Parkinsonism and Related Disorders xxx (2014) 1e2

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Letter to the Editor

A case of rasagiline-induced spontaneous orgasms in a female patient Dear Editor Parkinson’s Disease (PD) is a progressive neurodegenerative disease characterized clinically by motor, psychiatric and cognitive dysfunction. Rasagiline, a selective propargylamine inhibitor of monoamine oxidase (MAO) type B, at a dose of 1 mg/day has been used in PD as it may modify disease progression. Potential adverse effects of rasagiline include: flu-like symptoms, joint pain, depression, and gastric upset. Hypersexual behavior and other impulse control disorders have been reported in patients with PD when treated with rasagiline [1]. Here we report a patient with early-onset PD who experienced, spontaneous orgasms when taking rasagiline; these were unwelcome and occurred in the absence of hypersexual behavior. To the best of our knowledge, this is the first report of this adverse effect of rasagiline. A 42 year-old female with early-onset PD was admitted to the neurology department of our university hospital complaining of spontaneous orgasms. The patient reported that she had been taking rasagiline 1 mg/day for the previous 10 days. On the 7th day, the patient complained of hyperarousal and increased libido, which were accompanied by three to five spontaneous orgasms in the absence of sexual stimulation. The patient was on no medications other than rasagiline. Each spontaneous orgasm lasted 5e20 s and occurred 3 to 5 times a day. In between the episodes, her sexual function was normal there were no other autonomic symptoms. Laboratory, hysical, psychiatric and gynecological examinations were normal. On examination she had resting tremor, hypokinesia, and cogwheel rigidity in the left forearm. Blood counts, serum electrolytes, and biochemistry were all within normal limits. A brain MRI and an electroencephalogram were normal. Rasagiline was discontinued, and her symptoms resolved. However, when rasagiline was resumed 15 days later, the spontaneous orgasms recurred and rasagiline was again stopped. Rasagiline, at the recommended therapeutic dose, has been shown to be a potent and irreversible inhibitor of MAO-B in platelets. The precise mode of action of rasagiline is unknown. One possible mechanism is its MAO-B inhibitory activity, which causes an increase in extracellular levels of striatal dopamine [2]. The elevated dopamine level and subsequent increased dopaminergic activity likely mediate the beneficial effects evident in models of dopaminergic motor dysfunction. The appearance of spontaneous orgasms concurrently with the initiation of rasagiline and in the absence of any other drug therapy, suggests a direct effect of the rasagiline. To our

knowledge, no other rasagiline-induced spontaneous unwelcome orgasms have been reported in the literature. However, similar adverse effects have been reported for other drugs that act on the central nervous system (e.g. ziprasidone, risperidone, mirtazapine, venlafaxine, citalopram) [3e5]. One similar case has been reported by Chuang et al. [6], in which rasagiline-induced spontaneous ejaculation occurred in a male patient. The precise mechanism of rasagiline-induced spontaneous orgasms is unclear. Although the underlying neurochemical changes of spontaneous orgasms are not fully understood, spontaneous orgasms have been reported with dopamine receptor agonists (e.g. pramipexole, ropinirole) [7]. We hypothesize that the spontaneous unwelcome orgasms may be related to the dopaminergic stimulation caused by the use of rasagiline. We did not formally assess the drug’s adverse events nor did we measure serum levels of rasagiline, or perform a urine toxicology screen. These factors may impose limitations for further interpretation of the present case report. A previous study showed that only one third of women with sexual dysfunction reported them to a family physician or gynecologist [8]. Physicians initiate eighty percent of discussions about sexual problems rather than the discussions being initiated by female patients. Neurologists should be mindful of the possible sexual adverse effects of some drugs used to treat PD and question their patients accordingly. In conclusion, this case demonstrates that, although rare, unwanted sexual adverse effects can be triggered by rasagiline. However, prospective studies are needed to determine the precise frequency of this adverse effect.

References [1] Reyes D, Kurako K, Galvez-Jimenez N. Rasagiline induced hypersexuality in Parkinson’s disease. J Clin Neurosci 2014;21:507e8. [2] Youdim MB. Multi target neuroprotective and neurorestorative anti-Parkinson and anti-Alzheimer drugs ladostigil and m30 derived from rasagiline. Exp Neurobiol 2013;22:1e10. [3] Boora K, Chiappone K, Dubovsky S, Xu J. Ziprasidone-induced spontaneous orgasm. J Psychopharmacol 2010;24:947e8. [4] Shalev H, Ben-Zion I, Shiber A. A case of mirtazapine-induced spontaneous orgasms in a female patient. J Psychopharmacol 2009;23:109e10. [5] Altindag A, Gunes M. A case series of increased libido and spontaneous orgasm associated with venlafaxine treatment. Prog Neuropsychopharmacol Biol Psychiatry 2008;32:895e6. [6] Chuang RS, Lang AE. Rasagiline-induced spontaneous ejaculation. Mov Disord 2009;24:2160e1. [7] Kaut O, Asmus F, Paus S. Spontaneous unwelcome orgasms due to pramipexole and ropinirole. Mov Disord 2012;27:1327e418. 1353-8020/Ó 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Uca AU, Kozak HH, A case of rasagiline-induced spontaneous orgasms in a female patient, Parkinsonism and Related Disorders (2014),


Letter to the Editor / Parkinsonism and Related Disorders xxx (2014) 1e2

Ali Ulvi Uca*, Hasan Hüseyin Kozak Department of Neurology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey

[8] Shifren JL, Johannes CB, Monz BU, Russo PA, Bennett L, Rosen R. Help-seeking behavior of women with self-reported distressing sexual problems. J Women Health 2009;18:461e8.

* Corresponding

author. Necmettin Erbakan Üniversitesi Meram Tıp Fakültesi, Nöroloji Anabilim Dalı, Meram, 42080 Konya, Turkey. Tel.: þ90 332 2237981. E-mail address: [email protected] (A.U. Uca). 13 January 2014

Please cite this article in press as: Uca AU, Kozak HH, A case of rasagiline-induced spontaneous orgasms in a female patient, Parkinsonism and Related Disorders (2014),

A case of rasagiline-induced spontaneous orgasms in a female patient.

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