How does kidney disease affect your sexual health and reproductive function? What are your treatment options?
Kidney disease has a profound effect on sexual health, fertility, the ability to conceive, etc. I will cover the issues related to chronic kidney disease (CKD) and pregnancy in my next post. For today, lets try and understand how and why a reduction in your kidney function could affect your sexual health. Sexual dysfunction does tend to worsen as kidney disease progresses, and is part of the constellation of various signs and symptoms of advanced kidney disease.
SEXUAL DYSFUNCTION IN WOMEN WITH CKD
1) Disturbances in menstruation
Irregular menses could be present in women with advanced kidney disease. Usually, the menstrual flow tends to be scant and erratic; however, heavy bleeding could be seen since kidney disease does interfere with platelet function (the blood cells that play a role in stopping bleeds). One of the reasons for this disturbance is that the uremic toxins which accumulate in advanced kidney disease, interfere with normal ovulation and the hormonal changes that accompany that. Ovulation is central to normal menstruation, and also to a woman's ability to get pregnant (I will cover this in more detail later). Hormonal changes in normal menstruation involve initially an increase in the level of a hormone called FSH which peaks at around ovulation, after which another hormone called LH regulates the changes in the remaining part of the cycle. These sequential changes in hormone levels can go haywire in advanced CKD, resulting in abnormal menstruation. In fact, these abnormal cycles, called anovulatory cycles, are more common in advanced kidney disease than normal cycles are (this partly explains the high incidence of infertility in women with kidney failure). Women might experience this as an absence of expected increase in body temperature during the latter part of menstrual cycle.
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Elevated levels of prolactin (a hormone produced, among others, by the pituitary gland) also interfere with menses. Its levels can be high because of increased secretion, as well as the reduced ability of diseased kidneys to excrete it well. This can lead to spontaneous milk production (galactorrhea) from the breast, in both women and men.
2) Decreased libido
Women in advanced stages of kidney disease could experience a subjective decrease in libido due to the hormonal changes mentioned above, as well due to fatigue that could be present secondary to the CKD. This further gets exacerbated by vaginal dryness/atrophy that could be present as well, due to low estrogen levels. An inability to achieve orgasm is often seen.
SEXUAL DYSFUNCTION IN MEN WITH CKD
1) Erectile dysfunction
This is extremely common in men with advanced kidney disease. The causes are multifactorial, including low testosterone levels, as well as other organic co-morbidities that often accompany advanced CKD. To achieve a normal erection, a healthy nervous and circulatory system is required. However, patients with advanced kidney disease often will have significant vascular disease and neuropathy, both of which interfere with the erection process. Of course, the accumulation of uremic toxins exacerbates the problem via multiple complex mechanisms.
2) Decreased libido
Hormonal abnormalities like low testosterone and high prolactin seen in men with advanced kidney failure, and fatigue, all contribute to a reduction in the sexual drive. This is common in advanced stages of CKD.
3) Abnormal sperm production
Semen analysis of men with advanced CKD often reveals low sperm counts. Quite often, the quality of the sperms produced is sub-optimal as well, with the cells showing abnormal motility. Hormonal changes of CKD, and the consequent testicular damage all have a role to play in this. This again, expectedly, could lead to infertility.
4) Breast enlargement
Through mechanisms not completely understood, kidney failure and dialysis could be associated with breast enlargement in men. Rarely, milk production from the male breast could be seen as well. In fact, almost a third of men on dialysis could experience breast enlargement.
TREATMENT
The physical and psychological stress of advanced kidney disease and the demands of dialysis undoubtedly worsen sexual problems seen in CKD. However, patients along with their nephrologists and other physicians could still focus on the modifiable factors to improve their sexual health. Anemia is often present in advanced kidney disease, and could worsen sexual dysfunction. Treatment of anemia with a drug called erythropoietin (the same substance that Lance Armstrong claimed he never took!) has been shown to help with the symptoms. Progestin replacement can help restore menses in women. For women with low estradiol levels, estrogen replacement may be considered, which could also benefit women with vaginal dryness. Bromocriptine, a drug which interferes with prolactin's action, may help as well in both women and men.
Hormone replacement with testosterone may be tried in men, although it might not lead to any significant improvement in symptoms. Impotence in patients with uremia has been successfully treated with sildenafil (a.k.a Viagra), vacuum devices, and zinc supplementation. There are important caveats to the use of all of the above mentioned drugs, and you should discuss this thoroughly with your physician.
Since high levels of uremic toxins have a big effect on symptoms, the dialysis dose should be optimized to make sure patients are receiving adequate treatment. I remember a 65 year old female patient I once saw during my fellowship. She had just had a kidney transplant three weeks ago. As I was concluding my visit, I asked her if she had any major questions or concerns. She only had one..."doc, when can I start having sex? I haven't had it once in the last ten years?!" When it comes to the most effective treatment for sexual dysfunction in patients with kidney disease, getting a kidney transplant beats being on dialysis any day!
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