The Unasked Questions of Sexual Health in Nephrology Clinics

Written by Priti Meena, MD

We are living in an era where chronic kidney disease (CKD) affects nearly 9.1% of the global population—about 697.5 million people. That’s not a small subset of patients. That’s a population large enough to demand that we get the whole conversation right. And yet let’s be honest when was the last time reproductive health came up unprompted in our nephrology clinic? Nephrologists are very meticulous about eGFR trends, proteinuria, potassium levels, and dialysis adequacy. We debate decimals. We celebrate stable creatinine. But reproduction? Sexual health? Contraception? Fertility? These somehow get quietly deferred. Or worse, ignored. Which is ironic. Because parenthood and pregnancy are not niche concerns, they are defining life events. For many patients, they matter as much as, if not more than, the numbers we so carefully track.

Pregnancy in CKD: High Stakes, Hard Conversations

Pregnancy in CKD is not straightforward. It carries increased risks for both mother and child ranging from high maternal and fetal morbidity, GFR decline, and dialysis burden, to preterm delivery and its long-term consequences for the child. These risks force patients and clinicians alike to confront difficult realities, including the possibility of a shortened lifespan and complex medical trajectories. Which is precisely why preconception counselling and multidisciplinary care are not optional, they are essential.

The delicate and  Disrupted hormonal axis 

In women, normal reproductive function depends on a accurately coordinated hypothalamic–pituitary–gonadal (HPG) axis, where cyclical hormonal surges ensure oocyte maturation and ovulation. (Figure 1). A key event here is the luteinizing hormone (LH) surge, triggered by pulsatile GnRH secretion. In CKD, this system doesn’t quite behave as expected. There is reduced cyclical GnRH secretion, which leads to an inadequate LH surge, resulting in anovulatory cycles. Add to this the elevated prolactin levels commonly seen in advanced CKD, which further suppress GnRH via negative feedback, and the cycle becomes even more disrupted. Clinically, this translates into menstrual irregularities like amenorrhea, menorrhagia and premature menopause. And then, of course, there are drugs like cyclophosphamide, which we use with purpose but one that carries well-known direct gonadal toxicity, further compromising fertility.

In men, the story mirrors a similar disruption. CKD leads to dysregulation of the male HPG axis, resulting in reduced testosterone production and impaired spermatogenesis. Dysfunction of Sertoli and Leydig cells contributes to reduced levels of anti-Müllerian hormone and inhibin B, which in turn drive compensatory increases in LH and FSH, though often without restoring normal function, ultimately resulting in impaired spermatogenesis and decrease fertility.

Figure 1: Sexual dysfunction in CKD patients

More Than Hormones: The Psychosocial Dimension

The struggle in our CKD patients is also compounded by depression, reduced libido, and negative body image factors that are rarely discussed but deeply impactful. Which brings us to the real question.

We know all of this.

We understand the hormonal pathways. We recognize the risks. We even publish a lot on these topics. But what do we actually do when reproductive health quietly enters the clinic room?

Do we ask? Do we wait? Or do we… look away? Because, let’s be honest, most of the time, the conversation never even begins.

What Happens in Real Clinics: Insights from a recent study

To get more exploratory on  this,  in a recent article in KI reports by Semaska et al. based on a 52-question electronic survey of US nephrologists with 121 respondents. The survey examined how often reproductive topics are discussed, how confident physicians feel addressing them, and what barriers get in the way. The survey was structured into 6 important sections as follows: (i) demographics; (ii) concerns identified by female patients; (iii) reproductive health concerns addressed by physicians, including referral practices; (iv) physician confidence in addressing reproductive health for female patients with kidney disease; (v) influences on physician counselling regarding contraception and reproductive health in female patients with CKD; and (vi) barriers and resources. Among the 104 nephrologists analyzed, 51% were female, most were 41–50 years of age, and the median practice experience was 6–10 years. The majority practiced in academic settings (78%) and 58% reported caring for more than 15 women of child-bearing age with CKD in the previous year. However, 27.7% had not encountered a pregnant CKD patient during the same period.

Graphical abstract by Edgar V Lerma MD

The Communication Gap: When Silence Becomes the Norm

The survey showed a striking communication gap regarding reproductive health. Sexual dysfunction was the least discussed issue, with 90% of nephrologists reporting that patients rarely or never raised this topic, and 82% of physicians rarely initiated such discussions themselves. This silence is an intriguing finding particularly given the known hormonal and reproductive disturbances associated with CKD. Similarly, menstrual abnormalities were rarely addressed, with 61% of patients rarely raising the issue and 59% of nephrologists rarely discussing it. Infertility concerns were also infrequently mentioned by patients (70% “never/rarely” discussed). 

Physician confidence and  practice patterns

More than half reported no confidence in managing sexual dysfunction, and 42% lacked confidence in addressing menstrual disorders. The highest confidence was seen in managing antihypertensive therapy during pregnancy and pregnancy-related immunosuppression whereas confidence in breastfeeding counselling remained modest (34% quite/very confident). 

Contraception in CKD: Practical but Under-discussed

Contraception and family planning were more frequently discussed as compared to other issues, although practice remained inconsistent. Approximately one-third of nephrologists still reported rarely discussing contraception. When counselling did occur, intrauterine devices were the most commonly recommended contraceptive method, followed by barrier methods and hormonal contraception. Sterilization was rarely suggested. In the study, confidence of nephrologist was comparatively higher for contraception management, where 22% reported high confidence and only 13% reported no confidence. Appropriate contraception in CKD should be individualized based on disease stage, comorbidities, and medications. Long-acting reversible contraception, including intrauterine devices (copper or levonorgestrel) and implants, is preferred due to high efficacy and safety. Progesterone-only methods are suitable, especially in advanced CKD, as they avoid estrogen-related thrombotic risk (Figure 2). Combined hormonal contraceptives may be used cautiously in early CKD without hypertension or proteinuria. Barrier methods can be adjuncts but have higher failure rates. In transplant recipients, drug interactions must be considered.

Figure 2: Contraception for women with chronic kidney disease

A Mirror to Our Practice

Reading the study helps one realize the silence in the room about such an important topic, mirroring  nephrology practice. And the reflection is both quite familiar and slightly uncomfortable. The study asks a simple question: are nephrologists addressing reproductive health in women with CKD adequately or even at all? According to this survey, the answer seems to be “not really.” The disappointing numbers represent  the gap between what we expect nephrology care to include and what actually happens in clinic. 

The Quiet Feedback Loop

Let’s have a look on numbers. Surprisingly, 90% of nephrologists reported that patients rarely or never bring up sexual dysfunction, and 82% admitted they rarely initiate the conversation themselves. Which begs the question; why are patients not bringing up the topic known to affect a large proportion of women with CKD.   There is ample literature demonstrating sexual dysfunction and menstrual irregularities as common complains in CKD, yet they are among the least discussed topics in nephrology consultations. This creates a quiet feedback loop: patients hesitate to ask, doctors hesitate to ask, and the topic disappears entirely from clinical care.

Another interesting observation is the difference between comfort and clinical priority. Nephrologists seemed much more confident discussing pregnancy medications, and managing immunosuppression.  This gives us an idea about how physicians think. We tend to focus on the medical problems and issues. We are trained to manage drugs, blood pressure, transplant immunosuppression in a reactionary fashion. But topics like sexual health, fertility, and menstrual disorders sit at the intersection of nephrology, gynecology, and psychosocial care, and therefore often fall through the cracks.

Experience Over Time: What Builds Confidence?

Another intriguing finding in the study is what drives physician confidence. Years in practice had no impact on confidence in care. Instead, confidence increased when nephrologists actually saw more reproductive-age CKD patients. Physicians seeing more than 15 such patients annually were significantly more confident discussing contraception and pregnancy-related management.  Physicians who managed larger numbers of reproductive-age or pregnant CKD patients reported significantly greater confidence in counselling on contraception, immunosuppression during pregnancy, breastfeeding, and antihypertensive therapy. This puts a lens on medicine practices: experience with the right patient population matters more than time spent in practice.

Barriers or Excuses?

The barriers identified lack of guidelines, limited clinic time, and knowledge gaps; reasons all too familiar echoed in previous reproductive health and management studies..  But one has to wonder: are these true barriers, or are they sometimes our convenient explanations? After all, reproductive counselling may not always require following strict protocol and remembering the complex protocols. Sometimes it begins with a simple question: “Are you planning pregnancy in the future? How is your sexual life? Do you know changes in reproductive health are observed in CKD? How are you dealing with changes in the sexual life that CKD has brought in your life”

The Missed Window

The study rightly highlighted that what actually happens in the daily practice is that we start discussing reproductive health when the stakes are already high, at advanced stages of kidney diseases or surrounding kidney transplantation care, rather than earlier when prevention and planning would make the greatest difference.  

Pregnancy Changes the Kidney’s Story

Pregnancy does not merely coexist with CKD; it can significantly influence its trajectory. Studies suggests a measurable decline in kidney function following pregnancy. In one study, the estimated glomerular filtration rate (eGFR) declined at a baseline rate of approximately 1.8 mL/min/1.73 m² per year prior to pregnancy. However, the reduction between the pre-pregnancy and postpartum periods was more pronounced, averaging around 4.5 mL/min/1.73 m². Clinically, this indicates that pregnancy may accelerate the progression of underlying kidney disease. The magnitude of decline observed was comparable to approximately 1.7 years of pre-pregnancy disease progression in CKD Stage 3a, 2.1 years in Stage 3b, and up to 4.9 years in advanced CKD (Stages 4–5).

Data from the CURE-GN study reinforces this concern patients with complicated pregnancies show a significantly steeper annual decline in kidney function (−1.96 ml/min/1.73 m²/year) compared with those with uncomplicated pregnancies (−0.80) or no pregnancy history (−0.64).

Complications We Can’t Ignore

The risk of hypertensive disorders of pregnancy rises dramatically in CKD, compared to general obstetric population. Women with advanced CKD face not only reduced fertility, but also a much higher likelihood of unsuccessful or complicated pregnancies marked by hypertension, preeclampsia, anemia, miscarriage, polyhydramnios, prematurity, and intrauterine growth restriction. The consequences extend beyond the mother. Adverse perinatal outcomes like stillbirth, medically indicated preterm birth, and SGS infants

So perhaps the real question is no longer whether we should discuss reproductive health in nephrology clinics.

It’s this:

Can we afford not to?