Patients with chronic pain commonly experience sexual dysfunction, according to Stephen Colameco, MD, Director of Medical Services at Addiction Pain Associates in Sewell, New Jersey. Opioid-induced androgen deficiencies are a frequent and often overlooked cause of sexual dysfunction in women and men, he reported in the April Pain Treatment Topics.

Hypogonadal and androgen-inhibiting effects are a “class effect” of all opioids, to some extent, said Dr. Colameco. Therefore, he suggested that all patients receiving daily opioids equivalent to 100 mg or more of morphine should be evaluated for potential endocrine deficiency.

Common symptoms of androgen deficiency include anemia, decreased libido, decreased muscle mass, depression, erectile dysfunction, fatigue, hot flashes, menstrual irregularities, osteoporosis, sweating, and weight gain.

Validated questionnaires for screening for endocrine deficiencies in women are yet to be developed; however, several structured interview instruments have been proposed for use with men. The Androgen Deficiency in Aging Men questionnaire has been validated for men older than 40, and the Androtest is a 12-item structured interview for screening male hypogonadism. Predictive values for these tools were determined using laboratory assessments of male testosterone, and Dr. Colameco pointed out that both instruments have clinical limitations. He noted that laboratories report a wide range of normal serum testosterone levels (eg, 275 to 800 ng/dL) for men, without indicating age-range–specific values.

For women, dehydroepiandrosterone sulfate (DHEAS) levels may be the best indicator of androgen production. “While some specialists recommend testing for testosterone deficiency in women, most laboratories do not set a lower limit to the normal range for females,” said Dr. Colameco.

TREATING OPIOID-INDUCED SEXUAL DYSFUNCTION

For men, testosterone supplementation—gel, cream, buccal, transdermal patch, or intramuscular injection—is the primary treatment of opioid­induced endocrine deficiency resulting from hypogonadism. Topical and buccal medications are preferred over injections, because they provide fairly stable testosterone concentrations.

Although symptoms of hypogonadism would be expected to improve with testosterone therapy, erectile dysfunction may persist due to psychological factors or coexisting medical conditions. According to Dr. Colameco, patients who experience ongoing erectile dysfunction despite testosterone therapy may benefit from treatment with an FDA-approved erectile dysfunction medication (eg, sildenafil, tadalafil, vardenafil).

Research on opioid-induced endocrine deficiencies in women is lacking, however. Theoretically, contended Dr. Colameco, androgen treatment could relieve clinical symptoms and reduce the risk of osteoporosis in women. Oral contraceptive pills might also have some benefit; however, they have been linked with suppression of free testosterone. Opioid rotation may be another treatment option for women with androgen deficiency, he said.

One approach in women is DHEAS supplementation (50 to 100 mg/day), which may decrease postmenopausal bone loss and improve muscle strength, sexual performance, and memory. “Although the potential value of DHEAS therapy in women remains controversial, it may be the most appropriate treatment option for those with opioid-induced endocrine deficiency,” concluded Dr. Colameco.

—Karen L. Spittler

Suggested Reading
Colameco S. Opioid-induced sexual dysfunction: causes, diagnosis, and treatment. Pain Treatment Topics. pain-topics.org. April 2008..

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