The severity of andropause symptoms and its relationship with social well-being among retired male nurses: a preliminary cross-sectional study

Background Andropause is a syndrome that occurs due to decreased androgen levels in men. Various aspects of health, such as social well-being, can affect andropause status during men’s retirement. This study aimed to determine the severity of andropause symptoms and its relationship with social well-being among retired male nurses. Methods This preliminary cross-sectional study was conducted on 284 retired male nurses in Ardabil (northwest of Iran). The participants were selected through the census sampling method. Data were collected using a demographic information form, the Male Andropause Symptoms Self-Assessment Questionnaire (MASSQ), and the Social Well-Being Scale (SWBS). Data were analyzed using SPSS software (version 22.0). Results The study found that the overall mean scores of the severity of andropause symptoms and social well-being among retired male nurses were 57.24 ± 12.62 (range = 35–91) and 94.54 ± 12.77 (range = 75–123), respectively. The highest and lowest mean scores between dimensions of social well-being were related to social contribution (20.26 ± 2.47) and social acceptance (15.26 ± 2.77), respectively. Multiple linear regression analysis revealed that subscales of social well-being, age, marital status, and spouse’s menopause were predictors of the severity of andropause symptoms among retired male nurses. The selected predictors accounted for 53.1% of the total variance in severity of andropause symptoms (F = 36.613, p < 0.001). Conclusion The results showed a moderate to severe prevalence of andropause among retired male nurses and a significant association between andropause and social well-being. The study suggests further research to examine sexual orientation and other factors that may affect andropause in retired male nurses.


Background
Nursing is a stressful job, and nurses are exposed to physical, mental, sexual, and social disorders due to exposure to various stresses such as high levels of work pressure, individual conflicts, rotational shifts, exposure to mortality, and lack of psychological support [1][2][3].The National Association of Safety Professionals (NASP) has introduced nursing as one of the top 40 professions with a high severity of workplace-related disorders [4].Evidence suggests that psychosocial stress related to the workplace may affect sexual function and androgen levels [5].Kumar et al. [6] showed that the severity of sexual dysfunction was significantly higher in male nurses who endured stressful conditions in COVID-19-related wards than in those working in other departments.Pastuzak et al. [7] showed that men with non-standard working hours who do not have enough sleep and rest undergo decreased libido, increased hypogonadal symptoms, and sexual dysfunction.Güzel and Döndü [8] also reported that increased anxiety caused by the nursing work environment and a decrease in time spent with a spouse can cause sexual dysfunctions and even andropause in male nurses.Therefore, long-term work environment stress can affect different aspects of the social life of nurses and their family members and cause work-related family conflicts.
As a result of aging in men and physiological changes in the Hypothalamus-Pituitary-Gonadal (HPG) axis, plasma androgen levels decrease [9].The gradual decrease in plasma testosterone level associated with symptoms of androgen deficiency is called andropause or Late-onset Hypogonadism (LOH) [10,11].Testosterone levels drop by approximately 0.4-2.6% per year after age 40 [12].Testosterone levels at age 75 reach less than half of their amount compared to a healthy man between the ages of 20 and 30 [13,14].The severity of andropause varies among men in different parts of the world.Goel et al. [15] found the severity of andropause symptoms to be 11.6% in Indian men, and Araujo et al. [16] reported a severity rate of 5.6% in Spanish men.Khosravi et al. [17] showed the severity of andropause symptoms was 51.5% in Iranian men, and 3.5% of participants suffered from severe symptoms.The severity of andropause symptoms among Iranian nurses, especially retired nurses, has been less investigated.In a study conducted in northern Iran, the severity of sexual dysfunction in emergency male nurses was 40% [2].
Andropause is usually a hidden threat to men's lives after the age of 40, and its clinical manifestations and symptoms are initially asymptomatic [18].However, it is somewhat difficult to determine the specific range at which testosterone levels reach below the defined threshold level [19].In general, as a result of lower testosterone levels, men may experience a range of symptoms, including decreased physical strength, weight gain, depressed mood, concentration disorder, decreased libido, muscle atrophy, insomnia, and hot flashes [20][21][22].Although most of these symptoms are non-specific, their severity may vary in different people.Among the side effects of decreasing testosterone due to aging are the risk of metabolic diseases, diabetes mellitus, cardiovascular diseases, osteoporosis, hypertension, hyperlipidemia, decreased physical performance, and kidney diseases [22].
Trinick et al. [23] indicated a significant number of men suffer from hypogonadism, which does not have a definite diagnosis or treatment in scientific sources.Despite the importance of early diagnosis and treatment, several factors, such as the social environment and various aspects of health, such as mental health and social wellbeing, can negatively affect andropause in men during retirement [24][25][26].Tan et al. stated the social environment can have a significant effect on men's experiences of andropause.A supportive social environment can help men cope with the physical and emotional changes associated with andropause.In contrast, social norms, social isolation, and social stigma can exacerbate the adverse effects of this condition [27].
Social well-being (SWB) is considered one of the most important aspects of health in people's lives [28].SWB is one's perceptions and experiences in social situations and their successful response to social challenges [29].Physical, mental, emotional, and physiological disorders are less common in people with a high level of SWB [30][31][32].Omidi and Rad [33] showed a significant correlation between SWB and marital adjustment.Therefore, various factors such as socioeconomic status, type of job, work environment, age, and social support can affect SWB [34,35].Cho et al. [36] showed that the hospital environment can influence health.Taheri et al. [37] reported the SWB status of Iranian healthcare providers, especially nurses, was moderate.
Andropause is a complex issue that is affected by several risk factors.Therefore, studies on the social dimensions determining andropause in Iran are insufficient.Previous studies have also considered the necessity of assessing nurses' health status during the transition to retirement due to challenging factors [38,39].Therefore, conducting research such as this study to determine the severity of andropause symptoms in retired male nurses and its correlation with social well-being can play a role in filling the gap in the literature.

Design and participants
A preliminary cross-sectional study was conducted in Ardabil province in northwest Iran, following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [40].
The inclusion criteria were having no psychiatric disorders, taking no psychotropic medications (as selfreported by the participants), and retiring from one of the hospitals affiliated with Ardabil University of Medical Sciences.The exclusion criteria were lack of inclination to participate in the study, incomplete filling of questionnaires, and employment in private centers.

Data collection
Data were collected from March to May 2022 using a census sampling method.The researchers went to Ardabil's retirement centers.After stating the purpose of the study and obtaining permission from the relevant officials, they received the information of the retired nursing men (phone number, address, and Email).Based on this, telephone calls were made to establish an initial agreement (according to a similar protocol) with each selected individual.Then, after explaining the purpose of the study and obtaining informed consent, the questionnaire link was sent to each participant privately.So, all of them (309 people) agreed to participate in the study.
Data were collected using a demographic information form (including age, marital status, education level, underlying diseases, spouse's menopause, and the number of children) and the Male Andropause Symptoms Self-Assessment Questionnaire (MASSQ) and Social Well-Being Scale (SWBS).The questionnaires were designed with web-based software, sent to the participants via Email and virtual networks (e.g., WhatsApp), and then completed and self-administered.A total of 284 participants completed the questionnaires.The response rate to the questionnaires was 91%.

Male andropause symptoms self-assessment questionnaire (MASSQ)
The MASSQ consisted of 25 items [41].The items are rated on a five-point Likert scale.Each item was given a score from 1 (none) to 5 (severe).The overall scores of this scale ranged from 25 to 125, indicating no symptom to most severe symptom, respectively.The validity and reliability of this questionnaire among the Iranian population were assessed by Asadollahi et al. [41], with Cronbach's alpha of 0.89 for the whole scale.The Cronbach's alpha of the questionnaire in this study was calculated to be 0.81.

Social well-being scale (SWBS)
The Keyes SWBS (1998) [42] consisted of 33 items and five subscales, including social contribution (6 items), social cohesion (6 items), social acceptance (7 items), social integration (7 items), and social actualization (7 items).The questionnaire was scored on a 5-point Likert scale ranging from completely disagree (1) to completely agree (5).The range of scores obtained from this scale was 33 to 165, and higher scores indicated higher social well-being.The validity and reliability of the Persian version of this scale among the Iranian population were assessed by Nemati et al. [43], which showed satisfactory internal consistency (0.84) using Cronbach's alpha.The Cronbach's alpha of the scale was calculated to be 0.85 for this study.

Data analysis
The data were analyzed using SPSS software version 22.0 (SPSS Inc., Chicago, IL, USA) using descriptive statistics (frequency, percentage, mean, and standard deviation).To investigate the relationship between participants' andropause status, demographic variables, and social well-being, we used independent-sample t-test and Pearson's correlation coefficient.Before performing the tests, the normality of the data distribution was checked using the one-sample Kolmogorov-Smirnov test (p > 0.05).Andropause predictors were determined using the Enter method of multiple linear regression.It should be noted that the data were investigated for linearity relationship assumptions, multivariate normality, independence of residuals, and multicollinearity before using multiple linear regression.The level of significance was considered to be 0.05.

Ethical considerations
The proposal of this study was approved by the ethics committee of Ardabil University of Medical Sciences with the ethics code IR.ARUMS.REC.1400.321.No intervention was done on the participants, and doing this study was not dangerous for them.This study observed ethical considerations such as obtaining informed consent from the participants, principles of confidentiality, anonymity, and confidentiality of information.

Results
A total of 284 retired male nurses participated in this study.The mean (SD) age of the participants was 58.41 (3.76) years.Almost one-third of the participants had an underlying disease (n = 94, 33.1%), and the education level of most of them (n = 266, 93.7%) was bachelor's degree.The demographic characteristics of the participants are summarized in Table 1.
Table 2 identifies the relationship between demographic characteristics and the severity of andropause symptoms.There was a significant statistical correlation between The severity of andropause symptoms and certain demographic variables, such as age (r = 0.123, p < 0.001), marital status (t = -1.910,p > 0.001), spouse's menopause (t = -8.279,p < 0.001), and underlying diseases (t = -1.187,p = 0.046).The results revealed that older retired male nurses had higher severity of andropause symptoms, and single retired male nurses scored higher than married retired male nurses.Participants whose spouses had gone through menopause also had higher scores.In addition, people with underlying diseases also scored higher.
The mean scores for the MASSQ and SWBS as well as their subscales are presented in Table 3.The mean (SD) of SWB was 94.54 (12.77) and that of andropause status was 57.24 (12.62).Social contribution with a mean (SD) of 20.26 (2.47) and social acceptance with a mean (SD) of 15.26 (2.77) obtained the highest and the lowest scores, respectively (Table 3).
To explain the andropause status of the participants, the Enter method of multiple linear regression analysis was performed.The results showed that the participants' andropause status was determined by age, marital status, spouse's menopause, and subscales of SWB (social integration, social actualization, and social acceptance).These variables could predict 53.1% of the andropause variance (Table 4).

Discussion
The nursing profession is one of the occupations that disrupts nurses' life cycle due to high work pressure and may damage their sexual health after retirement.This study investigated the correlation between andropause status and social well-being in retired male nurses.
The severity of andropause symptoms in retired male nurses was moderate to severe, which is comparable to previous studies.In a survey conducted in the north of Iran by Samipoor et al. [19] using the Aging Male Symptoms (AMS) scale, 73.6% of men over 40 years (age range: 40 to 76) experienced andropause symptoms.
Using the Brief Sexual Function Inventory (BSFI), Mohammadian and Dolatshahi [44] showed that the severity of erectile dysfunction in Iranian men living in Tehran was 40.4%, premature ejaculation was 32.5%, and libido disorder was 10.6%.Ebrahimian et al. [2] also used the Men's Erectile Performance Questionnaire and showed that the severity of sexual dysfunction in emergency male nurses was 40%.In addition, studies conducted in other countries showed that the severity of andropause symptoms using ADAM and AMS questionnaires was 75.3% in South Korea and 70.94% in Indonesia, respectively [45,46].
The mean score of andropause symptoms in this study was 57.24 (12.62).The findings were similar to those of other studies conducted in Iran by Rezaei et al. [11] and Hakimi et al. [47] using the MASSQ questionnaire, with mean scores of 57.46 (17.56) and 53.7 (9.9), respectively.However, Çetin [48] in Turkey showed that the mean score of andropause symptoms based on the MASSQ questionnaire among men 40 to 70 was 42.33 (13.47).This finding indicates that the severity of andropause symptoms in retired male nurses is almost the same as other men in Iranian society.Perhaps the difference between the results of the studies is due to the different conditions of the research environment and the lower sample size (125 men) compared to this study (284 men).Hence, the current survey as a preliminary study showed that moderate degrees of andropause will become a critical  concern among the participants because, if neglected, they may experience severe andropause in the years to come.Public awareness, especially awareness among retired male nurses about the signs and symptoms of andropause, will help patients manage their sexual health problems with more appropriate treatments.
The results of this study indicated moderate SWB among the participants, which was 94.54 (12.77), which is in line with previous studies.In the study of Mozaffari et al. [28] conducted on Iranian nurses, the SWB was moderate, equal to 105.45 (15.87).In a study conducted on military retirees, the social well-being of the study group was desirable [35], which is in line with the present study's findings.Nevertheless, in the study conducted on Iranian caregivers, the mean score of SWB was 62.28 (11.22), and the SWB score of nurses as the largest subgroup was 62.02 (10.67) [37].Farahaninia et al. [49] also reported an SWB score of 67.32 (8.96) for nurses.In addition, a study in China on elderly people aged 60 to 89 years old showed the mean SWB score was 44.07 (6.69) [50].The difference between the SWB mean scores among the studies may be due to the use of the short form of SWBS and the participants' sociocultural differences.Accordingly, Salehi et al. [51] showed a statistically significant relationship between the nurses' psychosocial health and job performance.In fact, it can be inferred that people with high SWB can more successfully cope with the challenges of playing the main roles.Hence, they are likely to be able to participate more in the family and community and adapt more to social norms.
The current study's findings indicated a significant relationship between andropause symptoms and age.The severity of andropause symptoms increased with age.This finding was consistent with the results of previous studies [19,[52][53][54].The results of studies have shown that a gradual decline in serum testosterone levels after the age of 50 can affect sexual function and sexual satisfaction [55,56].However, this finding was different from the results of Khosravi and Samipoor et al. [57,58].Perhaps the conflicting findings were due to the difference in the participants' occupations and the instruments used to assess andropause symptoms.
Marital status was one of the effective and predictive factors for the severity of andropause symptoms.Married men had fewer andropause symptoms than single men.The results of a study in Kuwait on men aged 40 years and older showed a significant relationship between men's awareness of andropause symptoms and marital status [53].In contrast, the findings of Afsharnia et al. [54] were not consistent with the findings of this study.Andropause symptoms in men may be influenced by sexual relationships and satisfaction with the spouse's behaviors.Further studies are needed to increase the generalizability of these findings.
Participants' andropause symptoms were significantly associated with their spouse's menopause.Rezaei et al. 's study results were also consistent with our findings [11].Menopause in women is mainly associated with physical, mental, and sexual changes [59].On the other hand, andropause in men may occur at the same time as their spouse's menopause.The coincidence of andropause with menopause can be associated with a decrease in the quality of marital relationships and exacerbation of andropause symptoms in men [59], which confirms the findings of our study.
The linear regression model results showed that the underlying disease was not related to the participants' andropause symptoms.The findings of previous studies were consistent with our results [2,60].A review also showed that testosterone replacement therapy does not affect cardiovascular diseases [61].However, Rezaei et al. [11] showed that andropause scores were associated with depression, coronary heart disease, and urinary incontinence.Previous studies have indicated a relationship between decreased testosterone levels and chronic diseases such as hypertension, cardiovascular diseases, and mental disorders [17,62,63].These differences seem to be due to the different research communities and their work stress level.Further experimental studies The study results also showed an inverse relationship between andropause symptoms and SWB among retired male nurses.Comparing the results of this study with those of previous studies is somewhat difficult, as no studies have examined the relationship between andropause symptoms and the SWB status of retired nurses.According to a survey conducted in the United States on patients with brain tumors, the sexual function of patients was inversely correlated with their social wellbeing.The researchers attributed the finding to the type of brain tumor and its region [64].A study conducted in South Korea on the health-related quality of life in prostate cancer patients receiving androgen deprivation therapy (ADT) showed the lowest mean score for the social well-being subscale.The researchers suggested that given the limited evidence, the effect of culture on the SWB of men receiving ADT should be specifically considered [65].The findings of these two studies confirmed the results of the current study.It should be noted that the social integration, social actualization, and social acceptance subscales were the predictors of andropause symptoms, which is a new finding among retired male nurses.A study conducted in Indonesia on the relationship between sexual health and different aspects of health showed that social integration was one of the factors affecting sexual health [66].
As a preliminary study, these results suggest that more research is needed to fully understand the relationship between andropause symptoms and SWB among retired male nurses.Future studies are suggested to examine SWB and spouse's menopause.

Limitations
This research had some limitations.One of the limitations of this study was its cross-sectional nature, which constrained the interpretation of the causal relationship between the variables.Longitudinal and experimental studies are suggested to measure blood androgen levels to understand the causal relationship between the variables and explore more useful information about andropause.Furthermore, using a self-administered questionnaire to assess andropause symptoms may be another limitation of this study.Since andropause is an important issue, some participants may not have answered the questions accurately enough.Nevertheless, the current study's design was based on the population of retired male nurses, and the participants were selected by census sampling method, which is considered its strength.Therefore, it is possible to generalize the results to the whole population of retired male nurses.

Conclusion
In general, the findings of this study showed that SWB is an essential determinant of andropause symptoms in retired male nurses, and some background variables are effective in increasing the severity of andropause symptoms, including age, marital status, and spouse's menopause.Accordingly, the relatively moderate to severe severity of andropause in the Iranian elderly population, especially retired nurses, highlights the necessity of improving social conditions.In other words, strategies affecting the promotion of SWB, especially in dimensions that predicted andropause symptoms, should be developed and implemented.Nursing managers can consider these results to improve the SWB of retired nurses by planning and providing the necessary measures.Hence, assessing the severity of andropause symptoms and the SWB status of retired male nurses in other regions can provide useful information.In addition, more studies are recommended for the paraclinical evaluation of andropause and the discovery of other factors affecting it in retired male nurses.

Table 1
Demographic characteristics of the participants (n = 284)

Table 2
Association between the participants' characteristics and the severity of andropause symptoms (n = 284) Note.Correlation is significant at the p < 0.05.aResults of Pearson's correlation coefficient (r).b Results of the independent-sample t-test.

Table 3
Mean (SD) of social well-being and andropause status (n = 284)

Table 4
Linear regression analysis coefficients to examine predictors of andropause (n = 284)