PURPOSE: Autonomic dysfunction has been reported in myasthenia gravis (MG); however, its clinical relevance and relationship with sexual dysfunction (SD) remain unclear. This study aimed to evaluate autonomic dysfunction in MG and to investigate its association with SD using objective autonomic tests. METHODS: A total of 44 patients with MG and 50 age- and sex-matched healthy controls (HCs) were included. Autonomic function was assessed with the Composite Autonomic Symptom Score-31 (COMPASS-31), sympathetic skin response (SSR), and R-R interval variability (RRIV). Ocular autonomic involvement was evaluated using the Schirmer test, noninvasive tear break-up time, pupillometry, and corneal confocal microscopy. Sexual function was assessed using the Female Sexual Function Index, International Index of Erectile Function, and Premature Ejaculation Profile. Depression and anxiety were evaluated with the Beck Inventories. RESULTS: Patients with MG showed prolonged SSR latencies, reduced amplitudes, and lower RRIV than HCs (p < 0.05). COMPASS-31 total scores were higher, especially in vasomotor, secretomotor, gastrointestinal, and bladder domains. Corneal nerve fiber density, length, and branching were significantly reduced in patients with MG (p < 0.05). SD scores were significantly worse and correlated with selected autonomic measures. After adjustment for age, depression, and anxiety, reduced corneal nerve fiber parameters were independently associated with SD. In male patients, RRIV during hyperventilation and gastrointestinal autonomic symptom burden were associated with ejaculatory function. CONCLUSIONS: Patients with MG exhibit evidence of autonomic dysfunction based on objective autonomic assessments. SD is common in patients with MG and appears to be associated with autonomic dysfunction beyond psychosocial factors alone.