analysis showed that there was significant inverse relationship between BSFI score and TT (r = -0.3481, p < 0.05) and BSFI score and age (r = -3382, p < 0.02).
Fig. 1. The prevalence (%) of low, moderate and high libido according to BSFI score (a) and mild, mild to moderate, moderate and severe ED according to IIEF-5 score (b) in all patients.
Table 2. TT levels and degree of libido according to BSFI score in four cutpoints of TT levels and in all patients.
| ||BSFI score|
|< 200 ng/dL||29||1.5 ± 0.2||1.8 ± 0.2||No patients|
|200-250 ng/dL ||72||2.1 ± 0.1||2.3 ± 0.2||No patients|
|250-300 ng/dL ||109||2.6 ± 0.2||2.8 ± 0.1||2.85 ± 0.1|
|300-350 ng/dL ||124||3.1 ± 0.2||3.2 ± 0.2||3.4 ± 0.1|
|All patients||334||2.4 ± 0.3||2.9 ± 0.4||3.3 ± 0.5*|
*significant differences between all groups (p < 0.01). variables of BSFI score and TT (r = -0.3481, p < 0.05) variables of BSFI score and age (r = -3382, p < 0.02).
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