Endocrinologist

In the case of endocrine disorders, the first concerning symptoms are often symptoms related to sexual health, such as loss of libido or erectile dysfunction. Other possible symptoms include mood disturbances, fatigue, anxiety, sleep disorders, excessive weight loss, or weight gain.

The conditions commonly treated by an endocrinologist include:

• Diabetes
• Male hypogonadism (testosterone deficiency)
• Female hypogonadism (including menopause)
• Hyperthyroidism or hypothyroidism
• Hashimoto’s disease
• Obesity
• Adrenal insufficiency or adrenal overactivity, including Cushing’s syndrome
• Hyperandrogenism and polycystic ovary syndrome (PCOS)

Sexual Dysfunction and Diabetes

Diabetes is a condition that most commonly causes erectile dysfunction in men. It develops in more than half of men within ten years of being diagnosed with diabetes. The risk of sexual dysfunction is four times higher than in men without diabetes and increases with the duration of the disease, poor glycaemic control, and the presence of vascular complications and neuropathy.

In women with diabetes, the most common sexual difficulties include:

• reduced sexual desire and lubrication,
• depression,
• difficulties in relationships with a partner.

Key factors that improve the effectiveness of treatment for sexual dysfunctions in patients with diabetes include reducing excess weight, improving glycaemic control, and identifying and treating coexisting physical and psychological problems.

Sexual Dysfunction and Somatic Problems Associated with Testosterone Deficiency in Men

Testosterone plays a crucial role in regulating male sexual responsiveness at both the central and peripheral levels. It influences:

• motivation for sexual activity (sexual interest and pursuit),
• the spontaneous occurrence of erotic thoughts,
• sensitivity to sexual stimulation.

Testosterone replacement therapy in men with testosterone deficiency syndrome increases sexual desire and improves erectile function, orgasm, and ejaculation.

Common causes of testosterone deficiency:

The most common cause of testosterone deficiency syndrome (TDS) in developed countries is likely obesity and metabolic syndrome. It is estimated that testosterone deficiency occurs in approximately half of men with obesity-related diabetes and in more than half of men with a BMI >30.

• Testosterone deficiency is associated with ageing and develops unevenly among men. It results from the gradual decline in the secretory function of the gonads, as well as reduced activity of the hypothalamus and pituitary gland with age.
• Acute stress caused by psychological and physical factors can have a significant impact on the synthesis of hypothalamic-pituitary hormones (including increased synthesis of glucocorticoids and mineralocorticoids) and lead to reduced production of sex hormones. Such hormonal responses are usually temporary and may occur, for example, in patients after head injuries, strokes, myocardial infarction, acute inflammatory conditions, or abdominal surgery. Reduced testosterone levels may persist for up to 8 weeks or longer.
• Side effects of medications and psychoactive substances may also contribute to testosterone deficiency. These include opioids (including tramadol and methadone), glucocorticoids, 5α-reductase inhibitors, as well as substances that indirectly cause hyperprolactinaemia (e.g. some antipsychotic medications and metoclopramide) and those increasing SHBG levels (e.g. antiepileptic drugs).

Typical symptoms of testosterone deficiency syndrome:

• reduced sexual activity and decreased sexual desire,
• deterioration in erectile function (especially reduced frequency and firmness of spontaneous, morning, and nocturnal penile erections),
• mood changes (tendency towards depressive mood, irritability),
• impaired cognitive abilities (memory, concentration, spatial orientation),
• reduced energy levels, fatigue, and increased tiredness,
• decreased muscle mass and strength,
• increased body fat and BMI,
• reduced body hair growth and skin changes,
• decreased bone mineral density, increased risk of fractures, and reduced height,
• reduced testicular volume and gynecomastia,
• sleep disturbances and insomnia.

Sex hormone deficiency in women

Estrogens and testosterone regulate female sexual responsiveness at both the central and peripheral levels. A decrease in sex hormone levels in women is associated with an increased risk of sexual dysfunction, particularly disorders of sexual desire and arousal.

Estrogens

The reduction of oestrogen production in menopausal women results in many symptoms that directly or indirectly affect their sexuality. Changes in oestrogen levels most commonly lead to:

• atrophic changes of the vulva – reduced epithelial proliferation, decreased tissue permeability, reduced smooth muscle content, and changes in vascularisation and innervation,
• reduced tissue elasticity, shortening and narrowing of the vagina, fibrosis within the clitoris, and thinning of the labia,
• changes in vaginal pH from acidic to alkaline, reduced secretory activity, and related symptoms such as dryness, increased susceptibility to irritation, itching, burning sensations, and a higher risk of local inflammation,
• as a consequence of these changes, an increased incidence of dyspareunia and vulvodynia. This may result in reduced arousal, decreased sexual pleasure, and lower motivation to initiate sexual activity,
• urinary symptoms – increased frequency of urination, urgency, nocturia, dysuric symptoms, urinary incontinence (which may cause particular discomfort due to unpleasant odour or urine leakage, for example during orgasm), and recurrent infections,
• hot flushes and mood changes – affecting overall well-being, relationships, and sexual desire,
• reduced bone mineralisation and an increased risk of osteoporosis.

Testosterone

Similarly to oestrogen and progesterone, the concentration of testosterone synthesised from androgen precursors produced by the ovaries and adrenal glands decreases in women with age, although the pattern and rate of this decline are different.

During menopause, ovarian production of oestrogens stops, while ovarian androgen production decreases gradually and is additionally maintained by the adrenal glands. Women who undergo bilateral oophorectomy experience androgen deficiency caused by a 40–50% reduction in total and free testosterone levels compared with healthy women of the same age. As a result, they are more susceptible to reduced sexual desire and the distress associated with it.

Testosterone also plays an important role in maintaining adequate blood circulation in the vaginal area and preserving tissue integrity. The importance of testosterone is supported by the significant improvement in sexual function observed in women who received testosterone therapy due to reduced sexual desire and arousal.