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1 Shankun Zhao, Zhen Tang, and Qiang Xie have contributed equally to this work.
Shankun Zhao
Footnotes
1 Shankun Zhao, Zhen Tang, and Qiang Xie have contributed equally to this work.
Affiliations
Department of Urology & Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510230, China
Department of Urology & Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510230, China
Department of Urology & Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510230, China
Department of Urology & Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510230, China
Department of Urology & Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510230, China
Department of Urology & Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510230, China
Corresponding author at: Department of Urology & Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510230, China.
Department of Urology & Andrology, Minimally Invasive Surgery Center, Guangdong Provincial Key Laboratory of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510230, China
Both female and male patients with epilepsy are at risk of sexual dysfunction.
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Male epilepsy-patients had a higher risk of sexual dysfunction than female subjects.
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High prevalence of sexual dysfunction in patients with epilepsy may be multifactor.
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Sexual functioning assessment should be considered when treating epilepsy.
Abstract
Purpose
Sexual functioning is an important factor influencing quality of life. Mounting evidence suggests that both male and female patients with epilepsy (PWE) have an increased risk of developing sexual dysfunction (SD). The aim of this meta-analysis was to quantify the association between epilepsy and the risk of SD.
Methods
PubMed, Embase, and Cochrane Library database were systematically searched to identify the pertinent studies focusing on the association between epilepsy and SD. Relative risk (RR) for SD with 95% confidence interval (CI) was calculated. The overall quality of the evidence was generated by applying the GRADE-profiler. This meta-analysis was registered on the PROSPERO (ID: CRD42018103572, http://www.crd.york.ac.uk/PROSPERO).
Results
Nine studies (3 cross-sectional, 5 case-control, and 1 cohort) were included in this meta-analysis, for a total of 1556 subjects and 599 cases of epilepsy. Synthetic results demonstrated that epilepsy was associated with an increased risk of female SD (6 studies, pooled RR = 2.69, 95%CI: 1.48–4.89, P = 0.001; heterogeneity: I2 = 88.9%, P < 0.001) as well as male SD (3 studies, pooled RR = 4.85, 95%CI: 2.01–11.7, P < 0.001; heterogeneity: I2 = 74.2%, P = 0.021). The GRADE-profiler showed that the rate of events of SD on average in the PWE and the controls were 383/659 (58.1%) and 168/1017 (16.5%), respectively. The quality of evidence across outcomes was MODERATE.
Conclusions
Epilepsy is significantly associated with an increased risk of SD in both sexes. These findings suggest that both clinicians and patients should recognize that epilepsy has a potential hazardous effect on sexual functioning.
]. Some specific types of epileptic seizures can be completely controlled by surgical therapies. However, this chronic neurologic disorder generally requires a long time and even lifelong antiepileptic drugs (AEDs) treatment in most cases due to its chronic nature [
]. Moreover, although many new AEDs are currently introduced, nearly 40% of all the patients with epilepsy (PWE) continue to have intractable seizures [
Because epilepsy and AEDs have direct impacts on the regulation of the hypothalamic-pituitary-gonadal axis, PWE are at high risk to develop ovarian or testicular dysfunctions [
]. Abnormalities in central control (i.e., interference of the medial temporal lobe) and sex steroid hormones metabolism (i.e., reduction of androgen) may affect various aspects of sexual functions in both male and female sufferers. In addition, epilepsy can also induce comorbid neuropsychiatric disorders (i.e. depression and anxiety) which are known to contribute to sexual dysfunction (SD) [
]. Taken together, an increased rate of SD is to be expected in the PWE.
Research data showed that the proportion of SD in PWE varied across the studies, ranging from 38% to 71% and 23% to 60% in male and female patients, respectively [
]. However, results from different studies remain conflicted and inconclusive on the association between epilepsy and SD. A previous study indicated that only 8% of male PWE had SD as compared with 13% of the non-epilepsy control [
Although a high prevalence of SD in PWE has been observed, the evidence for this potential relation is still controversial among studies and the comprehensive information is limited. Therefore, we conducted the present meta-analysis in an attempt to explore whether epilepsy was a risk factor for SD.
2. Methods
The protocol of this systematic review and meta-analysis was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The PRISMA checklist was presented in Supplementary Table 1. In addition, we have registered a protocol for this meta-analysis on PROSPERO (ID: CRD42018103572, http://www.crd.york.ac.uk/PROSPERO).
2.1 Data sources and searches
Medline (PubMed), Embase, and the Cochrane Library databases were comprehensively searched for relevant studies from the inception to May 17, 2018. We restricted the search limit to English language and human participants. The following search subject headings and the text keywords were used for PubMed: ((((((("Erectile Dysfunction"[Mesh]) OR sexual function) OR sexual dysfunction) OR "Sexual Dysfunctions, Psychological"[Mesh]) OR "Sexual Dysfunction, Physiological"[Mesh]) OR Impotence)) AND (((((((((((("Epilepsy"[Mesh]) OR Epilepsies) OR Seizure Disorder) OR Seizure Disorders) OR Awakening Epilepsy) OR Epilepsy, Awakening) OR Epilepsy, Cryptogenic) OR Cryptogenic Epilepsies) OR Cryptogenic Epilepsy) OR Epilepsies, Cryptogenic) OR Aura) OR Auras).
2.2 Measurement of epilepsy and SD
Definitions of epilepsy and SD were in compliance with the international classification of diseases codes. PWE were diagnosed according to different diagnosing criteria, such as International League Against Epilepsy criteria, clinical and EEG evidence, etc. Male patients with SD mainly manifested as erectile dysfunction, diminished libido, and abnormal ejaculation; while female patients with SD mainly manifested as desire, arousal, orgasmic, and sexual pain disorders. In the present meta-analysis, SD was confirmed by using any of the existing and validated instruments, including the Arizona Sexual Experience Scale, International Index of Erectile Function, Diagnostic and Statistical Manual of Diseases Classification, and Female Sexual Function Index (FSFI).
2.3 Study selection
Any available epidemiologic evidence met our inclusion criteria were included in this study. In compliance with the patient, intervention, comparison, outcome and study design (PICOS), the question guiding for this meta-analysis was: Does epilepsy increase the risk of SD? The combinations for the PICOS evidence were: males and/or females subjects with SD or sexual problems (P); a history of epilepsy (I); compared with the general population (C); the diagnosis of SD (O); no limitations on study designs (S). We also included the studies providing the relative risk (RR), hazard ratio, or odds ratios with 95% confidence intervals (CI). The excluded studies were as follow: (1) without the control population data; (2) review article, comment, editorial, letter, and case report, etc.; (3) duplicated data; (4) animal experiment.
2.4 Data extraction
A standardized data collection form was performed to extract the following relevant information by two authors independently: the first authors’ names, publication year, country of origin, study design, disease duration, specific AEDs usage, the demographic and age of the study and the control sample, measurements of epilepsy and SD ascertainment, and variable adjustment for confounding factors.
2.5 Quality assessment
The reporting quality assessment of the cross-sectional study was depended on the cross-sectional study quality methodology checklist. The low quality, moderate quality, and high quality were judged with the scores at 0–3, 4–7, and 8–11, respectively. The methodological quality evaluation of the case-control/cohort study was based on the Newcastle–Ottawa Scale (NOS). NOS scores of 0–3, 4–6, 7–9 were regarded as low quality, moderate quality, and high quality, respectively. The grading of recommendations assessment, development, and evaluation (GRADE) approach was presented to exert the absolute estimates of the risk of SD in PWE and to rank the overall quality of the evidence.
2.6 Statistical analyses
The overall RR with its corresponding 95% CI was employed to assess the strength of the association between epilepsy and the risk of SD. In this analysis, results with a two-tail P values <0.05 were regarded as statistically significant. The I2 statistic and the Cochrane Q statistic were calculated to assess the heterogeneity of included studies (substantial heterogeneity was confirmed by I2 > 50%; statistical significance was validated by P value of Q test <0.10). In the present study, a random effect model rather than a fixed effects model was applied due to the high likelihood of between-study variance for differences in study design as well as the study population. Sensitivity analyses were conducted to detect the potential source of heterogeneity. Begg’s rank correlation test and Egger’s regression asymmetry test were employed to evaluate the publication bias. The current statistical analysis was conducted by using the Stata (version 13.0, Stata Corp LP, College Station, Texas, USA).
3. Results
3.1 Literature search
Through the initial search, a total of 924 articles were identified (503 from MEDLINE, 311 from EMBASE, and 110 from the Cochrane Library). Based on the initial reviewing of titles and abstracts, 878 publications were excluded after removing duplicates, leaving 46 pertinent studies for further full-text review. Among them, 18 articles were excluded for failing to provide the control group; 8 articles for insufficient outcome data; 6 articles for not meeting the inclusion criteria; and 5 articles for inappropriate grouping. Finally, 9 observational studies [
] met the pre-defined eligibility criteria and were included in quantitative analysis. Fig. 1 showed the process of selection.
Fig. 1Flow chart of study selection. A total of 924 publications were identified in 3 databases during the initial search. After reviewing of titles and abstracts, 878 publications were eliminating for duplicates and ineligible studies, leaving 46 pertinent studies for further full-text assessment. Finally, 9 articles were included in the current study.
]. These included studies have enrolled a total of 1029 female participants and 527 male participants, of whom 418 women and 181 men were PWE, respectively. Among the 9 eligible studies, 1 study reported the combined results from both genders [
] mentioned the specific AEDs usage, including carbamazepine, phenobarbital, phenytoin, valproate, gabapentin, lamotrigine, clobazam, oxcarbazepine, levetiracetam, and topiramate, etc. The mean age of the female subjects and male subjects among studies ranged from 29.6 to 43.6 years and 30.5–43.6 years, respectively. The detailed characteristics of the 9 included studies were summarized in Table 1.
As listed in Table 2, the GRADE-pro showed that the rate of events of SD on average in both female and male PWE was 383/659 (58.1%), whereas the general population was 168/1017 (16.5%). The absolute effect of epilepsy on SD was 344 more per 1000 (from 157 more to 641 more), and the overall quality of the evidence was judged as MODERATE. When the female individuals were analyzed independently, the rate of events of SD on average in PWE was 247/418 (59.1%), while the control group was 119/611 (19.5%); the absolute effect was 329 more per 1000 (from 93 more to 758 more); and the overall quality of the evidence was judged as LOW. When the male subjects were analyzed independently, the rate of events of SD on average in epilepsy was 106/181 (58.6%), while the rate of healthy subjects was 34/346 (9.8%); the absolute effect was 378 more per 1000 (from 99 more to 1000 more); and the overall quality of the evidence was considered to VERY LOW.
Table 2GRADE summary of evidence for the effects of epilepsy and sexual dysfunction (SD).
Quality assessment
No. of patients
Effect
Quality
Importance
No. of studies
Design
Risk of bias
Inconsistency
Indirectness
Imprecision
Other considerations
Epilepsy
Control
Relative (95%CI)
Absolute
Sexual dysfunction (assessed with: International Index of Erectile Function, Female Sexual Function Index, etc.)
patients with long duration and severity of epilepsy in had a higher risk of SD.
106/181 (58.6%)
34/346 (9.8%)
RR 4.85 (2.01 to 11.7)
378 more per 1000 (from 99 more to 1000 more)
⊕OOO VERYLOW
CRITICAL
CI: confidence interval; RR: relative risk;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
1 selection bias, performance bias, and detection bias were detected in several included studies.
2 some studies concluded that neuropsychiatric disorders and sex hormones disturbance might play roles in this association.
3 large sample, total 1676 female and male participants from 10 studies were included.
4 combined RR was 3.08 (95%CI: 1.95–4.88, P = 0.007).
5 patients with long duration and severity of epilepsy in had a higher risk of SD.
6 large sample, total 1029 female participants from 6 studies were included, the overall RR was 2.69 (95%CI: 1.48–4.89, P = 0.001).
7 inconsistent association between epilepsy and male SD was reported within the included studies (i.e. Calabro et al’s study).
8 total 527 male participants from 3 studies were included, combined RR was 4.85 (95%CI: 2.01–11.7, P < 0.001).
] for both sexes. When combined all the cases of both female and male subjects, synthetic results suggested that epilepsy was significantly associated with an increased risk of SD in both sexes (overall RR = 3.08, 95%CI: 1.95–4.88, P = 0.007; heterogeneity: I2 = 86.9%, P < 0.001). In the female individuals, synthetic RR from 6 studies [
] by using a random-effects model revealed that epilepsy conferred a 2.69-fold increased risk of SD compared to the general population (pooled RR = 2.69, 95%CI: 1.48–4.89, P = 0.001; heterogeneity: I2 = 88.9%, P < 0.001). Moreover, pooled results from 3 studies [
] investigating male subjects yielded a similar result (synthetic RR = 4.85, 95%CI: 2.01–11.7, P < 0.001; heterogeneity: I2 = 74.2%, P = 0.021).
3.5 Subgroup analyses
In this study, we performed the subgroup analyses to further elicit the association between epilepsy and the risk of SD and to explore the source of heterogeneity. Of note, the disease duration, specific AEDs, and mean age might serve as the confounding factors, by which might affect the actual role of epilepsy on the sexual functioning. However, because only a few studies provided the data of the mean duration of epilepsy and the specific AEDs, we did not conduct the subgroup analyses on these two factors.
In the included studies reporting female subjects, subgroup analysis on the study design indicated that the association between epilepsy and SD was existed in cross-sectional studies [
] (RR = 2.55, 95% CI: 1.89–3.43, P <0.001) and no significant heterogeneity was detected (I2 = 25.3%, P = 0.247). However, such association was not found in the cohort/case-control studies [
] (RR = 2.83, 95% CI: 0.9–8.82, P =0.074) and the substantial heterogeneity was observed (I2 = 92.8%, P <0.001). Stratified analysis by geographical area revealed that there was no significant relationship between epilepsy and female SD in studies conducted in the United States [
] (RR = 2.49, 95% CI: 0.81–7.71, P =0.113) and non-significant heterogeneity was found (I2 = 0.0%, P = 0.429). However, those studies conducted in other regions [
] confirmed a relationship between epilepsy and SD (RR = 2.7, 95% CI: 1.37–5.32, P =0.004; I2 = 93.2%, P <0.001). Based on the mean age, the results of subgroup analysis verified the positive association between epilepsy and the female SD, and such association seemed stronger in the PWE with age ≥35 years [
As shown in Table 3, the results of subgroup analyses for male studies showed that the association between epilepsy and male SD was detected in cross-sectional designed, study conducted in America, and mean age <35 years. Great heterogeneity was observed in those studies designed by cohort/case-control and conducted in Europe, and in those PWE with mean age ≥35 years.
3.6 Sensitivity analysis
To evaluate the influence of individual study on the overall risk of SD, we have conducted the sensitivity analyses subsequently. Omitting any one of the 6 studies of female subjects did not substantially change the new overall synthesis RR [ranged from 2.07 (95%CI: 1.38–3.12) to 3.29 (95%CI: 1.87–5.76)] and the heterogeneity (I2 ranged from 62.4% to 91.1%) (Table 4 and Supplementary Fig. 1 left panel).
Table 4Sensitivity analysis after each study was excluded by turns.
] (RR = 3.8, 95%CI: 0.7–20.55; heterogeneity: I2 = 83.2%, P = 0.015), and no significant association between epilepsy and SD was observed. Interestingly, the substantial heterogeneity was disappeared after omitting the study of Calabro et al. [
] (I2 = 0.0%, P = 0.598), indicating that the substantial heterogeneity of the included studies of male subjects might originate from this study (Table 4 and Supplementary Fig. 1 right panel) (Fig. 2).
Fig. 2Forest plots of meta-analysis of the included studies on the association between epilepsy and sexual dysfunction in both sexes. The synthesis relative risk using a random effect model showed that epilepsy was associated with a significantly higher incidence of sexual dysfunction in both genders. Substantial heterogeneity was detected across the studies.
As shown in Fig. 3, visualization of the funnel plot suggested that Begg rank correlation test and the Egger linear regression yielded no evidence of publication bias among the included studies (Begg’s, P > |z| = 1.000; Egger, P > |t| = 0.812, 95%CI: −5.3–4.28).
Fig. 3Begg’s and Egger’s tests to detect publication bias. Both Begg’s rank correlation test (left panel) and the Egger’s linear regression (right panel) yielded no evidence of publication bias in this study.
] reporting SD developing in two-thirds of untreated PWE, by Gastaut et al. in 1954, extensive studies were conducted to investigate the risk of SD development in epilepsy and to explore the underlying mechanism. Based on the combined RR from the 6 included studies reporting female subjects and 3 studies reporting male individuals, the present meta-analysis revealed that the prevalence of SD was remarkably higher among PWE than the general populations in both sexes. Female and male PWE might be at two-fold and four-fold higher risk of SD than the healthy female and male controls, respectively. Ascertained by GRADEpro, the rates of events of SD on average were 59.1% and 19.5% for female PWE and healthy individuals, respectively; and 58.6% and 9.8% for male PWE and the healthy controls, respectively. These results were in line with the findings of some other pertinent trials failing to meet our pre-defined eligibility criteria [
], which showed the suspicious association between epilepsy and SD. Sensitivity analyses suggested that the quantification of the risk for the SD in PWE remained prominently high in nearly all of the studies, indicating our findings were robust. However, there was substantial heterogeneity among studies. In addition to study design, geographical area, and the mean age which reflected by the subgroup analyses in this meta-analysis, the different mean disease duration of epilepsy, frequency and severity of the disease, AEDs usage, sample size, the assessment tool for SD, and variable characteristics of participants could all be partly responsible for the heterogeneity.
Although the current meta-analysis suggested that epilepsy might be linked with SD, no clear-cut etiology has been recognized to interpret this possible association. Multifactorial mechanisms may contribute to the development of SD in PWE, these include but are not limited to the innate nature of impairments in the nervous system (i.e., the site of origin of seizures, different types, duration and frequency of epileptic seizure), endocrine disorder, AEDs usage, psychiatric illness, and psychosocial deficits [
Sexual behavior is known to be controlled by the brain. Epilepsy is one of the diseases of brain lesions. The results of our study suggested an increased rate of SD in the PWE. The clinical manifestations of the impairment on sexual function in PWE seemed to depend on the site of the origin of seizures. Among the PWE, the occurrence of SD is distinctly higher in people with temporal lobe epilepsy (particularly on the right side) than those with extratemporal and primary generalized epilepsies [
] reported that anterior temporal lobectomy would result in postoperative seizure freedom in over 60% AED-resistant patients. Intriguingly, most patients who received the surgery have achieved an appreciable improvement in their sexual function postoperatively [
]. On the other hand, different types of epileptic seizure also have various effects on sexual functioning. Previous study suggested that the incidence of SD was higher in patients with focal epilepsy than those with generalized epilepsy [
]. FSFI is a 19-item questionnaire evaluating the sexual function of female, in which 6 domains of sexual desire, arousal, lubrication, orgasm, satisfaction, and dyspareunia are included, and a total scores less than 26.55 is considered as SD. In Karan et al.’s study [
], they observed that female patients with a longer duration of epilepsy had the remarkably low scores of FSFI. The effect of seizure frequency on sexual function was still controversial. Some investigators reported that seizure frequency was not related to the SD symptoms [
Abnormalities in the secretion of sex hormones are the important factors related to the etiology of SD in both male and female PWE. Mounting evidence has emerged suggesting that epilepsy could affect the hypothalamic–pituitary–testicular axis or the hypothalamic-pituitary-ovarian axis [
]. It is known that bioactive testosterone plays a key role in sexual functioning in both men and women. The bioactive testosterone was found to be significantly lower in both male and female PWE compared to the healthy controls, suggesting a consequent hyposexuality in the PWE [
]. In addition to the declination of testosterone, SD in male PWE might also be correlated with elevated levels of follicle-stimulating hormone / sex hormone-binding globulin / prolactin, and decreased levels of GnRH and dehydroepiandrosterone sulfate, thereby leading to hypogonadism [
]. Interestingly, there seems to be a bidirectional interaction between seizures and sex hormones, in which seizures may affect sex hormones levels and in turn hormones modulated seizures, suggesting a vicious cycle between epilepsy and SD [
]. AEDs have been demonstrated to be contributed to the development of sexual hormone disorders, thus resulting in SD. Those process might involve different mechanisms [
]. On the one hand, certain AEDs (i.e. phenobarbital, carbamazepine, and phenytoin) could induce liver enzymes, leading to direct suppression of gonadal testosterone synthesis and disturbance of other peripheral sex steroid hormones [
Differential effects of antiepileptic drugs on sexual function and reproductive hormones in men with epilepsy: interim analysis of a comparison between lamotrigine and enzyme-inducing antiepileptic drugs.
]. On the other hand, AEDs can also have a depressive effect on brain excitability, thus producing a deteriorative impact on sexuality. Due to the natural effect of AEDs is to control the seizure symptoms of the patients, it seems that the more sedative AEDs have a greater impact on the sexual functioning than those AEDs with less sedative effects [
]. Intriguingly, some clinicians found that oxcarbazepine (a keto-derivative of carbamazepine) not only had the beneficial effects on SD, but also was effective for well control in PWE [
]. In line with this finding, Atarodi-Kashani et al. reported that non-enzyme-inducing AEDs (i.e., Lamotrigine and Levetiracetam) could significantly improve the desire, orgasm, and satisfaction [
]. As for the possible association between AEDs and sexual functioning, both the clinicians and patients should take into account not only the seizure situation but also the sexual health to choose the optimum AEDs.
Psychiatric and psychosocial comorbidity might also play pivotal roles in the development of SD in PWE. Evidence from several epidemiological studies indicated that anxiety and depressive disorders were high in PWE, especially in those received AEDs treatment [
How changes in depression and anxiety symptoms correspond to variations in female sexual response in a nonclinical sample of young women: a daily diary study.
]. Since many patients further received psychotropic medications, which were considered as the risk factors for sexual impairment, thus these anti-psychiatric medications usage might contribute to the development of SD symptoms [
]. Moreover, psychosocial stresses have also been identified as causes of SD in epilepsy. A large proportion of the PWE have complained about poor self-esteem, feelings of stigma, and limitation of social contacts, including family relations, work, and education [
]. These psychosocial constraints might be one of the explanations for SD among PWE.
To the best of our knowledge, this is the first meta-analysis to summarize all available evidence for pooling the odds on the association between epilepsy and the risks of developing SD in both male and female subjects. However, there were also several inherent limitations in the study. Firstly, substantial heterogeneity across the included studies was found. Subsequent sensitivity analyses indicated that the potential origin for the observed heterogeneity of male’s studies might derive from Calabro’s study. However, heterogeneity was consistent in the studies of female subjects after excluding any one of the relevant studies. Secondly, we did not conduct the stratification analyses for the disease frequency, severity, duration, and specific AEDs because these data were not available in all the studies. Thus, high-quality prospective cohorts with large sample size are still warranted to validate the evidence of epilepsy predisposing to the development of SD in both sexes.
5. Conclusions
In summary, this meta-analysis suggests a hazardous effect of epilepsy on the development of SD in both female and male patients. Possible interpretations for this association may be multifactors, these include but are not limited to neurological impairment, AEDs usage, psychiatric and psychosocial comorbidities. Therefore, sexual functioning assessment and the preferred treatment should be given when managing the PWE in clinical practice.
Informed consent
The manuscript does not contain clinical studies or patient data.
Conflicts of interest
The authors declare that they have no confict of interest.
Ethical standard statement
For this type of study formal consent is not required.
Acknowledgement
This work was supported by the grants from Science and Technology Planning Project of Guangdong Province (No.2017B030314108).
Appendix A. Supplementary data
The following are Supplementary data to this article:
Differential effects of antiepileptic drugs on sexual function and reproductive hormones in men with epilepsy: interim analysis of a comparison between lamotrigine and enzyme-inducing antiepileptic drugs.
How changes in depression and anxiety symptoms correspond to variations in female sexual response in a nonclinical sample of young women: a daily diary study.
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