AUA 2019: Panel Discussion: Opioids and Urology – Opioids and Hypogonadism

Chicago, IL (UroToday.com) Dr. Alukal gave a summary on the association between opioids and hypogonadism.

Opioid abuse is common, with almost 50,000 deaths in the year 2017. There are 1.7 million people with a substance abuse disorder that involves opioids, according to the Center for Disease Control (CDC). It is important to note that opioid abuses occur differently in men and women. Symptoms of abuse and withdrawal can manifest in sexual function complaints including diminished libido, anorgasmia, and erectile dysfunction. Other quality of life impacts includes lethargy and pain1.

The symptoms of opioid abuse can mimic hypogonadism, and opioid abuse causes by itself hypogonadism, through central suppression of hypothalamic-pituitary-gonadal (HPG) axis. Hypogonadism is a well-described and common problem with a prevalence of more than 40% in 40-year-old men. It causes similar symptoms such as opioid abuse, including sexual function complaints, diminished quality of life, and signs that include decreased muscle mass, insulin sensitivity, and osteopenia.

The mechanism by which opioids cause hypogonadism is as follows: Mu receptor activation in the hypothalamus results in a decrease in GnRH (gonadotropin-releasing hormone) with subsequent decrease in FSH, LH and testosterone levels. It has an official name, called: Opioid-induced androgen deficiency (OPIAD), with an estimated prevalence amongst opioid abusers and prior abusers varying widely (19%-81%)2.

In addition to opioid abuse alone (behaviors, low FSH, etc.), hypogonadism also impacts fertility through diminished sperm counts. Fertility concerns are difficult to address in this population as there have been no studies performed in men. There are also no studies that have shown conclusive numbers as to the percentage of opioid abusers or prior abusers with concomitant hypogonadism. The prevalence amongst opioid abusers is likely higher than 50%.

The known negative health impacts of opioid abuse include the effect on bone density, insulin sensitivity, quality of life, and pain sensitivity. Treatment in the form of opioid agonists, such as methadone, and suboxone may help the physical symptoms, but do not resolve the associated hypogonadism. Therefore, testosterone replacement in these patients can help with issues of erectile dysfunction and sexual function complaints, bone density, energy level, and well-being. The associated risks include polycythemia, prostate health, and negative impact on fertility. Discussion on these risks with the patients should occur before starting treatment, especially for those planning to have children.

Another alternative treatment option is clomiphene citrate (off label) which does not carry the associated risk of testosterone treatment. Symptomatic relief is imperfect with clomiphene, but it can help with the physical issues. In any case, clomiphene citrate can always be transitioned to testosterone therapy when the family building has been completed3.

Dr. Alukal concluded by stating that male patients with opioid abuse or history of opioid abuse are at higher risk of hypogonadism (OPIAD). Unfortunately, the hypogonadism does not resolve with treatment of opioid dependence and carries a significant impact on health and quality of life, particularly with regards to sexual function and fertility. Testosterone or clomiphene citrate should be considered as possible treatments after proper discussion of the associated risks with the patients.


Presented by: Joseph Alukal, MD, Associate Professor of Urology, Presbyterian/Columbia University Irving Medical Center, New York, New York 

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, Twitter: @GoldbergHanan at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois

References:
1. McHugh et al. Clin Psych Rev 2018
2. Coluzzi et al. J. Endo Inv 2018
3. Mulhall et al. BJUI 2012