SEX AND LIVER DISEASE

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SEX AND LIVER DISEASE

Two sex-related issues that commonly concern people with liver disease are sexual function/dysfunction and methods of contraception. This section discusses these issues in detail. The medical treatment of sexual dysfunction in men, and which types of hepatitis can be transmitted sexually are also addressed.

Sexual Function and Dysfunction

Most people with chronic liver disease have normal sexual function and normal interest in sex. However, some people do complain of decreased libido, decreased ability to achieve and maintain an erection (a condition known as erectile dysfunction), and decreased satisfaction with sex.

Decreased sexual interest and erectile dysfunction occur in approximately 2 percent of healthy, middle-aged males without liver disease. This is about the same incidence noted in males in the early stages of liver disease. Men with advanced liver disease, however, are more likely to experience testicular dysfunction, loss of body hair, gynecomastia (enlarged breasts), redistribution of body fat, a female configuration of pubic hair, decreased muscle mass, decreased sexual desire, and erectile dysfunction. These characteristics are due to the changes in hormone levels that can occur in such men with advanced liver disease. The male hormone, testosterone, is typically low and the female hormone, estrogen, is typically high in such men. These findings are particularly applicable to men with alcoholic liver disease, as alcohol abuse (even in the absence of liver disease) may cause decreased testosterone levels, and thereby lead to sexual dysfunction.

Women with liver disease appear to have normal sexual function, with the exception of women whose liver disease is due to excessive alcohol consumption. Women who have undergone a liver transplant generally experience improved sexual interest, body image, and sexual intimacy.

Any chronic illness may be associated with sexual dysfunction. This is particularly true for liver disease, since it is so often associated with fatigue and depression, each of which can contribute to a decreased interest in sex. In addition, medications used in the treatment of liver disease, particularly interferon, may cause sexual dysfunction and decreased libido—especially in men. Sexual dysfunction is also a common side effect of many of the antidepressant medications often used to treat the depression and anxiety which arise from treatment with interferon and ribavirin. When medication is discontinued, the medication-induced sexual dysfunction abates. And, certain herbs often taken by people with liver disease, such as licorice, can cause decreased testosterone levels in men, thereby contributing to sexual problems. Other medical conditions unrelated to liver disease may also cause or worsen sexual dysfunction. Therefore, people should openly discuss any sexual problems with their doctors so that it can be determined whether some other medical condition, such as a prostate disorder or a psychiatric disorder, exists.

Women on interferon and ribavirin therapy for chronic hepatitis C often experience vaginal dryness. This may cause pain upon intercourse, vaginal irritation, and vaginal burning and itching. This results in decreased sexual interest. Vaginal discomfort may become particularly severe if a condition known as atrophic vaginitis – a condition of decreased estrogen in the body common in postmenopausal women, is present. Women should be aware of this potential side effect, and should use a vaginal moisturizing cream. A topical estrogen and progesterone cream may be needed to improve or alleviate these symptoms. However, oral estrogen supplements should generally be avoided, as they carry a risk of causing or worsening jaundice and cholestasis. And, “natural” soy estrogen which has been linked to causing hepatitis, should be avoided. Please refer to chapter 11 page xx for more information and women and decreased libido.

Treatment for Sexual Dysfunction in Men

Viagra (silenafil citrate) was the first oral medication for the treatment of erectile ­dysfunction to be approved by the FDA. The effects of Viagra on people with liver disease or in people who have undergone liver transplants have not been spe­cifically studied. Moreover, Viagra’s interaction with medications used to treat liver disease or with medications used after transplantation has not been evaluated. Therefore, the adverse effects of Viagra, if any, in people with liver disease (whether pre- or post-transplant) are not conclusively known. It has been noted, however, that about 2 percent of men experience abnormal liver function tests as a result of taking Viagra.

For people without liver disease, the recommended dose of Viagra is 50 milligrams taken one hour prior to sexual activity. Since this drug is metabolized through the liver, people with liver disease are advised to decrease this dose to 25 milligrams. Careful monitoring by a doctor, preferably a liver specialist, of a patient’s liver function is essential for anyone with liver disease who uses this drug. People using Viagra post-liver transplant are advised additionally, to have the levels of their antirejection medications checked with increased frequency. However, it may be best to refrain from using Viagra until studies documenting the effect of this drug on people with liver disease and on those who have received liver transplants have been published.

Studies have failed to conclusively determine whether testosterone replacement treatment improves sexual function in men with chronic liver disease. Furthermore, testosterone may even be dangerous for those with liver disease. There­fore, this type of treatment cannot be recommended until further research has confirmed its effectiveness.

Vitamin E may increase male sexual performance. This potential benefit of vitamin E has not been confirmed in people with hepatitis C. However, since vitamin E may increase response rates in people with hepatitis C treated with interferon and ribavirin it is probably a good idea to consume a vitamin E tablet if suffering from decreased libido. (See page xx chap 23 for more information on vitamin E).

Contraception

People often assume that most forms of hepatitis are easily transmitted through sexual contact. Such an assumption is incorrect. In fact, only one hepatitis has a high rate of sexual transmission - namely hepatitis B. Men with infectious hepatitis B should use a condom until such time as their partners have completed the hepatitis B vaccination series (see page xx) and have demonstrated immunity—as evidenced by the presence of HBsAb in their blood. Likewise, any woman with infectious hepatitis B should have their partners use condoms until such time as their partners have completed the hepatitis B vaccination series and have demonstrated immunity.

The incidence of sexual transmission of hepatitis C is very low, and most such cases likely stem from a mingling of blood during sexual contact. It appears that it is easier to transmit hepatitis C from men to women, than visa versa. Since there is no vaccination available for hepatitis C, men with chronic hepatitis C who are not in long-term monogamous relationships should wear condoms. This is especially important for those men who have multiple sex partners, who engage in anal sex (where the incidence of bleeding is higher than with vaginal sex), who have breaks or sores on their genitals (such as herpes sores, which may bleed), or who have frequent prostate infections. Similarly, women with chronic hepatitis C who are not in long-term monogamous relationships should have their partners wear condoms, especially if any of the above-mentioned circumstances apply. Extra precautions should be taken in situations where a woman with chronic hepatitis C is menstruating. How­ever, it should be emphasized that for people in stable, monogamous relationships, the incidence of sexual transmission of the hepatitis C virus (HCV) to the partner is extremely low. In fact, only about 3 to 6 percent of sexual partners of HCV-infected people are also positive for HCV. And since this statistic is based on ­indirect evidence, it is unclear whether the sexual partners of the HCV-infected people quoted in these studies became infected through sexual acts or by some other route.

People with liver diseases other than hepatitis B or hepatitis C (as well as the sexual partners of these people) need not take any special sexual precautions. Autoimmune hepatitis, primary biliary cirrhosis, nonalcoholic fatty liver disease ( NAFLD), alcoholic liver disease, and hemo­chromatosis are not liver diseases that can be transmitted sexually. As these diseases probably, to some degree, have a genetic basis, people (male and female) with one of these diseases may pass the susceptibility for the disease on to their offspring.

Although birth control pills are an effective form of contraception, they will not prevent the spread of a sexually transmitted disease nor do they lessen the likelihood of such a disease being transmitted. People with a benign liver tumor (hemangioma, focal nodular hyperplasia, or hepatic adenoma) are advised to avoid birth control pills containing estrogen, as estrogen may cause enlargement or rupture of these tumors. Furthermore, estrogen has been shown to cause and also worsen jaundice and cholestasis. Therefore, it is advisable for all women with liver disease to avoid taking estrogen-containing birth control pills. As an alternative, women may wish to consider the long-acting contraceptive medroxyprogesterone (Depo-Provera), which is preferable because it does not contain estrogen. Instead, it contains the hormone progesterone. However, women should be aware that progesterone-containing birth control pills may cause sodium retention, thereby making these contraceptives unsuitable for women with ascites. Intrauterine devices (IUDs) are associated with an increased tendency to bleed when used by a woman with cirrhosis who has a decreased platelet count. Such women are advised to avoid the use of IUDs.

All contents of this article are Copyright © Palmer, MD

Palmer, MD is the author of " Dr. Palmer's Guide of Hepatitis and Liver Disease". (Published 2004. Penguin Putnam).

The offices of Palmer, M.D. are located at:

1097 Old Country Road Suite 104

Plainview, N.Y 11803

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Lake Ronkonkama, N.Y. 11779

To arrange an appointment with Dr. Palmer, call

(516) 939-2626

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