Valproate & Testosterone:Lithium & the Male Reproductive System
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Q:  Valproate & Testosterone:  Lithium & the Male Reproductive System  


Dr Phelps,

I have had endocrine issues in the past, specifically hypogonadism, coinciding with the use of valproate. I never clearly connected the two but, to make a very long story short, my testosterone returned to normal on no mood stabilizers. Events have made it such that I have to confront the bipolar II diagnosis and get serious about long term use of mood stabilizers. I am trying Lamictal again, even though I got a rash at 100 mgs. The rash I believe was caused by raising the dose too quickly, 25 mgs/wk. I want to use the lowest dose of Lamictal I can and still get benefit. It really helped my depression at as low as 25 mg in the past but this dose would not have any anti-manic effect. So, I would like to add something to it to compensate for that but am wary of endocrine issues. I am specifically intrigued by low dose  lithium(300 mgs) as an add on but have seen conflicting articles on lithium's  effects on the male reproductive system. I usually respond to very low doses of medications. I am 58, am on thyroid replacement, and have had successful treatment of prostate cancer. I have a good doctor but she this is a question beyond her expertise, maybe anybody's. I will also ask my endocrinologist. Any input from you would be appreciated. Also thank you for all you have already done for folks like me.

Thank You,
Jim


Dear Jim --

1. Interesting, with the possible connection of valproate and testosterone levels. As you may know, there is a whole story about valproate and estrogen in women, including excess androgen production, as part of the story called "polycystic ovarian syndrome" which has been linked to the use of Depakote.

2. As you probably also know, the recommended rate for increasing Lamictal is slower than that, two weeks at 25 mg, two weeks at 50 mg, and so forth. You could talk to your doctor about an even slower start, beginning with 5 mg and increasing by that amount per week. I often use that strategy win for any reason I am trying to take the most cautious possible start with Lamictal.

Risk of rash is not related to total dose, but rather to the rate at which it is increased (okay, for someone who is being a stickler, it is related to total dose, and then you have to take more steps to get to a higher dose, and each step is associated with a risk of developing that rash). The point is, once you get to a given dose, unless you missed too many doses, the risk of the rashes back down to nearly baseline levels. This is true even if you're at 200-300 mg. So you should plan on using as much as is needed to get good sentiment control. Just reserve the caution for any time you are moving the dose up. Going by small steps and slowly will lower the amount of risk you take in the process. I often insert a week of 75 mg between the 50 mg and 100 mg stages, for example, for this reason.

3. In my experience and in my look at the literature, I see very little trouble with lithium in terms of effect on male reproductive function. With one exception perhaps call and it is an effective anti-manic, so that when people are having increased sexual activity associated with manic symptoms, they may see a reduction (sometimes a quite dramatic one) in their amount of sexual activity. Hopefully this will be accompanied by a reduction in anxiety, and improvement in sleep, an increase in the ability to concentrate and get things done -- and other words, clear benefits from the medication that might outweigh the loss of some fun sexually. Sometimes it is hard to find someone else who thinks that much sex is fun, so the net loss may not be as large as it looks.

The point was that erectile function and ability to orgasm are not affect it like they commonly are with serotonergic antidepressants, at least not very often.

Good luck with all that.

Dr. Phelps



Published December, 2007
 

 

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