Wednesday, 15 October 2014

Sexual dysfunction in MS

Multiple sclerosis and sexual dysfunction
Zhen-Ni Guo, Si-Yuan He, Hong-Liang Zhang, Jiang Wu, and Yi Yang, Asian J Androl. Jul 2012; 14(4): 530–535.

Among other clinical manifestations, sexual dysfunction (SD) is a painful but still underreported and underdiagnosed symptom of the disorder. SD in MS patients may result from a complex set of conditions and may be associated with multiple anatomic, physiologic, biologic, medical and psychological factors. SD arises primarily from lesions affecting the neural pathways involved in physiologic function. In addition, psychological factors, the side effects of medications and physical symptoms such as fatigue, muscular weakness, menstrual changes, pain and concerns about bladder and bowel incontinence may also be involved. Since MS primarily affects young people, SD secondary to MS may have a great impact on quality of life.

Figure: SD in MS patients can be owing to lesions affecting the neural pathways that are involved in physiologic function, among which the HPA axis and the HPG axis might be compromised. Psychological factors such as depression, side effects of medications and physical symptoms including fatigue and muscular weakness may contribute to the pathogenesis of SD in MS. (−) denotes compromising effects. HPA, hypothalamic–pituitary–adrenal; HPG, hypothalamic–pituitary–gonadal; MS, multiple sclerosis; SD, sexual dysfunction.

Any mention of sex, sexual dysfunction is sure fire way to kill a conversation, it's also very 'British' to skirt around personal and taboo subjects! However, as the topic featured one too many times in my clinic this week, I felt it was time to take another look at this...

MS like other chronic medical conditions is frequently associated with SD. Around 40-74% of female MSers report SD; most frequently due to a reduced drive, difficulty in orgasming, reduced sensation in the genital area and vaginal dryness leading to pain during intercourse. Whilst, men commonly report erectile dysfunction (50-75%), followed by ejaculatory dysfunction/ difficulty orgasming and reduced drive.

Why?

The causes are not well known, but largely multifactorial (refer to above figure). It is not only due to MS lesions affecting the neural pathways involved in sexual function, but also psychological factors, medication related (around 30-60% on SSRI anti-depressants have related SD), tiredness, muscle weakness, pain, and concerns over bladder/bowel incontinence etc.

Researchers have found an increase in the levels of the stress hormone cortisol in MSers, suggesting hyperactivity of the HPA axis (H=hypothalamus is the main link between the nervous and hormonal system, and is involved in a myriad of functions including the regulation of appetite, sleep-wake cycle, immune system, sexuality, mood etc.). 

While, the interruption of the HPG axis affects sex hormone production and reproductive function. We know that relapse activity in female MSers is related to sex hormones - low progesterone at the start of menstruation is associated with frequent relapses or worsening symptoms, whilst the relapse rate reduces during the last three months of pregnancy owing to increased oestrogen and progesterone levels, which later increases again in the three months post delivery as the hormones drop off. In male MSers low blood testosterone levels is associated with erectile dysfunction, diminished drive and potentially lowered sperm count.

Therapeutic options



The first-line for male SD are phosphodiesterase type 5 inhibitors (sildenafil = Viagra, Vardenafil = Levitra, Tadalafil = Cialis) which increase cyclic guanosine monophosphate levels (cGMP) leading to smooth muscle relaxation and increased inflow of blood. Other vasoactive agents (drugs which increase the calibre of blood vessels) such as prostoglandin E1 (Caverject, Viridal) also induce erections through smooth muscle relaxation can also be used. Dopamine agonists, such as apomorphine act in the central nervous system with an affinity for D2 brain receptors known to be involved in sexual function can be used in either sex. Replacement of sex hormones (oestrogen and progesterone) in those with low levels may also be another therapeutic option in SD. Alternatively, psychotherapy and counselling when done correctly can result in marked improvements in SD.

Overall, SD in MS is complex and requires a multifactorial approach. In men at least there appears to be several directly acting oral drugs, but in women hormonal therapy and psychotherapy may be the way to go.

10 comments:

  1. Re. "Researchers have found an increase in the levels of the stress hormone cortisol in MSers, suggesting hyperactivity of the HPA axis".
    Interesting so relapse triggered by stress could be due to spike in cortisol.

    Re. "We know that relapse activity in female MSers is related to sex hormones - low progesterone at the start of menstruation is associated with frequent relapses or worsening symptoms."
    I was asking my GP this a month ago, he said he wasn't aware of a relationship between MS relapses and mensturation cycles but I have noticed a possible pattern.

    ReplyDelete
  2. The HPA axis hyperactivity theory is in fact the very opposite, I should have explained that cortisol is immunosuppresive and high levels coincide with lowered inflammation. Conversely, low reactivity of the HPA axis may make you susceptible to the disease and disease severity - RRMS is more responsive than SPMS for instance.

    I agree with your second comment in some patients the pre-menstrual hormonal changes appear to worsen their MS symptoms.

    ReplyDelete
    Replies
    1. Thanks for your reply. Relapse triggered by stress does urgently need investigating, i'm not the only MSer to suffer from this. I've had to see a neuro-psychiatrist about a major stress triggered relapse. I have an MRI scan due in the next month so will be interesting to see if I have repaired at all. Had some unusual symptoms from that relapse incuding autonomic nervous system involvement.

      Delete
    2. Its not so simple. See this PNI article on relationship between stress, cortisol and other hormones with inflammation http://www.scq.ubc.ca/stress-cortisol-and-the-immune-system-what-makes-us-get-sick/

      Its not acute short-term stress that affects me (if it did, I'd be relapsing constantly as my work has lots of this type of stress). It is chronic emotional stress that appears to affect me. I've been looking at this for 15 years, and this always precedes a relapse. Coincidence? Thankfully for me, I have very mild MS and no EDDS, it also means I've had 15 years to monitor this.As I have very good levels of D3 etc etc, as I don't have heat intolerance, as I've never had a problem with flu, relapses sometimes but more rarely happen in spring (late summer and December mainly) I'm pretty convinced it is this type of stress that triggers relapses for me.

      Delete
    3. Interesting, this morning I got a book out of my uni library on intro to PNI. After what happened to me and that severe stress triggered relapse I'm keen to research into this. One of my other symptoms from this relapse was left foot jerking and lifting up the bed sheet. It felt like tension was coming out of my left foot big toe.

      I have been doing stress management for while now, since that relapse and am now much more assertive/ aware about stress and if the situtation I am in is controllable or not.

      Delete
  3. Stressors, such as loss of a loved one, moving house, interpersonal conflict and loss of a job have been reported to exacerbate MS. In a small study of medical student, exposed to stress in the form of their final exams (!!), TNF alpha levels were found to be significantly elevated the following day (evidence is from Lalive PH, Burkhard PR, Chofflon M. TNF-alpha and psychologically stressful events in healthy subjects: potential relevance for multiple sclerosis relapse. Behav Neurosci 2002; 116:1093-1097). They confirmed the stress levels by demonstrating both an elevation in urinary cortisol and reported stress scale scores. TNF alpha is an important cytokine in promoting inflammatory activity and may be the missing link in the relationship between stress and heightening of MS activity. Whether, control of the initial stress levels thorough relaxation techniques can induce a physiological change in the body remains to be seen.

    ReplyDelete
    Replies
    1. I think removing the stressor is best but often not possible - again it's the CHRONIC stress that is so damaging - I have been mobbed at work for a number of years and that is why my MS 'broke out' and got so much worse - I'm sure that I would have lived and repaired without any symptoms of MS if it were not for the constant fearfulness of new conflicts at work & loss of a job.

      Delete
    2. We can't get away from stress and sometimes we work better with stress. it happened to me. If we are unable to change the stress level, we need to find a way of dealing with it. Counselling can help and then the skills are there for good and can be used for future problems. One thing I have learnt is get rid of one nightmare and another one is waiting in the wings to replace it.

      Delete
    3. Before I had my first relapse I was suffering from stress at work. I used to work in a complaints contact centre for over five years and would have people phoning in swearing at me.
      I asked to go on an in house stresss management course that was being run. I was not allowed to go as the contact centre would of been short staffed. I should of contacted the union or gone to my GP. I wish I had been much more assertive about the stress and gone to my GP, had some time off work (I always felt guilty taking time off work when I was sick). If the GP could not of helped me then read a book on CBT from the library, taken up stress management or meditation then (It doesn't have to cost anything). It's controllability of the stress (as much as possible). People don't seem to realise that stress can be so damaging, as it it's physical wear and tear (and not just to MSers).

      Delete
    4. I keep coming across MSers who mention that anxiety triggers relapses too and a doctor. I know that stress can cause anxiety. MS can cause anxiety - through lesion location perhaps. And also having a diagnosis of MS can cause anxiety through the uncertainty of what symptoms may happen next . Anxiety is a close relation of stress and could be seen as a sister to stress. Meditation helps reduce anxiety and it would be interesting to see studies of MSers who meditate with regards to anxiety levels. Also meditation used for pain management in MS.

      Delete

Please note that all comments are moderated and any personal or marketing-related submissions will not be shown.