Sexual function in women with epilepsy

Are Endogenous Androgens Linked to Female Sexual Function? A Systemic Review and Meta-Analysis

BACKGROUND

The benefits of treatment with testosterone (T) in women with loss of desire suggest that low androgens may distinguish women with sexual dysfunction (SD) from others; however, evidence on this point is lacking.

AIM

To answer the question: is there an association between endogenous levels of androgens and sexual function in women?

METHODS

An extensive search was performed in MEDLINE, Embase and PsycInfo. Four separate meta-analyses were conducted for total T, free T, Free Androgen Index (FAI), and Dehydroepiandrosterone sulphate (DHEAS). Cohort, cross-sectional, and prospective studies were included.

OUTCOMES

The main outcome was the association between endogenous androgens and sexual desire. Global sexual function was considered as a secondary outcome. The effect measure was expressed as standardized mean difference (SMD).

RESULTS

The meta-analysis on total T included 34 studies involving 3,268 women, mean age 36.5 years. In 11 studies, a significant association was found between sexual desire, measured by validated psychometric instruments, and total T (SMD = 0.59 [0.29;0.88], P < 0.0001), with a moderate effect. The association with global sexual function (n = 12 studies) was also significant (SMD = 0.44 [0.21;0.67], P <0.0001). Overall, total T was associated with a better sexual function (SMD = 0.55 [0.28;0.82)], P < 0.0001), with similar results obtained when poor quality studies were removed. Age showed a negative relationship with the overall outcome. No differences were found when stratifying the studies according to menopausal status, type of menopause, age at menopause, use of hormonal replacement therapy, relationship status, method for T measurement, phase of the menstrual cycle or use of hormonal contraception. The meta-analysis of T derivatives (free T and FAI) also showed a significant, moderate association with sexual desire. In contrast, DHEAS seems not to exert any significant influence on desire, whilst showing a positive association with global sexual function.

CLINICAL IMPLICATIONS

Endogenous androgens show a moderate association with a better sexual function in women; however, the role of psychological, relational and other hormonal factors should not be overlooked.

STRENGTHS & LIMITATIONS

This represents the first attempt at meta-analyzing data available on the topic. A significant publication bias was found for total T.

CONCLUSION

There appears to be a moderate association between total T and sexual desire/global sexual function, which is confirmed, although weak, in studies employing liquid chromatography-mass spectrometry (LC-MS). Similar results on desire were obtained for free T and FAI. DHEAS only showed a positive association with global sexual function. More research is needed. Maseroli E and Vignozzi L. Are Endogenous Androgens Linked to Female Sexual Function? A Systemic Review and Meta-Analysis. J Sex Med 2022;19:553-568.

Sex Differences in the Epilepsies and Associated Comorbidities: Implications for Use and Development of Pharmacotherapies

The epilepsies are common neurologic disorders characterized by spontaneous recurrent seizures. Boys, girls, men, and women of all ages are affected by epilepsy and, in many cases, by associated comorbidities as well. The primary courses of treatment are pharmacological, dietary, and/or surgical, depending on several factors, including the areas of the brain affected and the severity of the epilepsy. There is a growing appreciation that sex differences in underlying brain function and in the neurobiology of epilepsy are important factors that should be accounted for in the design and development of new therapies. In this review, we discuss the current knowledge on sex differences in epilepsy and associated comorbidities, with emphasis on those aspects most informative for the development of new pharmacotherapies. Particular focus is placed on sex differences in the prevalence and presentation of various focal and generalized epilepsies; psychiatric, cognitive, and physiologic comorbidities; catamenial epilepsy in women; sex differences in brain development; the neural actions of sex and stress hormones and their metabolites; and cellular mechanisms, including brain-derived neurotrophic factor signaling and neuronal-glial interactions. Further attention placed on potential sex differences in epilepsies, comorbidities, and drug effects will enhance therapeutic options and efficacy for all patients with epilepsy. SIGNIFICANCE STATEMENT: Epilepsy is a common neurological disorder that often presents together with various comorbidities. The features of epilepsy and seizure activity as well as comorbid afflictions can vary between men and women. In this review, we discuss sex differences in types of epilepsies, associated comorbidities, pathophysiological mechanisms, and antiepileptic drug efficacy in both clinical patient populations and preclinical animal models.

Reproductive and Sexual Health Concerns in Transition-Age Adolescents and Young Adults With Epilepsy

A plethora of hormonal and physical changes occur as adolescents grow into adulthood. These changes pose additional challenges for youth with epilepsy. Providers, parents, and patients must be well educated about the hormonal influences, both intrinsic and pharmaceutical, on seizures and antiepileptics (AEDs). In addition, they must be made aware of safe/effective contraception, the importance of pregnancy planning, and potential menstrual and sexual health disturbances related to epilepsy and AEDS. Reproductive and sexual health should be an integral component of transition education and planning for all youth, but is especially important for the youth with epilepsy. While many clinicians will collaborate with adolescent gynecologists or pediatricians, it is important for all child neurologists to be aware of these issues.

Sexual dysfunction in people with epilepsy

Sexual dysfunction is a common comorbidity in people with epilepsy (PWE) that adversely affects their quality of life. Nearly one-half of men and women with epilepsy have sexual dysfunction, but in the majority, this often goes unnoticed. The wide variation in the reported prevalence of sexual dysfunction in PWE is due to the significant heterogeneity among the studies with regard to patient population, type and severity of epilepsy, number and type of antiseizure drugs (ASDs) used, and the tools used for assessing sexual dysfunction. Generally, patients with uncontrolled epilepsy, longer duration of epilepsy, focal epilepsy, higher seizure frequency, and those receiving enzyme-inducing and multiple ASDs are more likely to have sexual dysfunction. Women generally have dysfunction in the domains of desire, while males usually have arousal disorders such as erectile dysfunction and premature ejaculation. There is limited evidence to indicate that sexual function improves in patients rendered seizure-free following epilepsy surgery. Multiple mechanisms including direct effects of epilepsy, effects of ASDs, and psychosocial factors contribute to sexual dysfunction in epilepsy. Circumstantial evidence indicates that seizures and interictal epileptiform discharges can directly affect the hypothalamic-pituitary axis as well as production of gonadal steroids. Enzyme-inducing ASDs cause sexual dysfunction by affecting the metabolism of gonadal steroids. Limited data suggest that newer ASDs including oxcarbazepine, lamotrigine, and levetiracetam cause no or minimal sexual dysfunction. Depression and anxiety significantly contribute to sexual dysfunction in PWE. A multipronged and multidisciplinary approach is essential for optimizing the sexual functions. Every effort should be made to identify and treat reversible causes including changing to nonenzyme-inducing ASDs and to provide symptomatic relief. Large, prospective studies are required to improve our understanding on prevalence and mechanisms of sexual dysfunction in PWE.

[Epilepsy as a social problem]

The article considers the problem of social restrictions caused by epilepsy. Information on historical aspects and discrimination of patients with epilepsy is presented. The authors consider factors influencing marital status of patients in different countries and present information on the differences in medical restrictions to driving in different countries and in the Russian Federation. Employment status of patients with epilepsy, restrictions related to objective reasons and attitudes of patients and others toward epilepsy are elucidated.

The transition from pediatric to adult care for youth with epilepsy: Basic biological, sociological, and psychological issues

Transition from pediatric to adult health care for adolescents with epilepsy is challenging for the patient, family, and health care workers. This paper is the first of three that summarize the main findings from the 2nd Symposium on Transition in Epilepsies, held in Paris from June 14-25, 2016. In this paper we describe five basic themes that have an important effect on transition. First, there are important brain changes in adolescence that leave an imbalance between risk taking and pleasure seeking behaviors and frontal executive function compared with adults. Second, puberty is a major change during the transition age. The three most important but separate neuroendocrine axes involved in puberty are gonadarche (activation of the gonads), adrenarche (activation of adrenal androgen production), and activation of the growth hormone-insulin like growth factor. Third, sexual debut occurs during the transition years, and at an earlier age in adolescents with epilepsy than controls. Adult sexual performance is often unsatisfactory. Although AED-induced alterations in sexual hormones and temporal lobe epilepsy may play a role in hyposexuality, depression, anxiety, and other social factors appear most important. Fourth, psychological development is very important with an evolution from an early stage (ages 10-13years) with concrete thinking, to a middle stage (ages 14-17) with analytic and more abstract introspective thinking, and then to a late stage (ages 18-21) with at least the beginnings of adult reasoning. Epilepsy may derail this relatively orderly progression. Adolescents with autistic spectrum disorder may present with severe behavior problems that are sometimes related to undiagnosed epilepsy. Fifth, bone health in adolescence is critical to establish adequate mineralization for all of adult life. While AED interference with Vitamin D metabolism is important, there is evidence that the effects of AEDs on bone are more complex and involve changes in remodeling. Hence, some non-inducing AEDs may have a significant effect on bone health. All five of these themes lead to recommendations for how to approach adolescents and young adults during transition and some specific interventions to achieve maximum long-term adult independence and quality of life.

Sexual problems in people with refractory epilepsy

Sexual dysfunction is an important but often neglected aspect of epilepsy. The objective of this study was to explore the prevalence and types of sexual problems in patients with epilepsy and compare the results with similar data obtained from a representative sample of the general population. At the National Centre for Epilepsy in Norway, 171 of 227 consecutive adult inpatients and outpatients with epilepsy (response rate: 75.3%) and their neurologists participated in a questionnaire study about epilepsy and sexuality. The results were compared with data available from 594 adult Norwegians who had completed the same questionnaire. Patients with epilepsy had a significantly higher prevalence of sexual problems (women: 75.3% vs. 12.0%; men: 63.3% vs. 9.6%). The most commonly reported problems (>30%) were reduced sexual desire, orgasm problems, erection problems, and vaginal dryness. The patients reported considerable dissatisfaction regarding sexual functioning. Significantly more sexual problems were found in patients of both sexes with reduced quality of life and in women with symptoms of depression. We found no significant association between sexual problems and age of epilepsy onset, type of epilepsy, or use of enzyme-inducing antiepileptic drugs. Whereas age at sexual debut did not differ between the patients with epilepsy and the general population, men with epilepsy had a lower number of partners during the last 12months, and the proportion of women with a low frequency of intercourse was higher in the group with epilepsy. In conclusion, sexual problems are significantly greater in Norwegian patients with epilepsy than in the general adult population. As no single epilepsy type or treatment could be identified as a specific predisposing factor, it seems likely that there are multiple causes underlying our results, including both organic and psychosocial factors.

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.

Seizure occurrence, pregnancy outcome among women with active convulsive epilepsy: one year prospective study

PURPOSE

To determine the prevalence of active convulsive epilepsy, seizure frequency and the outcome of pregnancy amongst a cohort of pregnant women attending antenatal clinic (ANC) at two tertiary hospitals.

METHODS

An observational cohort study conducted at the University of Maiduguri Teaching Hospital and State Specialist Hospital, Northeast Nigeria. Pregnant women attending antenatal care were screened for previous history of active convulsive epilepsy, and recruited consecutively according to a specified protocol. A standardized questionnaire was administered to record pregnancy history, nature of epilepsy and treatments received. They were followed-up during the course of the pregnancy based on the ANC schedule up to delivery. The outcome of pregnancies was recorded.

RESULTS

A total of 7063 pregnant women were screened, of whom 103 (1.46%) subjects had at least a past history of seizure. Seventy-eight (1.10%) had a past history of seizure(s) from eclampsia and 23 (0.33%) pregnant subjects recruited were identified to have active convulsive epilepsy. The unadjusted prevalence of active convulsive epilepsy in pregnant women was found to be 3.33 per 1000 (95% CI: 2.1-4.8). Subjects who had a history of head injury and encephalitis were more likely to have seizures during pregnancy. (P=0.013 and P=0.041). Those who had recurrent seizures within the last six months before recruitment were more likely to have a negative pregnancy outcome (P=0.043).

CONCLUSION

Our study found a prevalence of active epilepsy of 3.33 per 1000 among pregnant women, with about one percent having a past history of seizure from eclampsia.

Sleep and epilepsy

The intimate relationship between sleep and epilepsy has long been recognized, yet our understanding of the relationship is incomplete. In this article we address four key issues in this area. First, we consider the reciprocal interaction between sleep and epilepsy. Sleep state clearly influences seizure onset, particularly in certain epilepsy syndromes. The converse is also true; epilepsy may disrupt sleep, either directly through seizures and epileptiform activity, or indirectly through medication-related effects. Unraveling the influences of sleep stage, epilepsy syndrome, and drug effects is challenging, and the current state of knowledge is reviewed. Secondly, accurate diagnosis of sleep-related epilepsy can be difficult, particularly the distinction of nocturnal frontal lobe epilepsy (NFLE) from arousal parasomnias. The challenges in this area, along with work from the authors, are discussed. Thirdly, we will explore the putative relationship between obstructive sleep apnea (OSA) and epilepsy, including the effect of OSA on quality of life; this will lead us to a brief exploration of the effects of OSA on neuroendocrine function. Finally, we will review the evidence surrounding the role of sleep in sudden unexpected death in epilepsy (SUDEP).

Neuroendocrine considerations in the treatment of men and women with epilepsy

Complex, multidirectional interactions between hormones, seizures, and the medications used to control them can present a challenge for clinicians treating patients with epilepsy. Many hormones act as neurosteroids, modulating brain excitability via direct binding sites. Thus, changes in endogenous or exogenous hormone levels can affect the occurrence of seizures directly as well as indirectly through pharmacokinetic effects that alter the concentrations of antiepileptic drugs. The underlying structural and physiological brain abnormalities of epilepsy and the metabolic activity of antiepileptic drugs can adversely affect hypothalamic and gonadal functioning. Knowledge of these complex interactions has increased and can now be incorporated in meaningful treatment approaches for men and women with epilepsy.

Depression as a prominent cause of sexual dysfunction in women with epilepsy

The etiology of sexual dysfunction in patients with epilepsy is perceived as multifactorial, with seizure and medication effects being the most often discussed and analyzed factors. We used common statistical methods to evaluate the impact of type of epilepsy, antiepileptic medication, hormones, seizure control, and symptoms of depression and anxiety on sexual function in a group of 78 women with epilepsy. To assess sexual function, we used the Female Sexual Function Index (FSFI). To assess symptoms of depression and anxiety, we used the Beck Depression and Anxiety Inventories (BDI, BAI). Of all the observed factors, only BDI score was significantly correlated with FSFI score. There was no correlation between FSFI, hormonal levels, seizure frequency, and symptoms of anxiety. No differences were found between patients with focal and those with generalized epilepsies; between seizure-free and non-seizure-free patients; or in relation to the number and type of antiepileptic medications.

Epilepsy, sex hormones and antiepileptic drugs in female patients

Women with epilepsy have a higher incidence of reproductive endocrine disorders than the general female population. These alterations include polycystic ovary syndrome, hyperandrogenemia, infertility, hypothalamic amenorrhea and hyperprolactinemia. Reproductive dysfunction is attributed both to epilepsy itself and to antiepileptic drugs (AEDs). Focal epileptic discharges from the temporal lobe may have a direct influence on the function of the hypothalamic-pituitary axis, thus altering the release of sex steroid hormones, including the production of luteinizing hormone, follicle-stimulating hormone, gonadotropin-releasing hormone and prolactin. AEDs may modulate hormone release from the hypothalamic-pituitary-gonadal axis and they may alter the metabolism of sex hormones and their binding proteins. Hepatic enzyme-inducing AEDs, such as carbamazepine and phenytoin, may be most clearly linked to altered metabolism of sex steroid hormones, but valproic acid, an enzyme inhibitor, has also been associated with a frequent occurrence of polycystic ovary syndrome and hyperandrogenism in women with epilepsy. Therefore, treatment of epilepsy and selection of AEDs are important for reproductive health in female patients. The aim of the present review is to critically evaluate the recently published data concerning the interactions between sex hormones, epilepsy and AEDs.

Managing epilepsy in women of childbearing age

Epilepsy affects the menstrual cycle, aspects of contraception, fertility, pregnancy and bone health in women. It is common for seizure frequency to vary throughout the menstrual cycle. In ovulatory cycles, two peaks can be seen around the time of ovulation and in the few days before menstruation. In anovulatory cycles, there is an increase in seizures during the second half of the menstrual cycle. There is also an increase in polycystic ovaries and hyperandrogenism associated with valproate therapy. There are no contraindications to the use of non-hormonal methods of contraception in women with epilepsy. Non-enzyme-inducing antiepileptic drugs (AEDs) [valproate, benzodiazepines, ethosuximide, levetiracetam, tiagabine and zonisamide] do not show any interactions with the combined oral contraceptive (OC). There are interactions between the combined OC and hepatic microsomal-inducing AEDs (phenytoin, barbiturates, carbamazepine, topiramate [dosages>200 mg/day], oxcarbazepine) and lamotrigine. Pre-conception counselling should be available to all women with epilepsy who are considering pregnancy. Women with epilepsy should be informed about issues relating to the future pregnancy, including methods and consequences of prenatal screening, fertility, genetics of their seizure disorder, teratogenicity of AEDs, folic acid and vitamin K supplements, labour, breast feeding and care of a child. During pregnancy, the lowest effective dose of the most appropriate AED should be used, aiming for monotherapy where possible. Recent pregnancy databases have suggested that valproate is significantly more teratogenic than carbamazepine, and the combination of valproate and lamotrigine is particularly teratogenic. Most pregnancies in women with epilepsy are without complications, and the majority of infants are delivered healthy with no increased risk of obstetric complications in women. There is no medical reason why a woman with epilepsy cannot breastfeed her child. The AED concentration profiled in breast milk follows the plasma concentration curve. The total amount of drug transferred to infants via breast milk is usually much smaller than the amount transferred via the placenta during pregnancy. However, as drug elimination mechanisms are not fully developed in early infancy, repeated administration of a drug such as lamotrigine via breast milk may lead to accumulation in the infant. Studies have suggested that women with epilepsy are at increased risk of fractures, osteoporosis and osteomalacia. No studies have been undertaken looking at preventative therapies for these co-morbidities.

Female issues in epilepsy: a critical review

The focus on gender-related issues for women with epilepsy has heightened in recent years. The emphasis, however, has been on the childbearing years. Epilepsy and antiepileptic drug treatment affect sexual development, the menstrual cycle, and aspects of contraception, fertility, and reproduction. Female patients with epilepsy at a reproductive age face a unique set of reproductive issues, ranging from descriptions of disorders of reproduction in epilepsy and its causes, to contraception, pregnancy, sexuality, menopause, and osteoporosis. Conditions and diseases that specifically affect women are discussed. The role of hormones across the life cycle--endogenous and exogenous hormones and their effects on drug interactions, drug metabolism, and therapeutic outcomes--is described. Contraception and pregnancy issues for women with epilepsy have received the appropriate attention.

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.

Pregnancy, epilepsy, and anticonvulsants

The majority of epileptic disorders are not self-limiting over time, and therefore require a long-lasting and often even lifelong antiepileptic drug (AED) treatment, in Wi/omen with epilepsy, the influence of their disease on the possibility and course of pregnancies, as well as the potential impact of the AED treatment on mother and child, are crucial questions.

This review addresses the clinically relevant knovledge concerning the impact of the disease itself and the AED treatment on fertility, pregnancy, delivery, the postpartum period, and teratogenicity. Some of the new AEDs appear to have a favorable profile due to a lack of clinically relevant interactions and promising teratogenic profiles. However, the finding of decreases in lamotrigine serum concentrations during hormonal contraception and pregnancy is an instructive example, shovt/ing that ongoing studies are urgently needed to further investigate stillunanswered questions. Several prospective multinational surveys are currently being performed, and should add essential information in this context.

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.

Toward an understanding of the cerebral substrates of woman's orgasm

The way women experience orgasm is of interest to scientists, clinicians, and laypeople. Whereas the origin and the function of a woman's orgasm remains controversial, the current models of sexual function acknowledge a combined role of central (spinal and cerebral) and peripheral processes during orgasm experience. At the central level, although it is accepted that the spinal cord drives orgasm, the cerebral involvement and cognitive representation of a woman's orgasm has not been extensively investigated. Important gaps in our knowledge remain. Recently, the astonishing advances of neuroimaging techniques applied in parallel with a neuropsychological approach allowed the unravelling of specific functional neuroanatomy of a woman's orgasm. Here, clinical and experimental findings on the cortico-subcortical pathway of a woman's orgasm are reviewed and compared with the neural basis of a man's orgasm. By defining the specific brain areas that sustain the assumed higher-order representation of a woman's orgasm, this review provides a foundation for future studies. The next challenge of functional imaging and neuropsychological studies is to understand the hierarchical interactions between these multiple cortical areas, not only with a correlation analysis but also with high spatio-temporal resolution techniques demonstrating the causal necessity, the temporal time course and the direction of the causality. Further studies using a multi-disciplinary approach are needed to identify the spatio-temporal dynamic of a woman's orgasm, its dysfunctions and possible new treatments.

Sexual dysfunction in patients with epilepsy: communication strategies and assessment tools

Sexual dysfunction is common among patients with epilepsy, but many clinicians do not include inquiries about this aspect of the patient's health in their routine evaluations. This article presents approaches for taking a sexual history and for discussing sexual problems. The utility of standardized sexual dysfunction questionnaires is reviewed and the important elements of appropriate and effective counseling are highlighted.

Sexuality in men and women with epilepsy

Most people with epilepsy maintain normal reproductive and sexual lives. However, a significant minority of women with epilepsy (20% to 30%) have some degree of sexual dysfunction, including problems with libido, arousal, and orgasm. Men with epilepsy are at risk for decreased sexual functioning, including sexual interest and sexual performance, at least in part because of increased sex hormone-binding globulin levels and lower bioactive testosterone levels, particularly in association with the use of enzyme-inducing antiepileptic drugs, such as phenytoin and carbamazepine. A decrease in bioactive testosterone levels probably has a significant effect on the sexuality of women with epilepsy as well. Antiepileptic drugs may also affect sexual function in women through alterations of serotonergic neurotransmission. Epilepsy itself appears to have the potential to affect sexual function. The amygdala is emerging as a brain structure with significant involvement in sexuality in patients with epilepsy, as shown by alterations in sexual functioning after temporal lobectomy. Preliminary evidence suggests that people with temporal lobe epilepsy have reduced genital blood flow in response to erotic stimulation; the etiology of this phenomenon is not well understood, but disruption of the limbic and frontal cortex by epileptic activity may be implicated. Psychosocial factors, including sexual anxiety and stigma associated with epilepsy, can also affect the sexual life of patients with epilepsy.

Pharmacologic treatment strategies for sexual dysfunction in patients with epilepsy and depression

Sexual dysfunction is a frequently encountered comorbid condition in patients with many medical and psychiatric conditions, such as epilepsy and depression. Most depressed patients experience some type of sexual dysfunction, decreased sexual desire being the most common. The association of sexual dysfunction with epilepsy is less clear. Changes in sex hormone levels are common in patients with epilepsy and may be attributable to the disease or to antiepileptic drugs (AEDs). Sexual dysfunction associated with depression or epilepsy is generally treated according to standard guidelines for the management of sexual disorders, since data from special populations are not available. The most common forms of female sexual dysfunction are lack of sexual desire and difficulty achieving orgasm. There are no approved pharmacotherapies for female hypoactive sexual desire disorder or female orgasmic disorder. Female sexual arousal disorder is treated with estrogen replacement therapy when indicated or vaginal lubricants. The most common male sexual dysfunction disorders are premature ejaculation and erectile dysfunction. Phosphodiesterase type-5 inhibitor drugs are now the first-line treatment for erectile dysfunction, and selective serotonin reuptake inhibitors and topical anesthetic creams are nonapproved but effective treatments for premature ejaculation. Testosterone and aromatase inhibitors have been used investigationally to treat sexual dysfunction in men taking AEDs. Patient education and follow-up appointments are essential to ensure optimal outcomes of pharmacologic treatments for sexual dysfunction.

Sexuality in women with epilepsy

Most women with epilepsy maintain normal reproductive cycles and sexual lives. However, a significant minority, approximately 20-30%, have some degree of sexual dysfunction, including problems with seizure exacerbation, libido, arousal, and orgasm. Fluctuating hormone levels may contribute to an array of reproductive cycling abnormalities. With regard to sexual dysfunction, there is some evidence of reduced genital blood flow in women with temporal lobe epilepsy. Other studies suggest that psychosocial factors, such as depression, feeling stigmatized, and being anxious about having seizures during sex, may contribute to the higher rates of sexual dysfunction in this patient population. Some antiepileptic drugs may adversely affect normal reproductive cycling and sexual function, particularly drugs that increase serotonergic transmission. Conversely, resective epilepsy surgery has been shown to restore sexual function. Treatments for sexual dysfunction include testosterone replacement, although transdermal testosterone replacement is not yet approved by the Food and Drug Administration for women. Given the possibility that women with epilepsy may experience inadequate vasocongestion during arousal, sildenafil may have a useful role, though it has not proved effective for women in general. This review focuses on potential sexual problems that are faced by women with epilepsy, with the suggestion that proper treatment may alleviate these problems.

Epilepsy and erectile dysfunction: a review

The association between epilepsy and erectile dysfunction (ED) has often been described but not clearly defined. This is a review of the literature regarding the current theories on the causes of ED in epilepsy, as well as the evaluation and treatment options available.

Relationship of sexual dysfunction to epilepsy laterality and reproductive hormone levels in women

Sexual dysfunction has been reported to be common among women with epilepsy. Controlled studies, quantitative data, and investigations of potentially contributory factors, however, have been few. The purpose of this investigation was to determine if (1) sexual dysfunction is unusually common among women with partial seizures of temporal lobe origin (TLE), and (2) sexual dysfunction varies in relation to the laterality of EEG epileptiform discharges, antiepileptic drug use, and serum gonadal steroid levels. This controlled prospective investigation used a quantitative sexual rating scale and reproductive hormone measures to compare sexual dysfunction in women with left and right unilateral temporolimbic epilepsy and controls. Sexual dysfunction scores were significantly higher in women with TLE, and sexual dysfunction affected substantially more women with epilepsy than controls. Women with right-sided foci were affected more than women with left-sided foci. There was a significant inverse correlation between sexual dysfunction and bioactive testosterone levels in women with epilepsy as well as in controls. Serum estradiol was lower in women with TLE but did not correlate significantly with overall sexual dysfunction. The findings suggest that sexual dysfunction is significantly more common in women with right-sided epileptiform discharges than in controls and is inversely correlated with bioactive testosterone levels. The value of hormonal replacement or supplementation remains to be explored.

Seizures, hormones and sexuality

Sexual disorders (both hyposexuality and sexual dysfunction) are common in people with epilepsy, occurring in up to two-thirds of patients. However, characteristically, patients do not spontaneously report these problems. Nocturnal penile tumescence testing suggests that the erectile dysfunction has a neurophysiological component. The aetiology remains uncertain but is likely to be multifactorial, involving neurological, endocrine, iatrogenic, cognitive, psychiatric and psychosocial factors. Epilepsy-related factors include the age of onset/duration of epilepsy along with the seizure type and focus. In addition, seizure frequency might be relevant as successful epilepsy surgery can result in an improvement in sexual functioning despite remaining on anticonvulsant medication. Endocrine changes (raised sex hormone binding globulin and reduced free testosterone) have been reported in men with epilepsy, especially when treated with hepatic-enzyme inducing antiepileptic drugs. Studies have not been performed evaluating anticonvulsants that do not induce hepatic enzymes such as lamotrigine. The association between these endocrine changes and hyposexuality is not known. The relationship between seizures, hormones and anticonvulsant medication in women is explored, focusing on issues such as catamenial epilepsy, the menopause, hormone replacement therapy and the polycystic ovarian syndrome. Suggestions for future research and treatment issues are discussed.

On the association between valproate and polycystic ovary syndrome

Recent studies by Isojärvi et al. have raised the issue of an increased incidence of polycystic ovary syndrome (PCOS) in women with epilepsy treated with valproate (VPA) and have proposed replacement with lamotrigine (LTG). Polycystic ovaries (PCO) are a common finding, with a prevalence >20% in the general population, and are easily detected by pelvic or vaginal ultrasonography, whereas PCOS is comparatively rare: few women with PCO have fully developed PCOS, which includes hirsutism, acne, obesity, hypofertility. hyperandrogenemia, and menstrual disorders. From an extensive review of the current literature, it appears that there are no reliable data on the actual prevalence of PCOS in normal women and in women with epilepsy. The pathogenesis of PCO is multifactorial, including genetic predisposition and the intervention of environmental factors, among which weight gain and hyperinsulinism with insulin resistance may play a part. The roles of central (hypothalamic/pituitary), peripheral, and local ovarian factors are still debated. PCO and PCOS appear to be more frequent in women with epilepsy, but there are no reliable data showing a greater prevalence after VPA. The recent studies by Isojärvi et al. may have been biased by the retrospective selection of patients. To date, there is no reason to contraindicate the use of VPA in women with epilepsy. However, patients should be informed about the risk of weight gain and its consequences.

The impact of epilepsy surgery on sex hormones and the menstrual cycle in female patients

We investigated the impact of temporal lobe epilepsy surgery on sex hormones and menstrual cycles. Sixteen female patients with temporal lobe epilepsy were investigated prior to surgery and 3, 6, and 12 months after surgery. The patients received carbamazepine (CBZ) as monotherapy (10 patients) or in combination with other antiepileptic drugs (six patients). Antiepileptic drugs were maintained after surgery. During the 1-year follow-up after surgery eight patients (50%) remained completely free of seizures. In another four patients (25%) only rare disabling seizures occurred. There were no significant differences between pre-surgical and post-surgical serum concentrations of testosterone, free testosterone, prolactin, dehydroepiandrosterone sulfate, growth hormone, cortisol and sex hormone binding globulin. There was, however, a significant increase in serum androstenedione concentration 6 months post-surgically (P < 0.02). Documentation of menstrual cycles in addition to laboratory parameters revealed individual post-surgical changes of the menstrual cycle in eight patients. Four patients had a change in menstrual periodicity: two patients with complete seizure control had regular cycles instead of oligomenorrhoea and two patients with incomplete seizure control had oligomenorrhoea instead of regular cycles. These data indicate that at least in some patients with temporal lobe epilepsy surgical treatment influences menstrual periodicity.

The effects of epilepsy and its treatment on sexual and reproductive function

Male and female sexuality and reproductive functions are complex systems with cortical, limbic system, hypothalamic, pituitary, and end organ interactions. Sexual steroids are produced in the sexual glands, the adrenals, and the brain. They undergo interconversion in the brain, bind to different brain areas, and have multiple effects behaviorally and neurophysiologically. Progesterone, estrogen and testosterone have neuroendocrine effects that alter epileptogenicity. Seizure frequency may change throughout the life cycle as a result of hormonal status. Changes in central control, peripheral hormone levels, and/or medication effects may all contribute to decreased libido, potency, and fertility. Antiepileptic drugs (AEDs) interact with hormone-binding metabolism, resulting in altered human reproductive function. AEDs alter contraceptive hormone treatments. Information on the effects of new AEDs is being gathered by the National Pregnancy Registry. Catamenial epilepsy and some sexual dysfunction in men may be treatable.

Epilepsy and the family: a review of current literature

Although the negative effect of epilepsy on patient's psychosocial well-being has been increasingly documented in the last decade, the influence of the condition on the family has attracted much less interest. This paper reviews the present state of family research, examining the influence of both childhood and adulthood epilepsy on the psychological and social well-being of family members. Studies indicate that epilepsy may cause high levels of psychosocial difficulties for all family members, including stigmatization, stress, psychiatric morbidity, marital problems, poor self esteem and restriction of social activities. Studies also suggest that the family environment may be an important intervening factor between the condition and the outcome for the family unit, and a number of family factors are reviewed which have been suggested to mediate this relationship, with recommendations being made for their use in intervention studies. Shortcomings of the family studies to date are discussed and these include: concentration on examination of issues around family life, studies being based on reports from single members of the family and the selection of subjects from clinical populations. Recommendations are made concerning methodological and conceptual issues that need addressing for future research.

Women's issues in the treatment of epilepsy

BACKGROUND

The management of women with epilepsy involves a number of important issues including conception control, sexual dysfunction and fertility, the effect of seizures on the fetus, possible changes in seizures frequency during pregnancy, potential teratogenic effects of antiepileptic drugs and management issues during pregnancy. The primary goal in the treatment of women with epilepsy remains optimal seizure control in the absence of unacceptable adverse effects. The advantages and disadvantages of the new antiepileptic drugs in women remain to be fully established but these new agents allow a wider choice for improved seizure control.