Psychotherapy Bulletin

Psychotherapy Bulletin

The Psychology of Hypogonadism

Silencing the Stigma

Clinical Impact Statement: Hypogonadism is a little-known endocrine disorder with wide-ranging psychological and physical impacts. This review of the literature offers a general overview of the condition, and it also offers some suggestions for therapeutic interventions.

Abstract


Hypogonadism is a little-known endocrine condition that is not easily noticed by psychologists and other medical professionals.  The disease can have a strong psychological and physical impact upon those who contend with it.  This paper offers an overview of the condition and suggests some interventions for clinicians who work with the patients who have it.  Hypogonadism occurs when the body fails to produce the necessary amount of sex hormones, and this lack of hormone production has a wide range of effects on the mind and the body alike.  Additionally, there is often a stigma attached to the condition.  As such, psychologists and other mental health professionals should be aware that clients may experience some discomfort when discussing or disclosing their hypogonadism.

 The Psychology of Hypogonadism: Silencing the Stigma

Description of the Condition

Hypogonadism, a chronic endocrine disorder, occurs when the body does not produce the necessary amount of sex hormones.  Both males and females contend with this condition.  When males fail to produce enough testosterone or when females do not create an appropriate amount of estrogen, then they have hypogonadism (Basaria, 2014; Sargis & Davis, 2018).  Patients can have one of two types of hypogonadism.  The first type, primary hypogonadism, indicates that a physical problem exists with the testes in men or with the ovaries in women, as these are the structures responsible for producing testosterone and estrogen, respectively.  The second type of hypogonadism, secondary hypogonadism, indicates that another area of the body, such as the pituitary gland, has malfunctioned while it tries to support the production of sex hormones.  In a twist that can further complicate patients’ feelings about the condition, it is not unusual for patients not to know whether their hypogonadism is primary or secondary.  Frequently, it proves impossible to pinpoint the exact causes of the disorder (Basaria, 2014; Sargis & Davis, 2018).

Hypogonadism can strike anyone, and it has surprisingly wide-ranging implications for the patients who have it (Sargis & Davis, 2018).  The only way for physicians to know that a patient actually has hypogonadism is to have them undergo a blood test that looks for lower levels of testosterone in males and lower levels of estrogen in females (Basaria, 2014).  Despite this easy detection method, hypogonadism is a complex disorder with a deep psychological impact.  Patients can experience infertility, which is oftentimes how the condition is discovered in younger adults (Lee & Ramasamy, 2018; van den Akker, 2012).  The condition frequently masquerades as Major Depressive Disorder and those who have it experience the same brain fog and difficulty concentrating that those with depression do (Smith et al., 2017; Zitzmann et al., 2012).  Additionally, individuals with hypogonadism often experience a decreased sex drive and an overall loss of energy.  In males, night sweats and hot flashes are common (Llaneza, 2017).

Not only can hypogonadism create psychological difficulty for those who have it, but also, it can put significant physical challenges in a person’s way.  For example, men may develop osteoporosis, have weaker muscles, and decreased growth of facial hair (Goldset et al., 2017; Grotts et al., 2018).  Physical problems are especially prevalent if especially if an individual develops the condition before puberty.  For instance, it is possible that a boy’s voice may not deepen, or an individual may present physically as neither obviously male nor obviously female (Hewitt & Warne, 2009; van den Akker, 2012).  These challenges can negatively impact a person’s self-esteem, self-image, and overall sense of well-being (Sargis & Davis, 2018).  As such, health psychologists can play a critical role in improving the lives of patients with hypogonadism.

Hypogonadism: Implications for Psychology

When viewed through a psychological lens, one can readily see that hypogonadism impacts many facets of the lives of those who contend with it.  The condition impacts different people in a variety of ways, and it is possible for two people to have the same type of hypogonadism but display their symptoms differently.  Additionally, children and teenagers with hypogonadism face a different set of psychosocial pressures and concerns than older adults with the condition do (Hewitt & Warne, 2009; Korenman et al., 2018; Wu et al., 2010).  For example, teenagers going through puberty may not develop as secondary sex characteristics as quickly as their same-aged peers (Hewitt & Warne, 2009) while older people’s only visible symptom may be muscle weakness, which is a symptom that does not necessarily suggest hypogonadism (Korenman et al., 2018).  Health psychology reminds medical professionals to remember that the developmental stage can impact how a person responds to the psychosocial impact of hypogonadism.  No matter what age they happen to be, patients with hypogonadism often experience “feelings of isolation, shame, and alienation” (Dwyer et al., 2019, p. 1) for two major reasons.

One such reason that patients struggle with the psychological effects of hypogonadism is that the condition is not terribly well-known, even among medical professionals. Dwyer et al. (2019) observed that individuals with hypogonadism “often experience a ‘diagnostic odyssey’ including incorrect diagnoses, incomplete information, delays in finding expert care…and misleading or frankly incorrect advice along the way…Such experiences can significantly erode patient confidence in healthcare providers…and affect quality of life” (p. 3).  Given the frustrating nature of this condition, it makes sense that health psychologists should intervene to help people to cope with it.

Another reason that individuals with hypogonadism have a difficult time getting the appropriate care is that a social stigma is attached to the condition (Orshan et al., 2009).  Hypogonadism encompasses some of the most intimate areas of an individual’s life.  For example, individuals may worry that others will question their gender or sexual identity if they reveal their personal struggles with the condition; people with hypogonadism may feel concerned that they will be judged negatively if others learn of their fertility problems (Dwyer et al., 2015).  Additionally, hypogonadism has a major effect on mood, and a stigma still exists around mood disorders (Turriff et al., 2011).  As such, individuals with hypogonadism frequently contend both with the stigma of having a mental health condition and the dual stigma of having a disorder linked to sexual characteristics (Barag et al., 2019; Orshan et al., 2009; Sumko et al., 2014).

Interventions for Treatment

When it comes to working with clients with hypogonadism, psychologists have the opportunity to implement a variety of interventions simply because patients display the condition in a variety of ways. Four of the most common components of the disease include infertility, obesity, mood dysregulation, and difficulty concentrating on tasks (Etoga et al., 2019; van den Akker, 2012).  These are seemingly disparate symptoms; yet, psychology offers tools for dealing with all of them. As such, health psychology interventions relating to these symptoms can directly benefit patients with hypogonadism.  Furthermore, to contend with hypogonadism successfully, patients need health psychologists to give them education about the physical and psychological effects of this chronic condition.

Psychologists can help patients comply with the prescribed medication regimens, which prove critical in the treatment of this disorder. Males with hypogonadism are prescribed testosterone, which can come in a variety of forms, including injections (Korenman et al., 2018). Females with the condition are usually prescribed estrogen, which usually comes in pill form. Adherence to medication is important for hypogonadism patients, as missed doses of medication can undo progress in treatment (Korenman et al., 2018; Schoenfeld et al., 2013). Additionally, since hypogonadism patients often cope with comorbid mood disorders, physicians often prescribe antidepressants for them (Khera et al., 2011; Walther et al., 2019).  As such, medications must be managed carefully and monitored for side effects.

While medication adherence certainly helps treat the disorder, it is not enough to treat its psychological effects. Weight loss is one intervention that can help patients with hypogonadism to begin to feel better.  Damas-Fuentes and Tinahones (2018) suggested that patients contending with hypogonadism adopt an exercise regimen; make dietary changes; and consider bariatric surgery if necessary.  Corona et al. (2013) observed that “hypogonadism can be considered as one of the many adverse consequences of…obesity.  Body weight loss and lifestyle interventions should be the first approach offered to obese hypogonadal men” (p. 168).  Especially for men, weight loss is a highly recommended intervention for patients with hypogonadism.  Weight loss can increase the amount of testosterone that a man produces (Damas-Fuentes & Tinahones, 2018).  Losing weight can also help patients to avoid sleep apnea, which often accompanies both obesity and hypogonadism (Carrageta et al., 2019; Corona et al., 2013).

Individuals with hypogonadism often struggle with body image issues (Dwyer et al., 2015) and see themselves as having less social support than people without hypogonadism do (Orshan et al., 2009).  As such, group psychotherapy can help people to feel less isolated and more connected with others who have the same condition.  Dwyer et al. (2015) found that: “Conducting patient focus groups brought together isolated patients and provided them an opportunity to discuss…problems, share experiences, and seek support” (p. 39).  A psychoeducational group that deals with the psychosocial impact of hypogonadism would have a beneficial effect on those who participate in it, especially if the group is conducted by a health psychologist who is qualified to educate patients about hypogonadism.

In addition, health psychologists can help clients with hypogonadism to combat the cognitive fog, which usually accompanies the condition (Lasaite et al., 2013).  Psychologists can teach patients with hypogonadism how to employ simple strategies, such as time management techniques and list-making skills, in order to be more organized and focused (Lasaite et al., 2013).  Although these practices designed to improve executive functioning seem elementary, they can help people to feel more successful in the present and more in control of their plans for the future.

Summary

Patients being treated for hypogonadism are coping with a complicated chronic condition with symptoms that vary from person to person.  Health psychologists can help patients with hypogonadism to cope with a set of symptoms that prove simultaneously psychologically distressing and physically painful.  Not only can health psychologists assist patients with the day-to-day concerns associated with the condition, but also, they can provide specific interventions for some of the major challenges posed by the disease.

Psychologists prove integral to integrated care, as they help with the adjustment to a condition and the alterations in identity that come with having a significant illness.  Psychologists possess a powerful platform for reducing the stigma associated with the disease.  Perhaps most importantly, psychologists can also bridge a chasm between patients and their doctors when they speak about hypogonadism, which is a disease that is often unfamiliar to all parties involved.

Cite This Article

Duberstein, A. (2020). The psychology of hypogonadism: Silencing the stigma. Psychotherapy Bulletin, 55(4), X-X.

References

Barag, S. H., Meshefedijan, T., Yim, J., & Wilson, A.  (2019). Current hypogonadism treatment options. Osteopathic Family Physician, 11(2), 579. https://ofpjournal.com/index.php/ofp/article/view/579.

Basaria, S.  (2013).  Male hypogonadism.  Lancet, 383.  1250-1263. https://doi.org/10.1016/S0140-6736(13)61126-5

Carrageta, D. F., Oliviera, P. F., Alves, M. G., & Montiero, M. P.  (2019).  Obesity and male hypogonadism: Tales of a vicious cycle.  Obesity Reviews, 20(8), 1148-1158 https://doi.org/10.1111/obr.12863

Corona, G., Rastrelli, G., Monami, M., Saad, F., Luconi, M., Lucchese, M.,…& Maggi, M. (2013). Body weight loss reverts obesity-associated hypogonadotropic hypogonadism: A systematic review and meta-analysis.  European Journal of Endocrinology, 168, 829-843. https://doi.org/10.1530/EJE-12-0955

Damas-Fuentes, M., & Tinahones, F.  (2018).  Secondary male hypogonadism: A prevalent but overlooked comorbidity of obesity.  Asian Journal of Andrology, 20(6), 531. https://doi.org/10.4103/aja.aja_44_18

Dwyer, A. A., Quinton, R., Pitteloud, N., & Morin, D.  (2014).  Sexual Medicine, 3, 32-41. https://doi.org/10.1002/sm2.50

Dwyer, A. A., Smith, N., & Quinton, R.  (2019).  Psychological aspects of congenital hypogonadotropic hypogonadism, Psychological Aspects of Congenital          Hypogonadotropic Hypogonadism, 10(353), 1-9. https://doi.org/10.3389/fendo.2019.00353

Golds, G., Houdek, D., & Arnason, T.  (2017).  Male hypogonadism and osteoporosis: The effects, clinical consequences, and treatment of testosterone deficiency in bone health. International Journal of Endocrinology, 46(2), 1-16. https://doi.org/10.1155/2017/4602129

Etoga, M. C. E., Akwa, G., Boli, A. O., Jingi, A. M., Katte, J. N., Ngambou, N. S. N.,…Sobngwi, E. (2019). The clinical and psychological profiles of patients with hypogonadism, followed in three reference hospitals of Cameroon: An observational study.  Pan-African Medical Journal, 22, 33-47.  https://doi.org/10.11604/pamj.2019.33.47.18352

Hewitt, J. K., & Warne, G. L. (2009). Management of disorders of sex development. Pediatric Health, 3(1), 51-59. https://doi.org/10.2217/17455111.3.1.51

Khera, M., Bhattacharya, R. K., Blick, G., Kushner, H., Nguyen, D., & Miner, M. M.  (2011). The effect of testosterone supplementation on depression symptoms in hypogonadal men from Testim Registry in the US. The Aging Male, 15(1), 14-21. https://doi.org/10.3109/13685538.2011.606513

Korenman, S. G., Grotts, J. F., Bell, D. S., & Elashoff, D. A.  (2018). Depression in nonclassical hypogonadism in young men. Journal of the Endocrine Society, 2(11), 1306-1313. https://doi.org/10.1210/js.2018-00137

Lasaite, L., Ceponis, J., Preiska, R. T., & Zilaitiene, B.  (2013).  Impaired emotional state, quality of life, and cognitive functions in young hypogonadal men. Andrologia, 46(10), 1107-1112. https://doi.org/10.1111/and.12199

Lee, J. A., & Ramasamy (2018). Indications for the use of human chorionic gonadotropic hormone for the management of infertility in hypogonadal men. Translational Andrology and Urology, 7(3), S348-S352. https://doi.org/10.21037/tau.2018.04.11

Llaneza, P.  (2017). Clinical symptoms and quality of life: Hot flashes and moods. In A. Cano (Ed.), Menopause (pp. 69-78). Springer. https://doi.org/10.1007/978-3-319-59318-0_4

Orshan, S. A., Ventura, J. L., Covington, S. N., Vanderhoof, V. H., Troendle, J. F., & Nelson, L. M. (2009). Women with spontaneous 46, XX primary ovarian insufficiency        (hypergonadotropic hypogonadism) have lower perceived social support than control women.  Fertility and Sterility, 92(2), 688-693. https://doi.org/10.1016/j.fertnstert.2008.07.1718

Sargis, R. M., & Davis, A. M.  (2018).  Evaluation and treatment of male hypogonadism. Journal of the American Medical Association, 319(13), 1375-1376. https://doi.org/10.1001/jama.2018.3182

Schoenfeld, M. J., Shortridge, E., Cui, Z., & Muram, D. (2013). Medication adherence and treatment patterns for hypogonadal patients treated with topical testosterone therapy: A retrospective medical claims analysis. The Journal of Sexual Medicine, 10(5), 1401-1409. https://doi.org/10.1111/jsm.12114

Sumko, D., Stoutt, W., Weis, S. E., & Wong, L.  (2014).  Congenital idiopathic hypogonadotropic hypogonadism: A case report. Journal of Case Reports, 4(6), 1-2. https://doi.org/10.4172/2165-7920.1000371

Turriff, A., Levy, H. P., & Biesecker, B. (2011). Prevalence and psychosocial correlates of depressive symptoms among adolescents and adults with Klinefelter syndrome.  Genetics in Medicine, 13, 966-972.  https://doi.org/10.1097/GIM.0b013e3182227576

Van den Akker, O. B. A. (2012). Reproductive health psychology. Wiley & Sons. https://doi.org/10.1002/9781119968382

Walther, A., Wasielewska, J. M., & Leiter, O. (2019). The antidepressant effect of testosterone: An effect of neuroplasticity. Neurology, Psychiatry, and Brain Research, 32, 104-110. https://doi.org/10.1016/j.npbr.2019.05.004

Wu, F. C. W., Tajar, A., Beynon, J. M., Pye, S. R., Silman, A. J., Finn, J. D.,…Han, T. S. (2010). New England Journal of Medicine, 363, 123-125. https://doi.org/10.1056/NEJMoa0911101

Zitzmann, M., Mattern, A., Hanisch, J., Jones, H., & Maggi, M.  (2012). IPASS: A study on the tolerability and effectiveness of injectable testosterone undecanoate for the treatment of male hypogonadism in a worldwide sample of 1438 men. The Journal of Sexual Medicine, 10(2), 579-588. https://doi.org/10.1111/j.1743-6109.2012.02853.x

0 Comments

Submit a Comment

Your email address will not be published. Required fields are marked *