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Sexuality and Reproductive Issues (PDQ®): Supportive care - Health Professional Information [NCI] - Pharmacological Effects of Supportive Care Medications on Sexual Function

The following sections describe the effects of various commonly used medications on sexual function in people with cancer. People undergoing cancer treatment are often treated with multiple medications that can cause diminished desire or other difficulties in sexual functioning, which can add to the impact of surgery, radiation, and chemotherapy on sexuality. Medications may adversely affect one or more of the physiologic (i.e., vascular, hormonal, neurologic) mechanisms that underlie normal sexual function. Drug therapy may also affect sexual functioning indirectly through concomitant effects on mental alertness, mood state, and/or social interactions. The evaluation of sexual problems in people with cancer must, therefore, be comprehensive and attuned to the multiple etiologies of these difficulties. The following sections may be helpful in identifying some of the possible medication side effects, though more than one may play a role in an individual.

Effect of Opioids on Sexual Function

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Reduced libido is a well-known phenomenon for those using heroin or participating in a methadone maintenance program. Unfortunately, this effect is poorly understood by clinicians prescribing opioids for pain. Animal studies confirm that opioids lower testosterone levels and suppress sexual function in males.[1] Early case studies of persons using heroin or methadone described diminished libido, sexual dysfunction, reduced testosterone levels in men, and amenorrhea in women.[2,3,4,5,6,7][Level of evidence: II]

Two mechanisms are thought to be responsible for the reported reduction in libido associated with opioid use.

  • Opioids inhibit the production of gonadotropin-releasing hormone, subsequently decreasing the release of luteinizing hormone (LH), thus decreasing the production of testosterone. Opioids also produce hyperprolactinemia, which causes negative feedback on the release of LH and decreases the production of testosterone.[8][Level of evidence: IV]
  • Opioids are known to alter the normal function of the hypothalamic-pituitary-gonadal axis.[9][Level of evidence: II]

These effects resolve after the opioid has been discontinued.

Other case reports of patients receiving opioids for relief of chronic pain suggest these same findings.[10,11][Level of evidence: III][12][Level of evidence: II] Another case-control study examined the effects of chronic oral opioid administration in survivors of cancer and, consistent with the research on intrathecal administration, found marked central hypogonadism among the opioid users with significant symptoms of sexual dysfunction, depression, and fatigue.[12] Although the limited research that has examined the relationships among sexual functioning, chronic pain, opioid therapy, and testosterone levels has been predominantly evaluated in men, anecdotal clinical experience supports similar relationships in women. Empirical support has been documented for women in a study that examined the endocrine consequences of long-term intrathecal administration of opioids. Reduced libido was reported in 95% of the men and 68% of the women, with significant reduction in serum LH for both groups and in serum testosterone for the men. All of the premenopausal women (n = 21) developed either amenorrhea or an irregular menstrual cycle, with ovulation in only one woman.[13][Level of evidence: II]

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