Some reports suggest that opioid use over long periods may increase the risk of sexual dysfunction in males. However, these studies have limitations and may not take other factors into account.

The role of opioids in sexual dysfunction is unclear, and the issue may result from an interaction of many variables, including chronic pain, depression, and smoking.

In this article, we look at the available evidence from clinical trials.

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Using opioids long-term might lead to levels of sex hormones in the body falling.

In 2016, the United States Food and Drug Administration (FDA) issued a warning regarding severe safety issues associated with opioid pain medications.

Among information about impeded renal gland function and central nervous system reactions, the FDA reported that "long-term use of opioids may be associated with decreased sex hormone levels and symptoms such as reduced interest in sex, impotence, or infertility."

The FDA based their decision on a review of published studies that assessed levels of sex hormones in people who used opioids on a long-term basis that the authors considered chronic.

They also identified brands of opioids that already carry warnings of this risk.

However, the FDA cautioned that all of the studies that they had reviewed on the topic "had limitations that make it difficult to determine whether the symptoms were caused by the opioids or other factors."

Sexual dysfunction is a common problem among people who experience chronic pain.

In spite of this, a relatively small body of medical literature covers the subject, possibly because doctors do not usually ask about sexual health when compiling a medical history of chronic pain.

As a result, confirming whether painkillers directly cause sexual dysfunction can be difficult.

For instance, one factor that may be masking a link between sexual dysfunction and opioid use is depression.

Depression is a risk factor for sexual dysfunction. Some people with depression use opioids, and research indicates that opioids may cause or exacerbate the mental health condition.

The medical community is still unsure whether depression, opiate use, or both reduce sexual function, or whether opiate use worsens both depression and sexual function.

Similarly, smoking has strong associations with prescription opioid use and erectile dysfunction, and it can be difficult to determine which factor has the strongest influence over sexual function.

A limited group of studies have investigated possible links between opioid use and sexual dysfunction.

A 2018 study involved 11,517 participants in Denmark who completed a questionnaire about living with cancer. Results showed that those who used opioids for longer than 6 months to manage chronic noncancer pain experienced suppressed sexual desire.

Results of a 2017 study involving 8,829 adult male participants showed a significant increase in the risk of erectile dysfunction during opioid use.

The authors noted that gathering more reliable data will require further randomized controlled trials.

Another study from the same year showed a very strong tendency to smoke in people recovering from opioid use disorder. Between 84 and 98 percent of participants smoked tobacco during addiction treatment for opioids.

Smoking has strong links to erectile dysfunction, and it may contribute to sexual problems during opioid use.

In 2013, a cross-sectional analysis of pharmacy and medical records found a strong association between people who used opioids long-term and those who took medications for erectile dysfunction.

The authors also identified age, comorbid medical conditions, and depression as having links to erectile dysfunction. The results help indicate the difficulty in isolating opioid use as a trigger for sexual dysfunction.

A 2013 study, published in the journal Spine, found that males who used opioids over long periods were significantly more likely than other males to use treatments for erectile dysfunction and hormone replacement therapies.

The study included 11,327 adult male participants who had received a diagnosis for back pain. The researchers found that 909 also received medications for erectile dysfunction or testosterone replacement.

These participants were significantly older than those who did not receive treatment for sexual dysfunction. They were also more likely to smoke, have depression, and use sedative-hypnotic medications.

The researchers calculated that nearly 20 percent of participants receiving high dosages of opioids over long periods had evidence of sexual dysfunction.

Hormones

Opioids may decrease sexual function because they affect hormones in the hypothalamic-pituitary-gonadal pathways. These control the production of sex hormones by secreting gonadotropin-releasing hormone (GnRH).

Opioids inhibit GnRH, leading to a decrease in the production of luteinizing hormone. This, in turn, inhibits the production of testosterone.

Having low testosterone can cause depression and sexual dysfunction in males and females.

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Some studies have suggested that the female partners of men who take opioids might experience a reduction in libido.

Investigations into a potential link between female sexual dysfunction and opioid use are scarce.

However, a study published in the Journal of Clinical Endocrinology and Metabolism reported decreased libido in 22 of 32 female participants receiving opioid treatment via the spine, compared with decreased libido or impotence in 23 of 24 male participants receiving the treatment.

Results of one study from 2016 suggest that female partners of males dependent on opioids may experience altered sexual function, desire, and attitudes toward sexual contact.

For men using opioids to treat pain, testosterone supplementation is the primary therapy. However, erectile dysfunction medication, such as sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra), may be more suitable.

Rehabilitation clinics and medical substitutes can help people with opioid dependency. Withdrawal symptoms may be severe, and a medical professional should oversee the process.

Because of the lack of research, doctors are less certain about treatments for opioid-related sexual dysfunction in females. Options may include androgen treatment, which is a form of hormone therapy, or the oral contraceptive pill.

Q:

What pain relief options will not lead to sexual dysfunction?

A:

Ideally, one should only use pain medications when needed and for the shortest duration of time needed. Even less potent pain medications, such as acetaminophen and ibuprofen, have links to sexual dysfunction in some people.

Talk to your healthcare provider about which pain medications may have the least impact on sexual function, and be prepared to experiment. One medicine may cause more or less dysfunction than another.

Work with your provider to identify the medication that achieves the best balance between pain control and sexual functioning.

Timothy J. Legg, PhD, CRNP Answers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.