Epilepsy and Sexuality
Possible Causes of Sexual Dysfunction
Sexuality is an important and private aspect of life. People with epilepsy appear to have a higher incidence of sexual dysfunction than persons with other chronic neurologic illnesses. Studies indicate that problems with reduced sexual desire and/or sexual arousal may affect a quarter to a third of people with epilepsy.
Types of Sexual Dysfunction
The causes of sexual dysfunction in people with epilepsy are multifactorial. Poor self-esteem or limited social opportunities may interfere with the development of normal sexual interactions. Sexual behavior may be negatively reinforced when sexual sensations are identified as part of actual seizures, or the aura that precedes the seizure. Many patients are concerned that sexual activity will precipitate a seizure, particularly if seizures can be triggered by hyperventilation or physical exertion. However, in addition to psychological factors, alterations in neurologic and endocrine function related to epilepsy may impact sexuality.
Disorders of Sexual Desire
Sexual desire is the willingness to engage in sexual behavior, and equates with libido, or sexual drive. The desire for sexual activity is variable, and difficult to define in absolute terms, but a person who does not think about sex, or desire sex, at least one to three times a month may have an abnormally low sexual drive. Sexual desire can be disturbed by psychological factors, such as depression and anxiety, but it also requires appropriate function of specific regions of the cerebral cortex, especially frontal and temporal lobes. People with complex partial seizures seem more prone to problems with sexual desire, particularly when seizures originate in the temporal lobe.
Disorders of Sexual Arousal
Sexual arousal is the capacity to respond physiologically to appropriate sexual stimuli with coordinated changes in vascular, neural and muscular systems. Normal physiologic responses involve cerebral cortex, brain stem, spinal cord and autonomic nervous system. Appropriate levels of pituitary hormones (gonadotropins and prolactin) and ovarian and testicular steroid hormones (estrogen and progesterone in the female and testosterone in the male and female) are necessary for normal sexual arousal.
A study evaluating self-reported sexual function in women with epilepsy finds a high incidence of dyspareunia (pain during intercourse), vaginismus (painful vaginal spasms during intercourse) and lack of vaginal lubrication. The women reported no problems in sexual desire or experience. These findings suggest dysfunction in physiologic sexual arousal, not a primary psychosocial disorder.
Men with epilepsy report problems in achieving and sustaining erections, and ejaculation. These patients not only report difficulties achieving erections in sexual situations, but with nocturnal erections as well. This indicates a primary physiologic problem, comparable to the study findings in women.
Anti-epileptic Medications and Seizures
Anti-epileptic drugs (AEDs) affect sexual behavior in several ways: alterations in hormone metabolism and binding, and direct effects on cortical function. AEDs are associated with elevations in prolactin and gonadotropin levels, hormones which may suppress sexual behavior. AEDs that induce liver cytochrome P450 enzymes increase the metabolism and binding of steroid hormones, which decreases brain interactions. AEDs that reduce cytochrome P450 enzyme activity increase levels of androgens and perhaps other steroid hormones as well. See also Contraception for WWE. These hormone changes can affect sexual function. Reductions in androgens reduce sexual interest and arousal in women and men. Diminished libido and arousal are most pronounced in patients using sedating AEDs such as barbiturates, but may occur with any AED in a specific individual. It may be important to consider alternative AEDs since patients may experience sexual deficits with one medication, but have normal sexual function with another.
Epileptic discharges in those brain regions that are related to sexuality (temporal and frontal lobes) may disrupt sexual function. Specific underlying mechanisms are currently unknown, but probably involve changes in neurotransmitters, and altered levels of pituitary and gonadal hormones. Many seizures result in transient elevation of serum prolactin, which has been associated with reduced libido and impotence. Improved seizure control may alleviate much sexual dysfunction, even if higher doses of AEDs are required to achieve that goal.
Additional Therapeutic Interventions
Therapeutic intervention begins with the explanation that sexual dysfunction may be related to epilepsy, offering relief to the patient who may attribute these problems to personal inadequacy. A sexual history can ascertain whether the dysfunction is chronic or situational, and whether other precipitating factors exist (such as acute or chronic stress, recent illness, medications other than AEDs, substance abuse).
A careful physical and neurological examination and appropriate laboratory studies should be performed to rule out other medical conditions that may cause sexual dysfunction (diabetes, hypertension, hyperlipidemia and endocrine disorders). Serum levels of testosterone, estrogen, prolactin and luteinizing hormone should be obtained. A urologic or gynecological consultation may be indicated.
Commercially available moisturizing and lubricating products may alleviate vaginal dryness and dyspareunia. Possible gynecologic interventions include graded dilatation of the vaginal opening to alleviate dyspareunia, or systematic desensitization to vaginal insertion for vaginismus.
Erectile difficulties may respond to medications which facilitate smooth muscle relaxation and vasodilation (alpha-adrenergic blockers, papaverine, with or without phentolamine, aqueous formulations of prostaglandin E1 and sildenafil).
If no correctable organic cause of sexual dysfunction is identified, the patient can be referred for psychotherapeutic intervention, such as couples therapy, sex education or primary psychiatric therapy.
For additional information, contact the Women and Epilepsy Initiative of the Epilepsy Foundation at (800) 332-4050.
Levine SB. Sexual Life: A Clinician’s Guide. New York: Raven Press; 1992.
Morrell MJ. Sexuality in Epilepsy. In: Engel J, Pedley TA, eds. Epilepsy. Philadelphia: Lippincott-Raven Publishers; 1997:2021-2026.