European Journal of Neurology 2004, 11: 483–488
Pergolide mesylate can improve sexual dysfunction in patientswith Parkinson’s disease: the results of an open,prospective, 6-month follow-up
M. Pohankaa, P. Kanˇovsky´b, M. Baresˇb, J. Pulkra´bekb and I. RektorbaDepartment of Sexology, Teaching Hospital, Brno Bohunice; and bFirst Department of Neurology, Masaryk University, St Anne Hospital,
One of the most disabling problems in males suffering from advanced Parkinson’s
disease (PD) is complex sexual dysfunction. The effect of dopamine replacement or
dopaminergic stimulation on sexual dysfunction has been recently examined anddescribed in patients treated by L-DOPA or apomorphine. Pergolide mesylate is
another dopamine agonist with a known high affinity to hD(2S) subtype and a lower
affinity to hD(2L) subtype of D2 dopaminergic receptors. It has been repeatedlyshown to be a highly effective treatment of the complicated and advanced stages ofPD. The current study has been designed to assess its efficacy in the treatment ofsexual dysfunction, which frequently accompanies the complicated stage of PD inmales. Fourteen male patients suffering from PD, each of whom had been treated withL-DOPA, and in whom additional treatment with peroral dopaminergic agonist (DA)was needed, were followed for a 6-month period. Pergolide mesylate (Permax) wasgiven to each patient, and titrated to a total daily dose of 3 mg. All of the patients weretaking L-DOPA. The assessments performed before the start of pergolide treatmentconsisted of a neurological examination, including Unified Parkinson’s Disease RatingScale (UPDRS) III and IV subscales scoring, Mini Mental State Examination(MMSE) scoring, the neuropsychological examination including Zung scale scoring toexclude depression, biochemical and haematological examinations including theexamination of prolactine serum levels; and a sexological examination during whichthe patients filled-in the International Index of Erectile Function (IIEF) questionnaire. These examinations were repeated during the control assessments at months 1, 3 and6. To compare the examination results, ANOVA, Friedmann’s ANOVA (non-parametric)and Tukey post hoc tests were used. There were statistically significant differencesbetween the values of UPDRS III motor subscale, UPDRS IV (complications oftherapy) subscale and all subscales of IIEF when months 0 and 1 were compared withthe results obtained at months 3 and 6. The differences between months 0 and 1 andmonths 3 and 6 (in these items) were virtually insignificant. In conclusion, pergolidesubstantially improved sexual function in the younger male patients who were stillinterested in sexual activities. In such cases, the introduction of pergolide might be abetter choice than treatment with sildenafile, which usually meets several contraindi-cations in common PD male population.
2002). It has been repeatedly shown to be a highly
effective and relatively safe treatment of the complica-
Pergolide mesylate is an ergolinic dopamine agonist
ted and advanced stages of Parkinson’s disease (PD)
with a known high affinity (100% when compared with
(Olanow and Alberts, 1987). Recently, its efficacy and
natural dopamine) to hD(2S) subtype, and a lower
tolerability have also been proven when it is used as a
affinity (80%) to hD(2L) subtype of D2 dopaminergic
monotherapy in the early stage of the disease (Hunde-
receptors (Millan et al., 2002; Newman-Tancredi et al.,
mer et al., 2000; Nausieda et al., 2002). Its pharmaco-logical profile, more than 8-hour duration of action ondopamine receptors, and general tolerability createpergolide’s most important advantages (Baresˇ et al.,
Correspondence: Doc. MU Dr Petr Kanˇovsky´ CSc, First Department
of Neurology, Masaryk University, St Anne Hospital, Pekarˇska´ 53,
One of the most disabling problems in males suffering
656 91 Brno, Czech Republic (tel/fax: +420 5 4318 2624;e-mail: pkanov@med.muni.cz, petr.kanovsky@fnusa.cz).
from advanced PD is complex sexual dysfunction
(Melis and Argiolas, 1995). The effect of dopamine
ishment following dopaminergic treatment in seven of
replacement or dopaminergic stimulation on sexual
32 patients treated with dopaminergic agonist pergolide
dysfunction has been examined and described in
(Kanˇovsky´ et al., 2002). This observation kindled a
patients treated by L-DOPA (Uitti et al., 1989; Cum-
greater interest in this phenomenon, and we prepared
mings, 1991; Rosen and Ashton, 1993; Weinman and
an open, prospective study. To assess male sexual
Ruskin, 1995; Jimenez-Jimenez and Tallon-Barranco,
functions, we decided to use the validated questionnaire
1999) and apomorphine (O’Sullivan and Hughes, 1998).
ÔInternational Index of Erectile FunctionÕ (IIEF), which
Sildenafile, phospohodiesterase (PDE-5) – five selective
is also available in national language, and which is, in
inhibitor, probably the most commonly used drug for
our opinion, better and less biased than the QoSL-Q
the treatment of erectile dysfunction, can meet several
(Rosen et al., 1997, 1999, 2002; Lukacs, 2001).
contraindications in common PD population, i.e. thehypertension or coronary heart disease with angina
In the 1990s, a study was published that focused on
All of the patients were well acquainted with the study,
the sexual functions (or rather dysfunctions) of young
and they all gave their informed consent. The study
patients suffering from PD, both male and female
protocol was approved by the institute’s ethical
(Wermuth and Stenager, 1995). The method (already
validated) of a structured interview and structured
Fourteen male patients participated in the study. All
questionnaire was used. There were 15 males and 10
of the patients suffered from PD, and were diagnosed
females examined, all over 36-years old. The most
on the basis of the UK–Parkinson’s Disease Brain Bank
important finding was that the females were signifi-
criteria (Hughes et al., 1992); another inclusion criteria
cantly more affected: a decrease of libidinous functions
were the normal cognition, assessed by neuropsycho-
was reported by 40% of male patients, but, interest-
logical examination, existing sexual relationship, cur-
ingly, by 70% of female patients. Similarly, a significant
reduction of common daily sexual activities was
Arzneimittel, Hamburg, Germany; NalcohÒ, CEK
reported by 30% of male patients, but these activities
Pharma, Ljubljana, Slovenia), and the intent to treat
were reported to be significantly reduced by more than
the patients with dopaminergic agonist.
The mean age of patients was 58.2 (SD ¼ 9.9) years;
Another important study also reviewed sexual dys-
the mean age at the disease onset was 50.8 years
function in PD, although the role of dopaminergic
(SD ¼ 10.1); the mean duration of disease was
medication was only briefly mentioned (Lambert and
7.3 years (SD ¼ 3.6). All of the patients were treated
Waters, 1998). Several years later, a psychosocial study
with L-DOPA; the mean duration of L-DOPA treat-
was published that dealt with the impact of PD on all
ment was 5.9 years (SD ¼ 2.7), and the mean daily
aspects of the daily activities (including sexual activity)
dose of L-DOPA was 783.6 mg (SD ¼ 412.7).
of young women affected by the disease (Posen et al.,
All of the patients were in the advanced, fluctuating
2000). Probably the deepest insight into sexual dys-
stage of disease, and all of them experienced frequent
function in PD patients was brought by a study pub-
daily Ôon-offÕ fluctuations with dyskinesias or Ôwearing-
lished last year, in which sexual life quality was assessed
offÕ of the L-DOPA dose. The mean duration of this
in more than 90 patients (Moore et al., 2002). For the
advanced, complicated stage of disease (measured
evaluation of sexual functions, the structured Quality of
from the first occurrence of the mentioned symptoms)
Sexual Life Questionnaire (QoSL-Q) was used. The
was 2.9 years (SD ¼ 1.7). This situation led to the
quality of life was assessed using the Parkinson’s Dis-
introduction of pergolide mesylate to the treatment.
ease Quality of Life (PDQ-39) questionnaire. The
Prior to the start of pergolide treatment (month 0),
quality of the sexual life, as assessed by the QoSL-Q,
the following examinations were performed: clinical
was significantly decreased in all patients. It signifi-
neurological examination, magnetic resonance imaging
cantly worsened with the disease progression and with
(MRI) examination of the brain, biochemical and
aging. However, no correlation between the results
haematological examinations, plasma prolactine level,
revealed using the PDQ-39 and those revealed by
neuropsychological examination and Zung scale scor-
QoSL-Q has been found. The authors recommended
ing (to exclude dementia, depression, or significant
implementing the QoSL-Q into the common QOL test
cognitive decline), Mini Mental State Examination
battery, because PDQ-39 does not sufficiently address
(MMSE), Unified Parkinson’s Disease Rating Scale
(UPDRS) III and UPDRS IV scoring, and all subscales
When these findings were published, we had observed
of the International Index of Erectile Function ques-
the phenomenon of sexual dysfunction and its dimin-
tionnaire (IIEF). The IIEF subscales and their point
Ó 2004 EFNS European Journal of Neurology 11, 483–488
Improvement of sexual dysfunction in patients with Parkinson’s disease
ranges are presented in Appendix. The side effects of
treatment were also recorded using a checklist.
Pergolide mesylate (PermaxÒ, Eli Lilly, Basingstoke,
UK) was added to the stable L-DOPA dose and was
titrated in all patients to a total daily dose of 3 mg. The
titration lasted (according to the classical schema)28 days. The control visits were carried out at month 1
(at the end of titration period), at month 3 (titrationperiod + 2 months) and at month 6 (titration per-
iod + 5 months). The examinations performed atmonth 0 were repeated at each control visit, except the
brain MR. The examination of the prolactine plasmalevels were done only at months 3 and 6. Treatment
continued after the month 6 visit. The study protocol
decreed that in case of side-effects, the withdrawal of
pergolide was possible at any moment during the fol-low-up.
Figure 1 The figure illustrating the changes in the mean value
The mean values of the items being tracked were
of IIEF subscale Ôerectile functionÕ. SE, standard estimation; SD,standard deviation; M, months.
calculated at each follow-up visit. ANOVA, non-para-metric Friedmann’s ANOVA, and post hoc Tukey testswere used for the statistical analysis of the results.
The results are presented in Table 1 and Figs 1–5.
There were no biochemical or haematological value
abnormalities present in any patient during the study. The prolactine plasma level varied in all patients
Table 1 The mean values of UPDRS III and IV, L-DOPA daily dose,MMSE, Zung scale, prolactine level, and IIEF subscores at months 0,1, 3, and 6
Figure 2 The figure illustrating the changes in the mean value
of IIEF subscale Ôorgasmic functionÕ. SE, standard estimation;
between 0.9 and 7.1 ng/ml (mean 3.9, SD ¼ 3.3) prior
to pergolide treatment. There was a decrease of mean
prolactine levels when the values between months 0, 3
and 6 were compared. There was no possibility ofestablishing statistical significance, because the prolac-
*The values, which are significantly different at the level P < 0.00000,
tine levels at months 3 and 6 reached <0.5 ng/l (under
which the laboratory methods are not able to differ-
UPDRS III, Unified Parkinson’s Disease Rating Scale – Motor
entiate); thus, the plasma level of prolactine was
Subscore (III); UPDRS IV, Unified Parkinson’s Disease RatingScale – Complications Subscore (IV); L-DOPA Dose, daily dose of
L-DOPA preparation (SinemetÒ, MadoparÒ, IsicomÒ, or NakomÒ)
The UPDRS III score (measured when the patients
expressed in milligrams of L-DOPA only (without dopa-decarboxylase
were ÔONÕ) at month 0 was 35.7 points, and there was a
inhibitor); MMSE, Mini Mental State Examination (according to
statistically significant (P < 0.001) difference when it
Folstein et al.); Zung, Zung depression scale; Prolactine, prolactine
was compared with the value at month 1. Nevertheless,
levels in ng/ml in the blood plasma; IIEF, International Index ofErectile Function.
the level of statistical significance was P < 0.00000
Ó 2004 EFNS European Journal of Neurology 11, 483–488
Figure 5 The figure illustrating the changes in the mean value
Figure 3 The figure illustrating the changes in the mean value
of IIEF subscale Ôoverall satisfaction with sex lifeÕ. SE, standard
of IIEF subscale Ôsexual appetenceÕ. SE, standard estimation;
estimation; SD, standard deviation; M, months.
There were statistically significant changes in the
mean values of all subscales of International Index ofErectile Function (the subscales and their point ranges
are listed in the Appendix). The differences between thevalues at month 0 and month 1, and also between the
values at month 3 and month 6 were minimal, without
statistical significance. In contrast, there were differ-ences at statistical level P < 0.00000 in the mean values
of all subscales when comparing month 0 and month 3,
The differences between mean IIEF values (and their
Practically no adverse or side-effects were reported
that might have led to the withdrawal of pergolide. Two
patients reported increased daily sleepiness (withoutsleep attacks) during the first month of the pergolide
Figure 4 The figure illustrating the changes in the mean value of
treatment, which disappeared within following 3 weeks.
IIEF subscale Ôsatisfaction with sexual intercourseÕ. SE, standardestimation; SD, standard deviation; M, months.
when the values at month 3 and 6 were compared with
The results of our prospective (albeit open) study con-
the value at month 0 (measured also when the patients
firmed our initial observation, that pergolide can
were ÔONÕ). The UPDRS IV subscore, measuring
impressively improve disturbed sexual functions in men
mainly the presence and duration of dyskinesias and
suffering from PD (Kanˇovsky´ et al., 2002). From our
ÔOFFÕ periods was improved at months 3 and 6; the
clinical experience, it seems that action of pergolide in
difference was statistically significant only when the
this field is the best of the commonly used peroral
mean value at month 0 was compared with values at
dopamine agonists (however, such evidence still cannot
months 3 and 6. There was a slight tendency to decrease
be found in any medical database). Why pergolide
the daily L-DOPA intake in all patients; however, the
produces such results is not completely clear. It is
differences of mean L-DOPA daily doses were not
probably not due to pergolide-induced suppression of
significant when the values at months 0, 1, 3, and 6 were
prolactine secretion, because in all of our patients the
compared. The mean value of the MMSE score
plasma levels of prolactine prior to pergolide treatment
remained stable. The mean values of the Zung score
were below the usual mean levels, and at the lower end
remained practically identical as before treatment,
of the normal laboratory range (2.8–19.2 ng/ml). It is
showing no tendency to increase or decrease.
not clear whether this was caused by the disease itself,
Ó 2004 EFNS European Journal of Neurology 11, 483–488
Improvement of sexual dysfunction in patients with Parkinson’s disease
or by the previous L-DOPA treatment. Such effect of
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Ó 2004 EFNS European Journal of Neurology 11, 483–488
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