Long-Term Opioid Use: How It Affects Hormones and Sexual Function

When you're living with chronic pain, opioids can feel like a lifeline. But what happens when that lifeline starts quietly breaking down your body from the inside? For many people on long-term opioid therapy, the most overlooked side effects aren’t nausea or constipation-they’re hormonal chaos and sexual dysfunction. These aren’t rare quirks. They’re predictable, well-documented, and happening to over half of men and a large portion of women taking opioids for more than 90 days.

How Opioids Break Your Hormone System

Opioids don’t just block pain signals. They also hijack your brain’s control center for hormones. The hypothalamus, pituitary, and gonads-collectively called the HPG axis-work together to keep testosterone, estrogen, and cortisol levels balanced. Opioids like oxycodone, morphine, and fentanyl shut down the signal from the hypothalamus that tells your body to produce these hormones.

It’s not a guess. A 2020 meta-analysis in the Journal of Clinical Endocrinology and Metabolism found that 63% of men on long-term opioids develop low testosterone, known as hypogonadism. That’s more than 2 out of 3. Testosterone levels can drop 30-50% within just 30 days of starting therapy. For women, the picture is more complex: estrogen levels often stay normal, but testosterone drops, and menstrual cycles go haywire. Up to 87% of premenopausal women on chronic opioids experience irregular periods, and nearly 1 in 5 stop having periods entirely.

Even low doses matter. Studies show hormone disruption can begin at doses as low as 60 morphine milligram equivalents (MME) per day-about two 30 mg oxycodone tablets. At 120 MME or higher, the drop in testosterone becomes almost universal.

Sexual Function Takes a Hard Hit

Low testosterone doesn’t just mean less muscle or energy. It directly kills libido, makes erections harder to get and keep, and reduces sexual satisfaction. Men on long-term opioids report decreased sex drive, erectile dysfunction, and even loss of morning erections. On Reddit’s r/ChronicPain community, one user wrote: “After two years on oxycodone, my testosterone hit 180 ng/dL. My doctor didn’t test it until I brought it up. Took six months to get help.”

Women aren’t spared. A 2021 survey of 342 women found 78% had lost interest in sex, 63% had irregular or absent periods, and 41% said their depression got worse. Many say their doctors dismissed these issues as “just part of chronic pain” or “aging.” But it’s not aging. It’s the opioids.

And it’s not just about sex. Hormonal imbalance affects mood, sleep, energy, and even bone density. Low testosterone is linked to increased fatigue, brain fog, and higher risk of osteoporosis. For women, low testosterone can contribute to vaginal dryness and pain during intercourse.

Opioids vs. Other Pain Treatments

Not all pain meds are created equal when it comes to hormones. Opioids are the worst offenders. Compare that to gabapentinoids like pregabalin-only 12% of men on these drugs show low testosterone. NSAIDs like ibuprofen or naproxen? Minimal to no effect on hormones. Even acetaminophen, while not perfect, doesn’t shut down your endocrine system the way opioids do.

That’s why guidelines from the American Pain Society and the CDC no longer recommend opioids as a first-line treatment for chronic non-cancer pain. They’re effective for acute pain-like after surgery or a broken bone-but for back pain, arthritis, or fibromyalgia? The risks outweigh the benefits. Studies show physical therapy, cognitive behavioral therapy, and certain antidepressants like duloxetine work better over time and don’t wreck your hormones.

What Doctors Should Be Doing (But Often Aren’t)

The Endocrine Society says it plainly: Every man on long-term opioids should get his testosterone checked before starting and every six months after. Women should be monitored for menstrual changes. Yet, a 2023 study found only 38% of primary care doctors routinely screen for this. Why? Because it’s not taught. Because it’s awkward. Because patients don’t bring it up.

Patients often feel embarrassed to talk about sex or libido changes. Doctors assume it’s depression or aging. But if you’re on opioids and your sex drive vanished, or your period stopped, it’s not in your head. It’s in your hormones.

And it’s fixable. Testosterone replacement therapy (TRT) helps 70-85% of men regain sexual function, energy, and mood when levels are restored. For women, off-label testosterone patches (1-2 mg daily) have shown promise in small studies, improving libido in about half of users. But TRT isn’t a magic bullet-it requires monitoring for side effects like increased red blood cell count, which can raise stroke risk.

What You Can Do Right Now

If you’re on opioids long-term and noticing changes in your sex life, energy, or menstrual cycle, here’s what to do:

1. Ask for a blood test. Request total testosterone, free testosterone, LH, FSH, and cortisol. Don’t wait for your doctor to bring it up.
2. Track your symptoms. Note changes in libido, erections, periods, mood, sleep, and energy. Bring this list to your appointment.
3. Ask about alternatives. Is there a non-opioid option that could work? Could physical therapy, nerve blocks, or antidepressants help?
4. Don’t quit cold turkey. Withdrawal can be brutal. If you want to reduce or stop opioids, work with a pain specialist. Unsupervised tapering leads to relapse in 73% of cases.
5. Seek a multidisciplinary team. A pain doctor, endocrinologist, and therapist working together gives you the best shot at reclaiming your health.

New Hope on the Horizon

There’s progress. In 2023, the FDA approved Belbuca (buprenorphine buccal film), which causes 40% less hormone disruption than traditional opioids. Cleveland Clinic researchers found that combining low-dose naltrexone (a drug that blocks opioid receptors) with reduced opioid doses improved testosterone levels by 25-35% in two-thirds of patients-without losing pain control.

And the research is shifting. The NIH spent $15.7 million in 2024 on projects to reduce opioid side effects and develop better alternatives. By 2028, experts predict nearly half of pain clinics will routinely screen for hormone disruption. That’s up from just 12% in 2022.

But until then, the burden falls on you. If you’re on opioids and your body feels like it’s falling apart-your sex life gone, your energy gone, your mood off-don’t accept it as normal. Ask for help. Demand testing. Push for alternatives. You deserve more than just pain relief. You deserve to feel whole.