BERKELEY, CA (UroToday.com) - This cross-sectional study was conducted in the National Center for Diabetes, Endocrinology and Genetics (NCDEG) in Amman, Jordan to determine the prevalence of hypogonadism among diabetic and non-diabetic men in Jordan.
A total of 1 717 men aged 30-70 years (1 089 with type 2 diabetes and 628 non-diabetics) were included in this study. Non-diabetic men were selected from accompaniers coming with their diabetic relatives or spouses to NCDEG -- after confirmation of a normal fasting blood sugar in two consecutive days and normal HbA1c. For diabetics, a total 1 089 consecutive diabetic men aged 30– 70 years were included in this study. Subjects with history of hypopituitarism, and chronic debilitating diseases such as renal failure, liver cirrhosis, malignancy, or receiving testosterone replacement therapy were excluded from the study.
During the visit of the participants, their socio-demographic characteristics were collected using a pre-structured questionnaire. Data related to the duration of diabetes, medications, and clinical history including the presence of neuropathy, retinopathy, and coronary artery disease for patients with diabetes were abstracted from medical records. Study participants were asked to complete an Androgen Deficiency in Aging Male (ADAM) questionnaire; A positive response was based on decrease in libido or strength of erections or any 3 nonspecific questions that included decrease in muscle strength, decreased enjoyment in life, fatigability, mood changes, falling asleep after dinner, and loss of height. Fasting early morning venous blood samples were collected for measurement of total testosterone, sex hormone binding globulin (SHBG), follicular stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), HbA1c, total cholesterol, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL), cholesterol, and triglycerides. Total testosterone (TT) was assessed using radioimmunoassay with inter- and intra-assay coefficient of variation 3.6% and 2.4%, respectively and normal detectable level was 1.56–8.77 ng/ml. Free testosterone was calculated from TT and SHBG using the equation of Vermeulen et al.
SHBG was tested by an immunochemiluminometric assay (normal 14.5–48.4 nmol/l). LH, FSH and prolactin were measured by chemiluminescent immunometric assays. Glycosylated hemoglobin (HbA1c) was analyzed using a high-performance liquid chromatography (HPLC) method (Bio-Rad). Total cholesterol, triglyceride, HDL, and LDL were assayed by the automated spectrophotometer, enzymatic colorimetric method, COBAS INTEGRA using commercial kits supplies by Roche Diagnostics. According to the Endocrine Society clinical practice guidelines for androgen deficiency syndromes in adult men, hypogonadism amongst both groups was defined as total testosterone b3.0 ng/ml and calculated free testosterone b5 ng/dl. Symptomatic androgen deficiency was defined as total testosterone < 3.0 ng/ml and calculated free testosterone < 5 ng/dl, in addition to a positive response to ADAM questionnaire. Primary hypogonadism was defined as total testosterone < 3.0 ng/ml and calculated free testosterone < 5 ng/dl with LH < 10 MIU/ml, while secondary hypogonadism was defined as total testosterone b3.0 ng/ml and calculated free testosterone b5 ng/dl with LH ≤ 10 MIU/ml.
In multiple logistic regression, the only variables that remained significantly associated with low total testosterone among diabetics were age, monthly income, BMI, and diabetic neuropathy . Compared to patients in the age group 30–39 years, patients aged 40–49 years (OR = 1.89), 50–59 years (OR = 1.96), and 60–69 years (OR = 2.57) were more likely to have low total testosterone level. Those who had a monthly income of less than 500 JD were more likely to have low total testosterone level (OR = 1.76) than those who had a monthly income of more than or equal to 500 JD. Compared to patients with obesity, those who had BMI b25 kg/m2 and those who were overweight were less likely to have low total testosterone levels. Diabetic neuropathy was associated with increased odds of low total testosterone level. None of the studied factors was significantly associated with low total testosterone level among subjects without diabetes.
One of the limitations of this study was that the testosterone measurement was done only once for the study subjects, due to several feasibility limitations of the study settings. Subjects on glucocorticoids and opiate therapy were not excluded, and this is another limitation of the study. Although our study included a large number of participants, because it was a cross sectional, it is impossible to determine the causality of whether the diabetes preceded or followed the decline of the serum testosterone levels.
In conclusion, hypogonadism is a prevalent disorder among the Jordanian diabetic population in comparison to non-diabetics. Symptoms of androgen deficiency should be corroborated with a low serum testosterone to establish a multidisciplinary approach for management of hypogonadism.
Ayman A. AL Hayek as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
National Center for Diabetes, Endocrinology and Genetics, Amman 11942, Jordan