Sexual dysfunction in epilepsy

Comparison of Psychological Difficulties in Patients with Migraine and Epilepsy Using PARADISE-24 Questionnaire

BACKGROUND

Patients with migraine or epilepsy suffer from a wide range of psychological difficulties, and various instruments are needed to separately assess each difficulty. However, the PARADISE-24 questionnaire is a comprehensive questionnaire for evaluating different psychological difficulties in cases with neurological disorders.

OBJECTIVE

The aim of this study was to compare psychological difficulties in patients with migraine and those with epilepsy by using the PARADISE-24 questionnaire.

METHODS

Overall, 240 migraineurs and 210 patients with epilepsy were enrolled. All the participants were asked to fill the Persian version of the PARADISE-24 questionnaire.

RESULTS

In migraineurs, the mean age and mean headache severity (by means of visual analogue scale, VAS) were 38.6±11.6 and 6.8±2.8, respectively. In patients with epilepsy, the mean age and mean duration of the disease were 33.6±13.4 and 12±10.3 years, respectively. The mean PARADISE score was significantly higher in migraineurs than in epileptic cases (57.9±12 vs 50.7±15.1) (p<0.001).

CONCLUSION

Patients with migraine suffer more from psychological difficulties than epileptic cases. This finding could help physicians to pay more attention to psychological well-being.

Evaluation of sex hormones and sperm parameters in male epileptic patients

OBJECTIVES

The aim of this study was to investigate the effect of carbamazepine (CBZ) and sodium valproate (VPA) monotherapy on sexual functions, sex hormones, and semen analysis and quality in male patients with epilepsy.

METHODS

A total of 59 male patients with epilepsy, of which 30 were on VPA monotherapy and 29 were on CBZ monotherapy, were included in the study between January 2015 and March 2016. A control group was established with 30 healthy males. Luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin (PRL), free testosterone (fT), estradiol (E2), sex hormone-binding globulin (SHBG) levels and bioactive testosterone (BAT)/bioactive estradiol (BAE), and BAT/LH ratio were studied in groups. All groups received semen analysis and International Index of Erectile Function Scale (IIEF-5) test for erectile dysfunction.

RESULTS

E2 and DHEAS levels were higher in VPA and CBZ groups compared to control group (P < .001, P = .014). The decrease in fT levels in the VPA group was statistically significant (P = .038). No significant difference was detected in levels of SHBG, LH, and FSH (P > .05). BAT/BAE ratios were low both in VPA and CBZ groups (P < .001; P < .001), while BAT/LH ratios were low only in CBZ group (P = .033). In semen analysis, semen volume and number of normal sperms were found to be significantly lower in patients receiving antiepileptic drugs compared to control group (P < .05). There were no differences between the groups in rates of abnormal sperm morphology. IIEF-5 scores were found to be significantly lower in VPA and CBZ groups (P < .001).

CONCLUSION

VPA or CBZ therapy may lead to dysregulation of sex hormones, sexual dysfunction, and alterations in semen analysis in male patients with epilepsy. This must be considered for the selection of antiepileptic drugs in young male patients.

Effects of different physical exercise programs on susceptibility to pilocarpine-induced seizures in female rats

In epilepsy, the most common serious neurological disorder worldwide, several investigations in both humans and animals have shown the effectiveness of physical exercise programs as a complementary therapy. Among the benefits demonstrated, regular exercise can decrease the number of seizures as well as improve cardiovascular and psychological health in people with epilepsy. While many studies in animals have been performed to show the beneficial effects of exercise, they exclusively used male animals. However, females are also worthy of investigation because of their cyclical hormonal fluctuations and possible pregnancy. Considering the few animal studies concerning seizure susceptibility and exercise programs in females, this study aimed to verify whether exercise programs can interfere with seizure susceptibility induced by pilocarpine in adult female Wistar rats. Animals were randomly divided into three groups: control, forced, and voluntary (animals kept in a cage with a wheel). After the final exercise session, animals received a pilocarpine hydrochloride (350 mg/kg i.p.; Sigma) injection to induce seizures. To measure the intensity of pilocarpine-induced motor signs, we used a scale similar to that developed by Racine (1972) in the kindling model. During a 4-h period of observation, we recorded latency for first motor signs, latency for reaching SE, number of animals that developed SE, and intensity of pilocarpine-induced motor signs. No difference was observed among groups in latency for first motor signs and in the number of animals that developed SE. Although the voluntary group presented more intense motor signs, an increased latency for developing SE was observed compared with that in forced and control groups. Our behavioral results are not enough to explain physiological and molecular pathways, but there are mechanisms described in literature which may allow us to propose possible explanations. Voluntary exercise increased latency to SE development. Further investigation is necessary to elucidate the pathways involved in these results, while more studies should be performed regarding gender specific differences.

Sexual dysfunction in women with epilepsy

BACKGROUND

Sexual functioning and variables that influence sexual functioning have not been studied in Indian women with epilepsy.

MATERIALS AND METHODS

In a pilot study, female (age, 18-45 years) outpatients with epilepsy who were in a stable sexual relationship for at least 1-year were screened using the mini international neuropsychiatric interview. Those without anxiety or depressive disorders (n = 60) were studied using the female sexual function index (FSFI; higher scores indicate better functioning). Findings were compared with age- and sex- matched sample of healthy control women drawn from the same sociodemographic population.

RESULTS

Women with epilepsy had significantly poorer sexual functioning on all FSFI subscales (desire, arousal, lubrication, orgasm, satisfaction, pain), as well as on the total scale scores, and >70% of these women were rated as dysfunctional on individual FSFI subscales and on the total scale. In multivariate analysis, use of clobazam and phenobarbitone, and longer time after the last seizure were each associated with significantly higher FSFI scores; and longer duration of epilepsy was associated with significantly lower FSFI scores.

CONCLUSION

There is a substantial impairment of sexual functioning in women with epilepsy. This study demonstrates the need for increased awareness of the problem, better case identification, and improved seizure control.

Sexual desire and satisfaction after resective surgery in patients with mesial temporal lobe epilepsy with hippocampal sclerosis

Utilizing a questionnaire, we inquired about the self-perceived sexual behavior of 50 married males with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) before and after anterior temporal lobectomy (ATL) and compared the results with those of 50 age-matched healthy married males. The sexual desire and satisfaction of the patients were poor when compared to the controls. Although a majority of the sexual domains improved following ATL, even after a median duration of five years, the sexual status of the patients did not match with that of the controls. Those who, after ATL, were seizure free, had one or no antiepileptic drug (AED) and had an EEG without epileptiform abnormalities achieved a better sexual outcome. We conclude that sexual dysfunction is frequent in male patients with MTLE-HS. They require preoperative assessment to identify their sexual inadequacies as well as counseling about the expected post-ATL sexual outcome. Discontinuation of enzyme-inducing AEDs facilitates post-ATL improvement in sexual function.

Association between epilepsy and erectile dysfunction: evidence from a population-based study

INTRODUCTION

Although the association between epilepsy and sexual disorders has long been known, very few studies have attempted to explore the association between epilepsy and erectile dysfunction (ED).

AIM

This population-based case-control study aimed to investigate the association between ED and a prior diagnosis with epilepsy.

METHODS

This study used data from the Longitudinal Health Insurance Database 2000 in Taiwan. The cases comprised 6,427 patients with a diagnosis of ED and 32,135 controls who were frequency matched with cases based on 10-year age groups and index year. Conditional logistic regression was used to calculate the odds ratios (ORs) for prior epilepsy.

MAIN OUTCOME MEASURE

The prevalence and risk of epilepsy between cases and controls.

RESULTS

Of the sampled patients, 3,861 (14%) were diagnosed before the index date: 1,358 individuals (19.7%) were cases and 2,503 (12.1%) were controls. After adjusting for hypertension, diabetes, hyperlipidemia, renal disease, coronary heart disease, obesity, alcohol abuse/alcohol dependence syndrome, and socioeconomic status, conditional logistic regression analysis revealed that patients with ED were more likely to have been diagnosed with prior epilepsy than controls (OR = 1.83, 95% CI = 1.51-2.21). Compared with controls, the adjusted ORs for prior generalized epilepsy and partial epilepsy for cases were 2.13 (95% CI = 1.52-3.00) and 1.64 (95% CI = 1.31-2.06), respectively. The most pronounced associations were detected in ED cases aged between 30 and 39 who were 3.04 (95% CI = 1.67-5.50) times more likely than controls to have been previously diagnosed with epilepsy.

CONCLUSIONS

Our findings suggest a positive correlation between ED and a prior diagnosis with epilepsy.

Behavioral risk factors among Arizonans with epilepsy: Behavioral Risk Factor Surveillance System 2005/2006

Modifiable risk factors to help improve health outcomes for people with epilepsy in Arizona were identified using the 2005-2006 Arizona Behavioral Risk Factor Surveillance System (BRFSS). Of 9524 adults who participated in this survey, 125 reported ever being diagnosed with epilepsy (lifetime prevalence=1.3%, 95% CI=1.1-1.6%). Individuals with active epilepsy (those who had seizures in the prior 3 months and/or were taking anticonvulsants) had an overall lower quality of life. This likely resulted from a large number of medical comorbidities and poor mental and physical health days. Regression models suggested that for individuals with active epilepsy, physical activity was associated with fewer activity-limited days, whereas for individuals with inactive epilepsy, medical comorbidity was positively associated with activity-limited days. Further research is needed to increase the reliability of the findings.

The pilocarpine model of epilepsy: what have we learned?

The systemic administration of a potent muscarinic agonist pilocarpine in rats promotes sequential behavioral and electrographic changes that can be divided into 3 distinct periods: (a) an acute period that built up progressively into a limbic status epilepticus and that lasts 24 h, (b) a silent period with a progressive normalization of EEG and behavior which varies from 4 to 44 days, and (c) a chronic period with spontaneous recurrent seizures (SRSs). The main features of the SRSs observed during the long-term period resemble those of human complex partial seizures and recurs 2-3 times per week per animal. Therefore, the pilocarpine model of epilepsy is a valuable tool not only to study the pathogenesis of temporal lobe epilepsy in human condition, but also to evaluate potential antiepileptogenic drugs. This review concentrates on data from pilocarpine model of epilepsy.

Sexual quality of life in epilepsy: correlations with sex hormone blood levels

Seventy-nine consecutive inpatients of an epilepsy center (34 women, 45 men) who had either generalized epilepsy, temporal lobe epilepsy, focal epilepsy of other origin, or no epilepsy completed the Derogatis Interview for Sexual Function-Self-Report Inventory. Quantitative assessments of blood levels were performed for prolactin, total testosterone, sex hormone-binding globulin, estradiol, dehydroepiandrosterone sulfate, luteinizing hormone, and follicle-stimulating hormone. In men, increasing sex hormone-binding globulin levels and duration of epilepsy decreased sexual quality of life. Sex hormone-binding globulin level in men was related to enzyme-inducing antiepileptic drugs and age. In women, we found no associations between blood hormone levels and sexual quality of life. Our results suggest that sexual quality of life is affected by sexual hormone blood levels in men, but not in women with epilepsy. Avoiding enzyme-inducing antiepileptic drugs may lower the risk of raised sex hormone-binding globulin levels and, thus, of lowered sexual quality of life in men with epilepsy.

Effect of hormonal replacement therapy in the hippocampus of ovariectomized epileptic female rats using the pilocarpine experimental model

Amado and Cavalheiro [Amado, D., Cavalheiro, E.A., 1998. Hormonal and gestational parameters in female rats submitted to the pilocarpine model of epilepsy. Epilepsy Res. 32, 266-274], studying the establishment of the pilocarpine epilepsy model in female rats observed that the estrous cycle was dramatically altered during the three periods of this experimental model. This work was delineated to study the function of sexual hormones in the development of the epilepsy model induced by pilocarpine in ovariectomized rats. Experimental groups were: (a) control animals during estrus phase of the estrous cycle (E) and ovariectomized female rats (OVX) treated with saline instead of pilocarpine in the same volume, (b) experimental animals, that developed status epilepticus (SE) and were studied during the chronic phase of this model: intact chronic rats (CHRON) and ovariectomized chronic rats (OVX+CHRON) and (c) ovariectomized chronic rats, that were submitted to hormonal replacement therapy treated with: medroxyprogesterone (OVX+CHRON+MPA); 17beta-estradiol (OVX+CHRON+E2), or both (OVX+CHRON+E2+MPA). All ovariectomized animals showed genital atrophy 4 days after the surgical procedure. Moreover, all animals that developed SE and survived showed spontaneous recurrent seizures during the chronic phase. Concerning to seizure frequency, animals receiving medroxyprogesterone associated with 17beta-estradiol showed decreased seizures' number. However, animals that received only medroxyprogesterone therapy also showed reduction in the number of seizures. In addition, hormonal treatment was also able to stabilize the mossy fibers sprouting process, showing the importance of these hormones in the development of the epilepsy in female rats.

Women with epilepsy: hormonal issues from menarche through menopause

Epilepsy is a multilayered disorder complicated by numerous comorbid conditions and hormonal changes. More than 1.5 million girls and women with epilepsy face side effects that are compounded at different ages by menstruation, fertility, pregnancy, fetal health, bone health, and other health issues. Changes in hormonal balance during maturation, from menarche through menopause, affect seizure thresholds and antiepileptic drugs, and vice versa. This overview provides physicians with a background on the multiple issues relevant to women of all ages in the reproductive years, including those planning to conceive and those who are pregnant, and beyond the childbearing years.

[Influence of neurological diseases on partnership and sexuality. Particularly in view of multiple sclerosis and Parkinson's disease]

A great number of neurological diseases exert a direct impact on sexuality, due to lesions in the central and peripheral nervous system and due to different neurological symptoms and their treatment (for example medication). The psychosocial basic needs for acceptance, intimacy, and security, which can be best fulfilled by sexual communication, attain essential importance in the situation of disease-induced helplessness. This implies that not only the experience of sexual pleasure and the functioning of reproduction can be influenced, but the partnership, too. A holistic treatment approach always requires the consideration of partnership aspects.

Hypersexuality in two patients with epilepsy treated with lamotrigine

PURPOSE

Lamotrigine (LTG) is a novel anticonvulsant drug that exerts an antiepileptic effect by decreasing glutamate release through inhibition of voltage-sensitive sodium channels. LTG has no effect on serum levels of most female reproductive hormones, but its effect on male reproductive hormones still remains unclear. Improvement in sexual function after LTG treatment has been reported, and could have been caused by reduction of seizures, inhibition of focal discharges, or an unknown effect of LTG on reproductive hormones and protein levels.

CASES

Two male patients exhibited acute hypersexuality while taking lamotrigine as add-on therapy: one patient on carbamazepine and one on oxcarbazepine. Neither prior history of psychiatric illness nor brain damage predisposed them to such a response to treatment, and in both patients, the hypersexuality was not a part of hypomania or a more diffuse psychiatric disturbance. In the first case, sexual hyperactivity resolved after discontinuation of LTG therapy without any concomitant treatment. In the second case, a reduction in the dose of LTG decreased the intensity of the hypersexuality and contributed to the patient's increased satisfaction with his sex life.

CONCLUSIONS

Lamotrigine may cause drug-related hypersexuality by an unclear underlying mechanism.

Erectile dysfunction associated with pregabalin add-on treatment in patients with partial seizures: five case reports

Sexual dysfunction has been reported in both men and women with epilepsy. Associated factors are diverse but include, among others, antiepileptic drugs. We present the cases of 5 men who reported mild to moderate erectile dysfunction or impotence for the first time when treated with the new antiepileptic drug pregabalin as add-on therapy.

Behavioral seizure correlates in animal models of epilepsy: a road map for assay selection, data interpretation, and the search for causal mechanisms

A broad spectrum of learning/memory, social interaction, and affective behavioral measures serve as functional correlates for neurobiological changes in seizure-prone animals as well as in epileptic clinical populations. The utility of such measures is demonstrated by their ability to distinguish anomalous characteristics in developing organisms predisposed to seizure onset, as well as to discriminate prior seizure history in organisms with established pathology. For instance, typical findings that generalize across species suggest that seizure-experienced organisms exhibit a variety of deficits in cognitive function as well as inappropriate social neglect and aggression. Behavioral testing batteries have also proven useful in assessing neural mechanisms for seizure induction, subcortical neural circuits, and neuropeptide modulators, for example, as well as in identifying neural pathology resulting from prior seizure activity. However, the wanton application of behavioral tests can also produce false positives in the identification of seizure-related disorders unless alternative performance and motivational hypotheses are discounted effectively. Accordingly, the present review attempts to provide the reader interested in behavioral phenotyping and characterization of seizure-prone rats and mice with a roadmap for rational selection, implementation, and interpretation of data from behavior assays while highlighting potential successes and pitfalls inherent in employing functional correlates of brain activity using animal models of epilepsy.

Reproductive and sexual dysfunction in men with epilepsy

Disturbances of reproductive and sexual health are common in people with epilepsy. Their etiology is not well understood but appears to be multifactorial, and both epilepsy itself and drugs used to treat it are implicated. Physiologically, sex steroid hormone levels, the hypothalamic-pituitary axis, and testicular function can be affected in men with epilepsy. Psychosocial complications associated with epilepsy can also affect reproductive health and sexuality. Clinicians need to investigate such problems carefully, both because of their multifactorial nature and because patients and physicians alike may often fail to recognize or be reluctant to acknowledge them; in particular, patients whose epilepsy had its onset before puberty may lack subjective awareness of impairments of sexual response and function. Treatments for reproductive and sexual dysfunction in men with epilepsy have been inadequately studied. Modalities such as medications for erectile dysfunction and surgery may be useful. Therapy with exogenous testosterone and an aromatase inhibitor may be helpful for men with epilepsy and sexual dysfunction due to testosterone deficiency.

The sexual and reproductive health in men with generalized epilepsy: a multidisciplinary evaluation

This study was specifically aimed to evaluate the sexual and reproductive health in a group of men with generalized epilepsy. In total, 44 men with generalized epilepsy were included in this study, their ages between 18 and 48 years (29.2+/-9.9) and duration of illness between 2 and 35 years (11.2+/-7.4); 34 patients were treated with conventional antiepileptic drugs (AEDs). Sexological and psychological interviews together with serum total testosterone, E(2), FSH, LH and prolactin were determined. Hyposexuality was diagnosed in 61.4%. Erectile dysfunction (ED) and premature ejaculation represented 70.4 and 66.7%, respectively. Variables such as hyposexuality, seizure duration and its poor control on AEDs were significantly associated with depressive symptoms. Compared to the normal control group, all patients reported elevated E(2) levels (P<0.001), 10 had FSH (n=4) and LH (n=6) levels exceeding that of the normal range for controls and two had hyperprolactinemia. Although the patients' mean value of total testosterone remained within the normal range, but it was significantly lower in hyposexual men compared to nonhyposexual (P<0.002), only two epileptic patients had markedly reduced level of total testosterone beyond normal control levels. This study strongly supports that: (1) The risk of hyposexuality and reproductive disturbances is high in epileptic patients with GTC convulsions despite the AEDs utilized. The risk for SD is further increased by poor seizure control and the frequently accompanied depressive manifestations. (2) It is possible that elevated E2 could increase the risk of SD by reducing active testosterone through negative feedback and the reduction of active testosterone could increase seizure intractability to antiepileptic medications.

Phenotyping the untouchables: environmental enhancement of behavioral and physiological activation in seizure-prone El mice

The onset and frequency of spontaneous and tail suspension-induced seizures in El mice appear to be influenced strongly by developmental and experiential factors over the first 3 months of life. To assess the impact of social factors on behavioral characteristics of El mice prior to the age of seizure susceptibility, locomotor activity and exploratory measures of arousal were recorded in 40-day-old El and control DDY mice exposed to group and isolation housing conditions. Once mice reached maturity, physiological reactivity to a tail suspension stressor was evaluated. The locomotor activity measure revealed circadian entrainment in both strains, nocturnal hyperactivity in El mice, and a locomotor activity-attenuating effect of group housing in El mice. In the two-compartment model of exploration, latency to enter, transitions to and from, and rearing in a brightly lit compartment were 50% higher in El relative to DDY mice, again suggesting a hyperactive phenotype. Finally, an acute 2-minute tail suspension stressor applied to 75-day-old mice implanted with radiotelemetry transmitters revealed a reactive tachycardia in El, but not DDY, mice. No seizures were observed during any of the experimental manipulations. Taken together, these results suggest that spontaneously occurring deviations in behavioral and cardiovascular measures of arousal characterize preseizure El mice and that motor features of hyperarousal can be exaggerated by the environmental manipulation of isolation housing.

Androgens in the hippocampus can alter, and be altered by, ictal activity

Steroid hormones, such as androgens, can modulate seizure processes. This review summarizes prior research and presents new data that support the role of androgens in modulating seizure processes. Testosterone, the primary endogenous androgen, has antiseizure effects in people and in animal models of epilepsy. Furthermore, testosterone's antiseizure effects may involve actions of its 5alpha-reduced metabolite and neuroactive steroid, 5alpha-androstane-3alpha,17beta-diol (3alpha-diol). The hippocampus is a target for androgen action and is involved in many types of seizure disorder. Data suggest that actions of androgens in the hippocampus may be important for androgens' antiseizure effects. Interestingly, there may also be a reciprocal relationship between androgens and seizures. Ictal activity can alter the gonadal responsiveness of people with epilepsy and in animal models of seizure disorder. Thus, this paper will review data in support of androgens' antiseizure effects. Further understanding of androgens' role in seizure processes is important for potential therapeutic effects.

Aromatase inhibition, testosterone, and seizures

The effect of testosterone on brain excitability is unclear. The excitatory aspect of testosterone's action in the brain may be due to its conversion to estrogen via aromatase. We report herein a 61-year-old man with temporal lobe epilepsy and sexual dysfunction due to low testosterone levels. Use of an aromatase inhibitor, letrozole, normalized his testosterone level and improved his sexual functioning. Letrozole, in addition to standard antiseizure medication, was also associated with improved seizure control. This was sustained and, further, was associated with seizure exacerbation after withdrawing letrozole, and subsequent seizure improvement after restarting it. During the course of treatment, his serum testosterone level increased, sex hormone-binding globulin decreased (SHBG), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels increased, while serum estradiol levels remained undetectable. Letrozole may, therefore, have produced a central alteration in the testosterone/estrogen ratio, thereby impairing estrogen-mediated feedback control of the pituitary, resulting in the observed increase in circulating LH and FSH levels. This experience suggests that aromatase inhibitors should be further investigated as a beneficial treatment modality for male patients with epilepsy.

Sexual outcome after epilepsy surgery

The aim of this study was to provide a description of patient-perceived sexual change after temporal lobe resection (TLR) and extratemporal resection (ETR). Fifty-eight TLR and sixteen ETR patients completed a semistructured interview and questionnaire assessing sexual change after epilepsy surgery. Five areas of sexual functioning were addressed: sexual drive, thoughts/fantasies, interest, masturbation, and activity. Each patient's perception of sexual changes relative to perceived levels of normal functioning was assessed. Characteristically, the onset of sexual change occurred in the first three postoperative months and persisted to the time of interview. A postoperative sexual change was significantly more likely to be reported by patients who had undergone TLR (64%) than ETR (25%). In the TLR group, sexual change was significantly more frequent following right-sided resections. Marked sexual change occurred more frequently in females than males. Postoperative sexual change is an important outcome feature after epilepsy surgery. The predisposition of TLR patients to postoperative change provides further evidence for a temporal lobe contribution to sexual function.

Sexual dysfunction and sudden death in epileptic male EL mice: inheritance and prevention with the ketogenic diet

PURPOSE

The EL mouse is an animal model for multifactorial idiopathic epilepsy. Although EL mice have been studied extensively for >45 years, the etiology of male sudden death and its relation to seizures have not been defined. Here we investigated the cause of EL male sudden death and its relation to epilepsy.

METHODS

For histopathologic analysis, the terminally ill EL mice (n = 15) were killed, and the tissues were fixed. Blood chemical composition was compared between the terminally ill EL (n = 9) and the healthy age-matched EL (n = 17) and DDY (n = 11) males. To determine the effect of the ketogenic diet (KD) on sudden male death, young male EL mice (P30) were randomly separated into two groups that were fed ad libitum with either Agway lab chow (control n = 38) or with the KD (treated, n = 39) for 5 months. The genetic predisposition to sudden death was analyzed in the backcross generation (n = 106) of a cross between EL and the nonepileptic ABP strains.

RESULTS

Sudden death coincided with the onset of seizures (70-80 days) and affected 94% of male EL mice by age 300 days. Urethral plugs were observed histologically in 13 of 15 longitudinally sectioned penises. Concentrations of blood urea nitrogen, creatinine, phosphorus, and calcium in the terminally ill mice were significantly elevated when compared with those of healthy animals. None of the mice treated with the KD experienced sudden death, whereas 15 (39%) of the untreated control mice died by age 5 months. The sudden death in male EL mice was inherited as an autosomal recessive sex-limited lethal trait.

CONCLUSIONS

The cause of sudden death in male EL mice arises from abnormal ejaculation, which produces a urethral plug with consequent urinary retention and acute severe uremia. The coincident onset of seizures and sudden death in EL males suggests that a sexual dysfunction is associated with epilepsy in this model.

Interictal hyposexuality in male patients with epilepsy

The purpose of this study was to compare the serum levels of androgens between hyposexual and non-hyposexual patients with epilepsy. Adult male patients with epilepsy were investigated. Serum levels of testosterone (T) and free-T, estradiol, and sex hormone binding globulin (SHBG) were measured and the free androgen index (FAI) was calculated. While there were no differences between hyposexual and non-hyposexual patients in the serum levels of T, free-T, and estradiol, or to the FAI, the serum levels of SHBG were significantly higher in hyposexual patients than in non-hyposexual patients. Thus, the effects of increased SHBG upon serum levels of testosterone biologically active in patients with epilepsy and hyposexuality were not detected by the methods used in this study. Four (44%) of nine hyposexual patients who were re-evaluated after two years follow-up improved sexual performance. Thus, clinical treatment that results in good seizure control may improve sexual performance in some patients with epilepsy.

Depression in Individuals with Epilepsy

Depression in epilepsy patients is not only extremely common, but is often poorly recognized and inadequately treated. Depression can have significant consequences including increased medical utilization, poor quality of life, social disability, and mortality. Etiology of depression is multifaceted with prominent psychosocial determinants. Salient medical issues include iatrogenic causes, especially side effects of antiepileptic drugs (AEDs). In addition, seizures with increased frequency and with "forced normalization" can be associated with mood disturbance. After a thorough search for correctable causes, treatment should not be delayed, and should include both psychotherapy and pharmacologic therapies. Antidepressants remain the mainstay of pharmacologic intervention with the selective serotonin reuptake inhibitors (SSRIs) considered first-line treatment. Venlafaxine, nefazadone, and tricyclic antidepressants (TCAs) can also be used, but with some important caveats. Decreasing the seizure threshold is a common side effect of all antidepressants, but the risk can be minimized and should not prevent vigorous treatment of the depressive state. Other side effects present with varying frequency from the common (eg, sexual dysfunction as seen with SSRIs) to uncommon withdrawal reactions and rare complications of serotonin syndrome. Depression must also be considered a recurring disease, and when a successful regimen is ascertained, adequate continuation of treatment is a necessity. Care must be taken to treat the patient until complete resolution is achieved. Many patients with a major depressive disorder (MDD) will improve with inadequate treatment, but remain encumbered by a smoldering, low-level dysthymia that, in itself, can severely restrict the patient's quality of life.

The effect of seizures and kindling on reproductive hormones in the rat

Reproductive dysfunction and endocrine disorders are common among both women and men with epilepsy, and, in particular, with temporal lobe epilepsy. In clinical studies, it is hard to separate the effects of seizures from the effects of medication and life style. Studies in rodents, however, suggest that seizures per se can contribute to reproductive dysfunction. In female rats, generalized seizures disrupt normal ovarian cyclicity in adults, and repeated electroshock seizures delay the onset of puberty in juveniles. Right amygdala kindling in adult female rats causes acyclicity, the development of polycystic ovaries and premature aging of the hypothalamic-pituitary neuroendocrine axis, leading to chronic anovulation and continuous estrogen exposure. In adult male rats, repeated electroshock seizures result in transient hypogonadism, characterized by decreased serum testosterone levels and lowered gonadal tissue weight. In contrast, right amygdala kindling increases serum testosterone, estradiol levels and gonadal weight. These findings suggest that reproductive dysfunction in women and men with epilepsy may result from recurrent seizure activity, due to seizure-related interference with the normal functions of the hypothalamic-pituitary-gonadal axis.

Special considerations for women with epilepsy

Women with epilepsy present health care providers with unique problems and opportunities for advancement of care. The fundamentals of epileptic pathophysiology are similar in both sexes. There are, however, some significant differences. Cosmetic effects of antiepileptic drugs (AEDs) may have different implications for women. Women who have seizures associated with their menstrual cycle may need special attention regarding their cyclic hormonal changes and AED selection. Antiepileptic drugs may reduce the effectiveness of hormonal contraception. Women with epilepsy have higher rates of infertility and an increased prevalence of reproductive and endocrine disorders. The majority of women with epilepsy have normal, healthy children, but their pregnancies are considered high risk due to an increase in seizure frequency, metabolic alterations of AEDs (which complicate management), and an increased risk of adverse pregnancy outcomes. These issues and an approach to optimize the management of women with epilepsy are discussed.

Sexual dysfunction in epilepsy: identifying the psychological variables

In order to evaluate the psychological variables that affect sexual dysfunction (SD) in epilepsy, where compared 60 epileptics (Group 1) with 60 healthy individuals (Group 2), through the State-Trait Anxiety Inventory (Spielberger et al., 1970), Beck Depression Inventory (Beck, 1974) and Sexual Behavior Interview (Souza, 1995). Sexual dysfunction (SD), anxiety and depression were found more frequently in Group 1 than in Group 2 and were not related to sex. Variables such as the onset duration and frequency of seizures as well as the use to medication were not associated with SD. Temporal lobe epilepsy was related to SD (p = 0.035) but not to anxiety or depression. Anxiety and depression were related to SD in both groups. Perception in controlling the seizures was closely related to anxiety (p = 0) and depression (p = 0.009). We conclude that psychological factors play an important role in the alteration of sexual behavior in epileptics and that suitable attention must be given to the control of these variables.

Neuropsychiatry of hypersexuality

Relatively few studies of the psychobiology of hypersexuality have been undertaken. Nevertheless, the literature does suggest the possibility of a neurobiology of hypersexuality. Three cases of hypersexual behavior are presented in the context of neuropsychiatric disorders, and the literature on this phenomenon is briefly reviewed. These case studies and the literature provide evidence that different brain systems may play a role in this disorder. Frontal lesions may be accompanied by disinhibition, including impulsive hypersexual response to external cues, while striatal lesions may be accompanied by repetitive triggering of internally generated response patterns. Temporal-limbic lesions may be accompanied by disturbances in sexual appetite itself, including change in the direction of sexual drive. These case studies demonstrate that a neurobiology of hypersexuality may prove of some heuristic value in the clinic. However, further research is required to consolidate the literature in this area.

Limbic seizures alter reproductive function in the female rat

PURPOSE

Reproductive dysfunction and endocrine disorders are common among women with temporal lobe epilepsy. This study used the kindled rat model to test the hypothesis that limbic seizures directly contribute to reproductive dysfunction.

METHODS

Kindling electrodes were implanted in the basolateral amygdala in adult female rats. Females were kindled by either brief, daily, suprathreshold stimulations with a bipolar electrode or sham-kindled (controls). Electrographic and behavioral seizures were monitored. Estrous cycles also were monitored with daily vaginal smears.

RESULTS

Seizures arrested ovarian cyclicity in all (n = 42) kindled animals, the rats exhibiting persistent vaginal cornification (PVC). In these animals PVC was associated with high serum estradiol, increased pituitary weight, and polyfollicular ovaries consisting of many cystic follicles, as well as follicles in various stages of growth and atresia. In 93% of females, this effect occurred after the development of stage 5 motor seizures, when focal seizures had secondarily generalized. In contrast, only five (21%) of 24 sham-kindled controls exhibited PVC. A single injection of progesterone (P4) temporarily restored cyclicity in five (18%) of 28 kindled females exhibiting PVC. In contrast, P4 administration restored cyclicity in all five sham-kindled controls that had spontaneously stopped cycling. P4 treatment to kindled females in PVC resulted in a different endocrine profile than that in non-P4-treated, kindled rats in PVC. P4-treated rats had high serum estradiol, testosterone, and prolactin levels; they showed an increase in pituitary weight; and their ovaries contained numerous corpora lutea and cystic follicles surrounded by markedly overdeveloped thecal cell layers.

CONCLUSIONS

Seizures initiated in the amygdala result in impairment of the hypothalamic-pituitary axis, resulting in loss of ovarian cyclicity.

Alterações sexuais na epilepsia: resultados de uma avaliação multidisciplinar

Onze pacientes do sexo masculino com epilepsia e queixa de alteração sexual foram submetidos a avaliação multidisciplinar. A média de idade foi 27 anos (20-34), a duração média da epilepsia foi 19 anos (0,5-32) e a frequência média das crises foi duas por semana (0-7). Dez pacientes apresentavam crises parciais e um, mioclônicas. Dez pacientes recebiam drogas antiepilépticas (difenil-hidantoína - 1, carbamazepina - 8, clonazepam - 3, clobazam - 2, valproato - 3, vigabatrina - 1). Segundo os critérios do DSM III -- R, as queixas foram disfunção erétil (9), redução da libido (4), froteurismo (4), inibição do orgasmo (3), ejaculação precoce (3), fetichismo (2), voyeurismo (2), exibicionismo (2), pedofilia (1) e aversão sexual (1). A avaliação endocrinológica mostrou hipogonadismo hipogonadotrófico em dois pacientes. A avaliação urológica revelou disfunção erétil orgânica em outros dois. Em um paciente a alteração sexual foi considerada psicogênica. Em seis pacientes não foi possível estabelecer diagnóstico etiológico definitivo. Este estudo mostra que a alteração da sexualidade na epilepsia é multifatorial e necessita de abordagem multidisciplinar.

Epilepsy in older adults: causes, consequences and treatment

OBJECTIVES

Seizures and epilepsy are common problems in older adults. Although, the highest incidence of seizures and epilepsy occurs in individuals more than 65 years of age, the magnitude of this public health problem, and its consequences on the quality of life of older adults, are not appreciated. Moreover, there is no consensus on the most appropriate way to diagnose or manage epilepsy in this population. This report reviews the current literature on all aspects of epilepsy in older people.

DESIGN/METHODS

The medical literature was reviewed for all articles pertaining to pathophysiology, diagnosis, and treatment of epilepsy in older people.

RESULTS

Epidemiology, etiology, diagnosis, use of diagnostic tests including EEG and imaging, new medical and surgical treatments, and psychosocial issues as they relate to older epilepsy patient are discussed. Several questions that merit future systematic investigation are presented.

CONCLUSION

Seizures and epilepsy in older people are much more common than is generally known. There are unique issues related to this population with regard to diagnosis and treatment. Several new medical and surgical therapies are now available for all epilepsy patients, some of which may be helpful for the older epilepsy patient.

Sexual behavior and hemispheric laterality of the focus in patients with temporal lobe epilepsy

Various studies have described an unusually common incidence of sexual and reproductive dysfunction in patients affected by temporal lobe epilepsy (TLE). The purpose of the present study was to further investigate, by means of an ad hoc questionnaire, the relationship between sexual disorders and the hemispheric laterality of the epileptic focus in men and women with right (R) TLE and left (L) TLE. The results suggest a reduction of sexual interest in patients with R-TLE as compared with L-TLE in both men and women. This effect was fundamentally observed when sexual interest was implicitly explored. No significant difference was found between R-TLE and L-TLE groups concerning most aspects of sexual performance. Various hypotheses are discussed to interpret this effect of hemispheric lateralization on sexual interest.

Maximizing the health of women with epilepsy: science and ethics in new drug development

Issues of unique concern to women with epilepsy largely arise from gender-based physiological differences. Female sex steroid hormones may alter the expression of epilepsy and the efficacy of antiepileptic drugs (AEDs). Seizures and AEDs in turn affect the hypothalamic-pituitary axis and can adversely impact reproductive function and bone health. Maternal seizures and exposure to AEDs may compromise fetal development. At this time, women with epilepsy and their medical caretakers do not have access to all the information necessary to formulate a treatment plan that will have the least impact on reproductive and general health. In part, this is because reproductive aged women are excluded from the earliest phases of drug testing and pregnant and lactating women are excluded from all aspects of new drug development. Therefore, as new AEDs enter the marketplace, women with epilepsy must decide whether a new AED is appropriate for therapy based on very limited information. Postmarketing surveillance of gender-specific adverse effects, as with all adverse effects, depends on voluntary reporting. Only a small percentage of significant adverse events are believed to be captured by the present system. Consumers, ethicists, and some physician groups are now arguing that women should be included in all aspects of the development of drugs they will ultimately use-even pregnant and lactating women. Some of the issues of concern for women with epilepsy regarding epilepsy treatment, reproductive function and general health will be reviewed, followed by a discussion of the drug development process and how it does, and could better, address the concerns of women.

Nocturnal penile tumescence and rigidity evaluation in men with epilepsy

PURPOSE

Men with epilepsy appear to have an approximately fivefold increase in risk of erectile dysfunction (ED). We attempted to determine whether ED in men with epilepsy was due to a physiological basis and whether erectile function could be adequately evaluated with an ambulatory nocturnal penile tumescence and rigidity monitor.

METHODS

The physiologic integrity of the sexual response in men with epilepsy and ED was assessed with an ambulatory nocturnal penile tumescence and rigidity monitor (NPTR). Six men with localization-related epilepsy of temporal lobe origin (TLE) and ED, 2 men with TLE and normal sexual function, and 1 man with nonepileptic seizures (NES) and ED underwent evaluation of nocturnal erections for at least 2 nights.

RESULTS

Five of 6 men with TLE and complaints of ED had abnormal ambulatory NPTR evaluations. All others had normal ambulatory NPTR. All abnormal evaluations showed reduced levels of rigidity, often with normal levels of tumescence.

CONCLUSIONS

Previous studies have shown this abnormal ambulatory NPTR pattern to be associated with neurogenic rather than vasogenic ED. Therefore, epilepsy-related ED may have a substantial neurophysiologic component.

Epilepsy in women

Physicians should be aware of certain gender-related issues in the treatment of women with epilepsy. Although in the past reproduction was discouraged in women with epilepsy, more than 90% of the pregnancies in such patients currently have an uneventful outcome with appropriate management. Oral contraceptive agents are not contraindicated in women with epilepsy; however, the contraceptive failure rate increases fourfold if patients are being treated concurrently with enzyme-inducing antiepileptic drugs. In pregnant patients, free drug levels of carbamazepine, phenobarbital, phenytoin, and valproate may change because of alterations in protein binding, clearance, and possible absorption. The dosage should be adjusted if the patient's seizures are increasing. Women with epilepsy may have disease-related or treatment-related menstrual dysfunction, complications of pregnancy (slightly increased risk of toxemia and fetal loss), endocrine dysfunction, appearance changes (a general coarsening of facial features with long-term administration of antiepileptic agents), and psychosocial maladjustment. Some effects are drug specific. Although control of seizures remains the primary goal of treating women with epilepsy, the widening choice of antiepileptic drugs may facilitate optimal management of secondary and gender-specific complications.

Does naming contribute to memory self-report in temporal lobe epilepsy?

The present study evaluated the hypothesis (Mayeux et al., 1980) that visual confrontation naming deficits may underlie the memory complaint in patients with temporal lobe epilepsy (TLE). Thirty-nine patients with medically refractory left (n = 23) and right (n = 16) TLE were compared with an epilepsy control group with idiopathic primary generalized epilepsy (n = 38). All subjects completed selected subtests of the Multilingual Aphasia Examination and Wechsler Memory Scale (Form 1) together with a measure specifically designed for quantification of the memory complaint in TLE. Objective verbal memory test performance, confrontation naming, repetition, and comprehension were unrelated to memory self-report. Controlled Oral Word Association was the only measure to exert an influence on memory self-ratings, and this relationship was specific to the TLE group. The hypothesis of Mayeux et al. (1980) was not specifically supported, but the present findings do suggest that cognitive processes reflected in orthographically based and internally generated word retrieval play a role in memory self-report.

Development of the quality of life in epilepsy inventory

We developed an instrument to measure health-related quality of life (HRQOL) in epilepsy. A 99-item inventory was constructed from the RAND 36-Item Health Survey (generic core), with 9 additional generic items, 48 epilepsy-targeted items, and 6 other items concerning attitudes toward epilepsy and self-esteem. We administered the 99-item inventory to 304 adults with epilepsy at 25 epilepsy centers. Patients and patient-designated proxies completed the inventory and were retested 1-91 days later. A multitrait scaling analysis of these data led to retention of 86 items distributed in 17 multiitem scales (Cronbach's alpha ranged from 0.78 to 0.92). Factor analysis of the 17 multiitem scales yielded four underlying dimensions of health: an epilepsy-targeted dimension, a cognitive factor, mental health, and physical health. Construct validity was supported by significant patient-proxy correlations for all scales and correlations between neuropsychologic tests and self-reported emotional and cognitive function (all p values < 0.05). There were significant negative correlations between the four factor scores derived from the HRQOL scales and neurotoxicity, systemic toxicity, and health care utilization (except for the correlation between mental health factor and health care utilization; all p values < 0.05). Patients who were seizure-free in the preceding year reported better HRQOL for the overall score, three of the four factor scores, and 8 of the 17 scale scores than did patients with a high frequency of seizures. Relative validity analysis showed that the epilepsy-targeted factor and three of its four component scales were more sensitive to categorization of patients by severity of seizure frequency and type than scales tapping physical health, mental health, or cognitive function. These cross-sectional data support the reliability and validity of this measure of HRQOL in epilepsy. The addition of an epilepsy-targeted supplement to the generic core improved the sensitivity to severity of epilepsy. The 86 items included in the field testing were supplemented by three additional items to form the Quality of Life in Epilepsy (QOLIE-89) inventory.

Ovulatory function in epilepsy

Women with epilepsy have lower fertility rates than women without epilepsy. We hypothesized that limbic dysfunction in temporal lobe epilepsy (TLE) alters the release of hypothalamic trophic hormones that secondarily affect release of the pituitary gonadotropins, causing ovulatory failure. We assessed ovulatory function over three consecutive menstrual cycles in 17 women with partial seizures arising from the temporal lobe (TLE), 7 women with primary generalized epilepsy (PGE), and 12 controls. We devised scores to reflect ovulatory function that were based on daily basal body temperature and monthly serum progesterone levels. Seizure frequency, antiepileptic drugs (AEDs), and depressive symptomatology were also evaluated. Anovulation was more frequent in subjects with TLE (35.3%) than in subjects with PGE (0%) or in controls (8.3%). Anovulatory cycles tended to occur more frequently in subjects with TLE who were treated with polytherapy than in those receiving monotherapy, but this result was not statistically significant. Seizure frequency and symptoms of depression did not affect ovulatory function. Although AED polytherapy may increase the likelihood of anovulation, our results suggest a mechanism of infertility related to temporal lobe dysfunction.

Sex hormones and pituitary function in male epileptic patients with altered or normal sexuality

Male epileptic patients frequently complain of sexual dysfunction, particularly impotence and loss of libido. Epilepsy itself, antiepileptic drugs (AEDs), and psychosocial factors are believed to contribute to impaired sexuality. We studied luteinizing hormone (LH) pulsatile secretion, gonadotropin, and prolactin (PRL) responses to LH-releasing hormone (LHRH) and thyrotropin-releasing hormone (TRH) in 37 adult male epileptic patients receiving AED monotherapy who were seizure-free and had normal EEGs. Sexuality was assessed by psychological interview. Impotence was diagnosed in 8 patients (in 2 combined with loss of sexual desire). The occurrence of hyposexuality (approximately 20%) was independent of epilepsy syndrome or AED. No change in total testosterone (T) level was observed. Free T (fT) and dihydrotestosterone (DHT) levels were lower and sex hormone binding globulin (SHBG) levels were higher in epileptic subjects than in healthy controls, but a statistically significant difference was not observed between hypo- and normosexual patients. In impotent epileptic patients, estradiol (E2) levels were significantly increased as compared with those of patients with preserved sexuality and of healthy controls. The unbalanced relation between androgen and E2 levels was emphasized by decreased T/E2, fT/E2, and DHT/E2 ratios obtained in hyposexual epileptic patients. In this group, LHRH induced blunted LH peaks. No changes were noted in LH pulsatility features. These findings of higher E2 levels and of decreased LH response to LHRH administration in some epileptic patients with impaired sexuality, may suggest they have subclinical hypogonadotropic hypogonadism.

Likelihood of pregnancy in individuals with idiopathic/cryptogenic epilepsy: social and biologic influences

We interviewed 1,558 adults with idiopathic/cryptogenic epilepsy ascertained from voluntary organizations and 316 of their siblings without epilepsy to determine their personal history of marriage and pregnancy. We examined the effects of seizure type, age at onset, and family history of epilepsy on the sex-specific likelihood of pregnancy in individuals with idiopathic/cryptogenic epilepsy as compared with their same-sex siblings. Overall, men with idiopathic/cryptogenic epilepsy were only 36% as likely as male unaffected siblings ever to have fathered a pregnancy. In men, the reduced likelihood of fathering a pregnancy was associated with partial-onset seizures, early age at onset (< 20 years), and a negative family history of epilepsy, and the effects of these epilepsy characteristics appeared to be mediated through reduced marriage rates. Among men with epilepsy who had ever been married, reproductive disadvantage was confined to those with early-onset (< 10 years) partial epilepsy. Overall, women with idiopathic/cryptogenic epilepsy were only 37% as likely ever to have had a pregnancy as female unaffected siblings; this effect was not strongly influenced by seizure type, age at onset, or family history of epilepsy. In women who had ever been married, unlike in men, reduced likelihood of pregnancy persisted, regardless of seizure type, age at onset, or family history of epilepsy.

Advances in the assessment of refractory epilepsy

The assessment of patients with refractory epilepsy presents both a challenge and an opportunity. The use of appropriate instruments to carefully and consistently measure a patient's seizure type and frequency, hormonal function, and medication side effects and the impact of those variables on quality of life ensures consistent, standardized assessment. A patient's epilepsy then can be classified as refractory based on any combination of factors that preclude a reasonably normal life-style by current practice standards, given the person's capabilities. Diagnostic studies and treatment strategies should address all significant adverse findings resulting from the assessment process. Accurate diagnosis of seizure type usually requires electroencephalographic (EEG) monitoring. Postictal hormonal assays and periodic measurements of estrogen and progesterone may be useful diagnostically in a selected group of patients. Awareness of a patient's compliance history, environmental stressors, and seizure triggers may reduce seizure frequency without a change in medication. For patients with medication intolerance, the usual strategy is to modify the medication regimen or treatment schedule to minimize side effects while maximizing seizure control and compliance. For most patients, monotherapy provides a greater therapeutic window than combination therapy. Devising an effective and safe therapeutic regimen is an ongoing process and can be lengthy depending on seizure type(s), frequency, and temporal pattern; anticonvulsant pharmacokinetics; drug interactions and side effects; patient's life-style; and other factors. Serial measurements of quality-of-life variables may assist in the process. Rapid strides have been recently made, and as the pace of new antiepileptic drug development quickens and surgical centers become more widely available, clinicians will need to redefine refractoriness as the expectations improve for patients with epilepsy.