Sexual Dysfunction and Sex Hormone Abnormalities in Patients With Cirrhosis: Review of Pathogenesis and Management

Abstract

Healthy sexual function is important to maintain a good quality of life but is frequently impaired in patients with cirrhosis. The degree of sexual dysfunction appears to be linked with the degree of hepatic dysfunction. In men, sexual dysfunction can be related to the hyperestrogenism of portal hypertension and/or to decreased testosterone resulting from testicular dysfunction. In women, suppression of the hypothalamic–pituitary–gonadal axis appears to be a principal contributor, with no significant effect of portal hypertension. There is also a huge psychological barrier to break through as there is a component of depression in many patients with cirrhosis. Sexual dysfunction is often underdiagnosed in the cohort with cirrhosis. Management of sexual disorders in patients with cirrhosis can be challenging as they are often multifactorial. A multidisciplinary approach is key in managing these patients. We review the current literature on the pathogenesis of sexual dysfunction in patients with cirrhosis and propose a stepwise algorithm to better manage these patients.

Testicular Atrophy and Hypothalamic Pathology in COVID-19: Possibility of the Incidence of Male Infertility and HPG Axis Abnormalities

“…FSH and LH have also been known to play roles in non-reproductive functions, while increased levels of FSH and LH have been reported to be the biomarkers for testicular damage and some secondary pathological consequences [108,109]. The dysregulation of the HPG axis has been associated with diseases like chronic kidney disease and liver cirrhosis [110][111][112][113]. Also, the incidence of disorders of HPG axis ranging from hypothyroidism to neurodegenerative senescence could be a likely consequence [102,114,115].…”

Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases

“…( 21,22 ) Libido can be decreased in the context of chronic illness and hormonal abnormalities. ( 10,19,23 ) The differential diagnosis of sexual dysfunction includes psychogenic causes, alcohol use, medication effects (e.g., spironolactone or beta‐blockers), hypogonadism (including as seen in hemochromatosis), and autonomic dysfunction (as seen in diabetes). ( 19 ) Open and directed inquiry in clinic provides an opportunity for patients to identify and disclose sexual dysfunction.…”

“…( 13‐15 ) Produced in the liver, SHBG synthesis is stimulated by estrogens, although with further progression from compensated to decompensated cirrhosis, SHBG levels ultimately decline. ( 16,17 ) Estrogen levels are also elevated in the setting of portosystemic shunting, ( 10,18 ) and increased circulating levels suppress the hypothalamic‐pituitary axis, ( 19 ) contributing to erectile dysfunction, oligospermia, testicular atrophy, and feminization. ( 20 )…”

Hepatocrinology

“…Cirrhosis in men can manifest with features of hypogonadism such as loss of secondary sexual characters and decreased libido [ 63 ]. Gynecomastia is reported in up to 44% of men with cirrhosis, and ascribed to the elevated estrogen:testosterone ratio [ 64 , 65 ]. Testosterone levels are low in patients with cirrhosis, and progressively decrease while the severity of the liver disease increases [ 66 ].…”

“…It can be attributed to the direct toxic effect of alcohol on the testis [ 69 , 70 ]. Hypogonadotropic hypogonadism that partially reverses after liver transplantation is described in most other forms of cirrhosis [ 65 ]. Low testosterone levels stimulate the synthesis of sex-hormone-binding globulin (SHBG) in cirrhosis.…”