Male body dysmorphic behaviour leads to profound hypogonadism

Young men who starve themselves to achieve a lean muscular appearance are at risk of developing profound hypogonodotrophic hypogonadism, Victorian endocrinologists warn.

Societal pressure to attain an ideal male body image is pushing otherwise healthy young men into rigorous training and obsessive low calorie protein supplement diets to shed body fat, which results in suppression of the male gonadal axis, according to clinicians from the Department of Endocrinology, Austin Health, and the University of Melbourne.

In a review published in Clinical Endocrinology, Dr Henry Wong and Professor Mathis Grossmann report on a case series of 23 men with energy-deprivation related hypogonodotrophic hypogonadism.

All the men were young (median 20 years) and underweight, with a BMI of 15.9 kg/m2. The mean total testosterone levels were 3.0 nmol/L (0.6-21.3), and LH 1.2 mIU/L (<0.2-7.5), with 91% of cases demonstrating hypogonadotropic hypogonadism.

Other significant findings included evidence of GH resistance, hypercortisolaemia in 50% of cases, and a nonthyroidal illness picture low T3 in 67% with either low or normal T4 and TSH).

The condition appeared to be reversible following weight regain, with serum testosterone increasing from median 3.2 nmol/L to 14.3 nmol/L, and LH from 1.2 IU/L to 3.5 IU/L.

The report authors said disordered eating and low energy intake been officially recognised as ‘female athletic triad’ in 1992 but it had only been defined as Relative Energy Deficiency in Sport (RED-S) in males in 2014 and was still under-recognised.

In terms of pathophysiology, the combination of exercise-related stress and energy deficiency could result in changes to LH pulses, marked reductions in circulating leptin and elevated ghrelin levels that could contribute to central suppression of the gonadal axis, they said.

The diagnosis was difficult as the condition could often only be differentiated from the widespread practice of anabolic steroid misuse by asking the patient, they said. Most cases featured a history of marked weight loss, low haemoglobin, increased SHBG, evidence of associated non-reproductive endocrine abnormalities

Treatment should be based on weight regain, analogous to the reversibility of obesity-related hypogonadism with weight loss, although psychiatric input may be needed to restore healthy eating pattern, they added.

“Caloric restriction and overtraining may be increasing in young men who strive to attain the ‘ideal’ male physique. This combination can result in detrimental effects on the gonadal axis, a complication that may be underrecognised and underappreciated in clinical practice,” they concluded.

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