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Women

1. Periods in women with kidney failure and after transplantation

Irregular periods can occur in women with kidney failure and after transplantation. It is common for women with advanced kidney failure either to stop having periods, or to have irregular periods. However that does not mean these women are completely infertile (unable to have a baby), so contraception should still be used. After a successful kidney transplant, periods usually return to a more normal pattern.

Menstrual periods and fertility

It is common for the menstrual periods to become irregular when women develop kidney failure. If a woman has kidney function less than 20% of normal (blood creatinine level roughly over 250 micromoles per litre in a young woman), she will probably be less likely to become pregnant than normal, even if she is having regular sex. However, contraception should still be used, as pregnancy is possible.

In dialysis patients, periods often stop completely or are irregular. This means that women on dialysis are very unlikely to become pregnant. However, again, women should not rely on this as a form of contraception. It is still possible to get pregnant even if the periods are absent.

Treatment with erythropoeitin (EPO) has been shown to restore menstrual periods in about 50% of women on dialysis. This is thought to be due to two effects of EPO, improving disturbed hormone levels, and treating anaemia. Treatment with EPO increases a woman's chance of becoming pregnant, so contraception should always be used to avoid an unwanted pregnancy. 

1. Should women with kidney failure have hormone replacement treatment?

Young women on dialysis who have no periods, and all women with kidney disease after the menopause, should consider hormone replacement treatment.

Hormone replacement therapy should be considered by post menopausal women with kidney failure, and also by younger women who do not have periods, or have very irregular periods. Research has shown that women with kidney failure do not often receive hormone replacement. The reasons for this are not clear.

Women should discuss the advantages and disadvantages of treatment in their own case with their own kidney doctors and nurses.

Advantages

Will someone on hormone replacement therapy feel better?  Normally hot flushes will go away and there has been very little research on this in kidney failure, but one study did report an increase in well being and sex drive.

Post menopausal women are at increased risk of heart problems and osteoporosis and it would seem likely at first sight that carrying on with oestrogen hormones after the meonpause would reduce the development of these problems. Unfortunately, the data from clinical trials is not yet conclusive.  It may be that starting HRT soon after menopause has some delaying effects on bone and heart disease and women taking HRT seem slightly less likely to die prematurely.  However, these data have not been proven in women with kidney disease and the benefits to the bones and the heart may not happen if HRT is started a long time after the menopause.

Disadvantages

Hormone replacement therapy causes menstrual bleeding to occur.  There are also side effects of hormone replacement therapy that may occur in anyone, such as high blood pressure.

Also, some research has suggested that the dose of hormone replacement therapy needed by women may be affected by kidney failure or dialysis. The hormones in HRT can increase the risk of developing blood clots and this might be even more important in patients with kidney disease, especially if they are on dialysis, where higher haemoglobin levels have been shown to increase the risk of blood clots.  There may also be an increased risk of breast cancer.  A woman with kidney disease who is thinking of taking HRT should have a detailed discussion with their medical 
team about the risks and benefits of the treatment.

1. Sex and dialysis treatment

Sex is possible for women with kidney failure. Some people worry that the catheter (tube) for peritoneal dialysis, which hangs from the tummy just below the belly button, will stop them having sex. Others worry that a kidney transplant, which is placed low down in the tummy, might also be a problem. Neither of these should prevent anyone on peritoneal dialysis having sex.

t is possible that the tip of a peritoneal dialysis catheter might lie low in the pelvis and that sex could cause discomfort for a woman, but this does not seem to happen often. It is said that it is best to tape down a peritoneal dialysis catheter, or have some clothing over, in case your partner grabs hold of it during a moment of passion.

Research in Coventry (UK) has shown that people on peritoneal dialysis and haemodialysis both report similar sex lives (scoring 40/100 on a questionnaire). People with functioning kidney transplants did better, scoring 59/100. Although these scores do not sound very high, the general public do not score anywhere near 100.

1. Loss of sex drive and other sexual problems

Although loss of sex drive can be an emotional problem, women should not think that this is always the case. Problems such as anaemia and hormone deficiency can cause loss of sex drive in women, and these are treatable

Whilst the sexual difficulties of male dialysis patients are often neglected, those of female patients are almost completely ignored. As yet, there has been very little research carried out into the sexual difficulties of female dialysis patients. The largest study was a survey of 99 Italian female haemodialysis patients. Compared to women who did not have kidney failure, the dialysis patients had sex less often and were less able to have an orgasm. Also, most patients noticed a loss of sex drive. If a young woman is not having periods, research has shown that, with hormone replacement therapy, sex drive is often improved. This is in addition to the other benefits of hormone replacement therapy. Some women with kidney failure are deficient in testosterone. Although this is normally thought of as a male hormone, it is required, in small amounts, to play a part in female libido (sex drive). Sex life frequently returns to normal after a successful kidney transplant.

Specific sexual problems for women

Inhibited desire
Inhibited desire, not wanting sex, may be due to many factors. Women may still want to be intimate with their partners but not want penetration. If the physical problems associated with kidney failure (such as anaemia and hormonal problems) have been dealt with, then sex therapy may be an effective treatment, encouraging the couple to talk through problems and learn new techniques in lovemaking.

Lack of ability to orgasm
Many women can have pleasurable sex without orgasm, but lack of orgasm is a problem for many women. It is a myth that female orgasm is associated with penile penetration and thrusting. Most women need clitoral stimulation. Anaemia and hormonal disturbance can affect the ability to have an orgasm, and these should be treated. However, some women may require additional clitoral stimulation. This can be achieved using manual stimulation or a vibrator. If these do not work, a vacuum device called Eros (www.eros-therapy.com), which stimulates clitoral blood flow, may suit some women, though it is advised that it is used after advice from a doctor or psychosexual therapist. Trials are under way to investigate the value of creams containing a drug called alprostadil, which may increase genital and clitoral blood flow. This drug is also used to give impotent men erections.

Pain on intercourse (also called dyspareunia)
Pain during penetration is a common problem for women. It may be due to a lack of lubrication, or an infection such as thrush. An allergy to condoms or contraceptive creams may also be responsible.
A doctor or therapist may need to be consulted. If a women gets into a cycle where sex is always associated with pain, it may be damaging for the woman and her relationship with a partner.

Vaginismus
This is an involuntary spasm, or tightening, of the muscles around the vagina, which may make penetration painful or impossible. Many different factors can cause vaginismus, such as painful intercourse, anxiety and previous traumatic experiences such as sexual abuse or complicated childbirth. It is important to recognise that vaginismus may occur in women who are otherwise sexually responsive and affectionate with their partner. A doctor or sex therapist should be able to help someone with vaginismus.

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The National Kidney Federation cannot accept responsibility for information provided. The above is for guidance only. Patients are advised to seek further information from their own doctor.