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Practice Lesson of the Week

Opioid induced hypogonadism

BMJ 2010; 341 doi: (Published 31 August 2010) Cite this as: BMJ 2010;341:c4462
  1. Raghava G Reddy, specialist registrar,
  2. Theingi Aung, specialist registrar,
  3. Niki Karavitaki, consultant,
  4. John A H Wass, professor
  1. 1Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford OX3 7LJ
  1. Correspondence to: J A H Wass john.wass{at}
  • Accepted 7 July 2010

Hypogonadism in both sexes is a common result of ongoing treatment with opioid analgesics and can be treated with suitable hormone replacement therapy

“[Opium] has kept, and does now keep down the population: the women have fewer children than those of other countries … the feeble opium-smokers of Assam … are more effeminate than women.”

Charles Alexander Bruce, 18391

Opioids (any drug which binds to the opioid receptors in the central nervous system, of which (natural) opiates are a subclass) are now increasingly prescribed worldwide in every age group, for acute and chronic, cancerous and non-cancerous, pain.2 They are also used in managing people who have been addicted to heroin. The NHS Prescription Services reported a 5.6% increase in prescription of analgesics in 2008 compared with 2007 (buprenorphine prescriptions rose by 41.3%, morphine sulphate by 15.3%, tramadol hydrochloride by 11.6%, and co-codamol by 5.9%).3 In 2008, around 14.8 million opioid prescriptions (32% codeine or dihydrocodeine, 38% tramadol, and 30% others) were dispensed in the community in England.4 Opioids are considered to be the main drugs of misuse worldwide.5 According to a survey published by the UK Home Office, in 2006-7 in England, 273 123 people aged 15-64 used opioid drugs.6

The high prevalence of opioid induced hypogonadism in both sexes is not widely recognised.7 8 9 10 11 12 13 14 15 16 17 We report two cases of opioid induced hypogonadism and discuss the literature on the effects of opioids on the hypothalamic-pituitary-gonadal axis.

Case reports

Case 1

A 42 year old man, followed up in our department for primary hyperparathyroidism, presented with episodes of flushing and sweating. His medical history included chronic back pain secondary to a lumbar spine disc prolapse, polycythemia rubra vera, cholecystectomy, colonic polyps, and osteoarthritis of knees. As his back pain was uncontrolled by regular …

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