SEMINARS IN NEUROLOGY-VOLUME

12, NO. 2 JUNE 1992

Sexual Aspects of Parkinson's Disease

Parkinson's disease (PD) was first described in 1817 by James Parkinson.' T h e main symptoms are akinesia, rigidity, tremor, and postural instability. It is a chronic disease with a varied individual course.* T h e disease usually has a slow onset, and consequently the time of onset can be difficult to determine. It usually occurs between the ages of 55 and 65 years.3 The course of the disease has changed significantly since the introduction of levodopa into treatment in the late 1960s, for patients with onset after 1970 have had a milder progression of disease and can maintain a better performance in daily living for a longer time than previ~usly.~

SEXUAL FUNCTION Obviously, sexual function is very complex, but in a simplified way can be understood as comprising an emotional element, the libido, and a physical element, the ability to have satisfactory intercourse. The mechanisms controlling libido in man are not well understood. However, the limbic cortex and the hypothalamus are believed to be involved. Neurophysiologically, several transmitter systems are involved, including the serotonergic, dopaminergic, and possibly other^.^ The physical element in man consists of an intact erectile function, emission, ejaculation, orgasm, and being able to carry through an intercourse. In women the physical part includes the ability to be sexually stimulated by caressing of genitalia, having orgasm, and intercourse. For younger women, the possibility of pregnancy and giving birth are considered to be part of normal sexual function. Therefore sexual dysfunction can be defined as changes in libido as well as changes in physical

sexual function. Sexual dysfunction is frequently seen in neurologic diseases, such as multiple sclerosis (see Stenager et a1 in this issue of Seminars), paraplegia, tetraplegia, and tumors and other diseases in the hypothalamus and the p i t ~ i t a r yAge .~ and having a chronic disease also influence sexual function. Sexual dysfunction is more common in the aged. However, sexual dysfunction is often related more closely to concomitant illness than to aging alone.6

SEXUAL FUNCTION IN PARKINSON'S DISEASE Because the dopaminergic transmitter system is involved in both PD and libido, it might be expected that several studies on sexual aspects of PD would be available. However, this is not the case. Only a few studies on sexual function in PD have been performed and none includes a physiologic examination of the patients. Our knowledge of sexual function in PD is thus very limited. Two studies, published as abstracts, have reported reduced sexual f u n ~ t i o n . In ~ . ~one study, 54% of 48 consecutively admitted male patients with PD had erectile dysfunction,7and in the other study of 44 consecutive patients with PD, 81% of the men and 43% of the women reported reduced sexual activity, which they related to their health.8 A questionnaire study compared the sexual function of 4 1 married men with PD and 2 1 married men with arthritis. The mean age, mean use of alcohol, and mean score on the Zung Depression Scale were comparable. The mean duration of illness was 6 years in PD and 15 years in arthritis. For both groups, increased age, severity of illness, and depression were associated with reduced sexual function. The authors concluded that sexual dys-

Department of Neurology, Odense University Hospital, Odense, Denmark Reprint requests: Dr. Wermuth, Department of Neurology, Odense University Hospital, DK-5000 Odense C, Denmark Copyright O 1992 by .Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.

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Lene Wermuth, M.D., and Egon Stenager, M.D.

SEMINARS IN NEUROLOGY

PREGNANCY AND PARKINSON'S DISEASE Usually, onset of PD occurs relatively late in life. Consequently, only a few women have onset of PD before the menopause. However, there are reports of women with PD who have been pregnant and given birth.I7.l8 In a study by GolbeI8 of 18 women with 24 pregnancies after onset of PD, it was found that 10 of 17 completed pregnancies were associated with a permanent worsening of PD symptoms, which did not affect overall disability. Use of amantadine during the first trimester was associated with a heterogeneous group of obstetric complications, including miscarriage. However, in the series as a whole there was no excess incidence of obstetric complications o r fetal defects.

CLINICAL EXPERIENCE At Odense University Hospital, a comprehensive neurologic, neuropsychologic, and psychiatric examination, including sexual dysfunction, in PD patients younger than 55 years is under way. All the patients receive appropriate levodopa therapy. In the group as a whole, the patients do not have sexual dysfunction, either in change in libido o r in physical function.

CONCLUSION In the light of present knowledge, it appears that erectile dysfunction and reduced libido occur in PD patients, but, according to the only available controlled study, no more often in PD men than in men with other chronic disease not affecting the nervous ~ y s t e mLevodopa .~ may induce increased libido in some men with PD, but usually only transiently. Hypersexuality as a consequence of levodopa therapy is rare. Bromocriptine is suspected of being capable of inducing impotence. No specific treatment of sexual dysfunction in PD has been tried. We believe that proper treatment of the locomotor symptoms in PD should result in better sexual function. However, much remains to be learned about the sexual function of PD patients before improvement in their lives is possible.

REFERENCES Parkinson J . An essay on the shaking palsy. London: Whittingham and Rowland, 1817 Hoehn MM, Yahr MD. Parkinsonism: onset, progression and mortality. Neurology 1967; 17:427-42 Wermuth L. Epidemiologisk undersGgelse af Parkinsonpatienter fra et ambulatorium. Ugeskr Laeger 1986; 148: 1702-4 Wermuth L. Outpatient treatment of Parkinson's disease. Eur Neurol 1988;28: 152-5 Lundberg PO. Sexual function in men with neurological disorders. In: Hafez ESE, ed: Human semen and fertility regulation in men. St. Louis: CV Mosby 1976: 504-12 Mulligan T, Retchin SM, Chinchilli VM, Bettinger CB. The role of aging and chronic disease in sexual dysfunction. J Am Geriatr Soc 1988;36:520-4 Singer C, Sanchez-Ramos J , Weiner WJ, Anckerman M. Sexual dysfunction in parkinsonian men (abstr.). Neurology 1989;39(suppl 1):145 Longstreth WT, Linde M. Sickness impact profile in Parkinson's disease (abstr.). Neurology 1984;34(suppl 1): 207-8 Lipe H, Longstreth WT, Bird TD, Linde M. Sexual function in married men with Parkinson's disease compared to married men with arthritis. Neurology 1990; 40: 1347-9 Hyyppa M, Rinne OK, Sonninen V. T h e activating effect

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function was common in PD, but no more so than in men with a chronic disease that did not involve the nervous ~ y s t e m . ~ After the start of levodopa treatment in the late 1960s, articles reported increased sexual activity related to the treatment. In the first report, by Hyyppa et all0 in 1970, 10 of 41 patients (seven men, three women) reported increased libido and half of them, increased sexual activity. In a study by Bowers and associates" in 197 1, seven of 19 patients reported activation of sexual behavior at some point, but the authors concluded that it was a transient effect and only in a small percentage of patients, so that levodopa could not be used as an aphrodisiac. In a case report from 1973, hypersexuality as a consequence of levodopa therapy was considered an unusual complication.'~na study from 1978 by Brown et all3 on seven male patients with PD, it was concluded that only patients who possess an intact hypothalamic-pituitary-gonadal axis experience increased sexual function, which is related to levodopa treatment. As a consequence of the first reports, Senkert et all4 tried to treat 10 impotent men with levodopa, but with lack of success, for none of the men had an erection sufficient to consummate sexual intercourse. In books on PD and its treatment, increased sexual activity as a side effect of levodopa therapy and even hypersexuality have been reported.I5 However, based on the available literature, this seems to be rare. Contrary to the preceding reports is the occurrence of impotence in four men with PD after start of bromocriptine treatment.lVorma1 prospective studies on this subject have not been performed. No controlled trials of treatment of sexual dysfunction in PD have been made.

V O L U M E 12, N U M B E R 2 JUNE 1992

SEXUAL ASPECTS OF PARKINSON'S DISEASE-WERMUTH,STENAGER 14. Benkert 0, Crombach G, Kockott G. Effect of L-dopa on sexually impotent patients. Psychopharmacologia (Berl) 1972;23:91-5 15. Stern G, Lees A. Parkinson's disease. The facts. Oxford: Oxford University Press, 1982 16. Cleeves L, Findley LJ. Bromocriptine induced impotence in Parkinson's disease. Br Med J 1987;295:367-8 17. Bland PB, Goldstein L. Pregnancy and parkinsonism. JAMA 1930;95:473-6 18. Golbe LI. Parkinson's disease and pregnancy. Neurology 1987;37: 1245-9

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of L-dopa treatment on sexual function and its experimental background. Acta Neurol Scand Suppl 1970; 43:2234 11. Bowers MB, Van Woert, Davis L. Sexual behavior during L-dopa treatment for Parkinsonism. Am J Psychiatry 1971;127:1691-3 12. Shapiro SK. Hypersexual behavior complicating levodopa therapy. Minn Med 1973;56:58-9 13. Brown E, Brown GM, Kofman 0,Quarrington B. Sexual function and affect in Parkinsonian men treated with L-dopa. Am J Psychiatry 1978;135:1551-5

Sexual aspects of Parkinson's disease.

SEMINARS IN NEUROLOGY-VOLUME 12, NO. 2 JUNE 1992 Sexual Aspects of Parkinson's Disease Parkinson's disease (PD) was first described in 1817 by Jame...
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