HSX8595 - SECTION 11: MEDICATIONS: A FACTOR IN SEXUAL PROBLEMS
Medications are notorious for causing sexual problems, and yet this is a topic often NOT addressed when medications are prescribed. Even over-the-counter drugs such as Tagamet can cause erection problems in men and lubrication problems in women. It is important that health care providers address potential sexual side effects with clients/patients, or two things may happen:
1. The patient may determine that a change in sexual performance (e.g., an erection problem) has something to do with the medications and may stop taking them—this has become particularly true with the antihypertensive medications, as the “word is out” about the sexual effects of these drugs.
2. The patient may not be aware of sexual side effects, and these may have a long-term impact on the patient’s relationship.
Example: Several years ago a woman was put on a medication, Danazol, for endometriosis. Over time she and her husband grew further and further apart and rarely had sexual interactions. (Please realize that this is an oversimplification of the problem—there were other issues in the relationship, but the medication certainly had a major negative impact).
After five years of taking the medication, the woman’s physician discontinued it, and the woman’s sexual desire returned. She approached her husband, telling him that her sexual desire was back, and his response was, “I’m sorry. I’m having an affair and I want a divorce.”
When the woman related her story to her gynecologist, he said, “Oh, I should have told you—loss of sexual desire is a common side effect of this medication. But every time you came in, I asked you how things were going, and you always said they were ok.” She responded, “That’s because it never occurred to me that this was a side effect of the medication.” Later the woman sat in the therapist’s office and cried for an hour because of what had happened.
In terms of addressing the possible impact of medications on sexuality, some providers have said, “Don’t tell patients, because then it will become a self-fulfilling prophecy,” or “They’ll figure it out if something happens.” Or it may not be considered or discussed at all.
Medication side effects are an important issue to address, and it is the professional’s responsibility to do this. Perhaps one of the best statements to use is, “Sometimes these medications cause changes in sexuality. If you notice any changes, let me know, and we’ll talk about what to do about it.”
Some professionals choose to add to this and say something like, “Sometimes these medications cause changes in sexuality—for example you may have a decrease or even an increase in sexual desire. If you have any changes that bother you, let me know, etc.”
Specific commonly prescribed drugs that often involve negative sexual side effects include the following:
1. Psychoactive agents, particularly the Selective Serotonin Reuptake Inhibitors (SSRIs) such as Prozac, Zoloft, Paxil, Luvox, and Celexa. These medications inhibit the neuronal reuptake of serotonin, hopefully leading to the desired antidepressant effect, but also frequently resulting in the undesired sexual side effects of decreased libido, dulling of genital sensation, and delayed orgasm or anorgasmia. Addressing sexual desire and other potential sexual side effects of the SSRI medications when treating depression may improve compliance and overall outcome. (Interestingly, these drugs are actually being used to treat premature ejaculation because of the delayed ejaculation side effect.)
Note: The drug Sarafem, prescribed primarily for women, is Prozac renamed.
2. Antihypertensive drugs, particularly Beta Blocker drugs, many of which end with “olol” (atenolol, metoprolol, propranolol)
3. Sleeping pills
4. Contraceptive drugs*
5. Heart medications such as digoxin
6. Some peptic ulcer medications
7. Cancer chemotherapy drugs
Note: Nicotine, alcohol, and cocaine can also have adverse sexual side effects.
* Some practitioners have thought that the contraceptive pills with lower doses of hormones or the triphasic pills (which deliver differing amounts of hormone every week) rather than the monophasic pills (which deliver the same amount of hormone each dose) might interfere less with sexual desire. A recent paper published in the Journal of Sex and Marital Therapy reviewed the medical literature from the past 30 years and found that despite the noted sexual side effects in various subgroups of women using hormonal contraception, no consistent pattern of effect exists to suggest a hormonal or biological determinant. The conclusion was that the effects on sexual desire most likely represent a complex and idiosyncratic combination of biological, psychological, and social factors. Further research is needed to identify which factors may have the greatest impact
The following is printable for use with clients:
WAYS OF COUNTERACTING SEXUAL SIDE EFFECTS OF MEDICATIONS
1. Wait four to six weeks for sexual side effects to resolve.
2. Lower the SSRI dose to a dose that is still effective in treating the depression.
3. Alter timing of the daily dose.
4. Plan a two-day drug holiday (for sertraline [Zoloft] and paroxetine [Paxil]). This will be less effective with fluoxetine (Prozac), as Prozac has a long half life. Note: Some clinicians have concerns about stopping SSRIs because of possible withdrawal symptoms.
5. Switch to another antidepressant.
a. Wellbutrin (Bupropion) is an antidepressant drug that inhibits neuronal reuptake of norepinephrine and also dopamine and possibly serotonin, although to a much lesser degree than the SSRI medications. Although it is not FDA approved for treatment of decreased libido, many practitioners are prescribing it for men and women with fair success. This success is most likely due to its dopaminergic properties. The drug may be the antidepressant of choice for depressed people with sexual dysfunction of almost any type. Although Wellbutrin is now available in a generic form, it is still relatively expensive ($80+ per month) and cannot be used in people with a history of seizures or anyone on MAOIs (Mono Amine Oxidase Inhibitors). It should generally be avoided in people with alcoholism or other chemical dependencies other than nicotine. Indeed, Bupropion (brand name Zyban) is used to help people stop smoking.
b. Buspar (Buspirone) is primarily prescribed for the relief of anxiety, although it can also provide relief of depression for some individuals. People are thought to be less likely to become dependent on Buspar than on benzodiazepine medications. While its action is not fully understood, it appears to work through effects on serotonin receptors in the brain, similar to the SSRI medications. For some individuals, the sexual side effects are minimal.
c. Cymbalta (Duloxetine) acts on both serotonin and norepinephrine (SNRI). Study results have varied in terms of degree of sexual side effects. Recently, some therapists have reported that some of their clients appear to be responding favorably to the switch from the SSRIs to Cymbalta (personal communication, AASECT listserve, 2006). One patient who was switched from Effexor to Cymbalta reported that she has been “thinking about sex more.”
d. Lexapro (Escitalopram) A recent study by Aston, Mahmood, and Iqbal (2005) found that 68% of patients with SSRI/SNRI-induced sexual dysfunction seemed less impaired when they were switched to Escitalopram, particularly if the dosage was not high.
e. Remeron (Mirtazapine), a tetracyclic antidepressant, has been found to have fewer sexual side effects (Saiz-Ruiz, et. al, 2005).
f. Serzone (Nefazodone), an antidepressant with a chemical structure similar to trazodone (Desyrel), has been found to have fewer sexual side effects and fewer problems related to sleep. However, its maker Bristol-Myers Squibb pulled it from the market in May of 2004 because of a possible link to liver injury and failure. At this time the drug remains available as a generic medication, but its use is not widespread (About.com, 2004).
6. Add another medication.
a. Wellbutrin (75 mg-100 mg in the AM) added to an SSRI antidepressant seems to reduce the negative sexual side effects of the SSRI medications in some cases. The adrenergic effect seems to help.
b. Buspar (Buspirone) 5-15 mg tid or qid for loss of desire and anorgasmia
c. Periactin (Cyproheptadine), an antihistamine that has serotonin-blocking properties (2-28 mg 1/2 hour to several hours before sex or 2-4 mg bid or tid). This may cause drowsiness.
d. Amantadine (Symmetrel), an antiviral and antidyskinetic, is a dopamine agonist that may reduce the SSRI-associated apathy, including lowered libido (100 mg bid or tid).
e. Trazodone (Desyrel), another class of antidepressant, has been found effective in some cases, particularly with loss of desire and erection problems. It has strong sedating properties and is often used in a single nighttime dose as a sleep aid. Before the development of Viagra, Trazodone was used as a pharmacological aid for erection problems, because one of the side effects of this medication is priapism (a sustained erection that is a medical emergency). In prescribing Trazodone, practitioners were hoping to create erectile capability while avoiding priapism.
f. Ritalin (Methylphenidate) 10 mg tid or qid
g. Dexedrine (Dextroamphetamine) 5 mg tid or qid (Crenshaw & Goldberg, 1996)
Adjunctive Drug Therapy for SSRI-Induced Sexual Dysfunction
Drug Symptom Dosage
As Needed Daily
Amantadine Anorgasmia 100-400 mg 75-100 mg bid
(Symmetrel) Decreased libido (for two days or tid
prior to coitus)
Bupropion Anorgasmia 75-100 mg q a.m. 75 mg bid
(Wellbutrin) Decreased libido 75-150 mg or tid
Buspirone Anorgasmia 15-60 mg 5-15 mg bid
(Buspar) Decreased libido tid, or qid
Cyproheptadine Anorgasmia 2-28 mg 1/2hr to 2-4 mg bid
(Periactin) Decreased libido several hrs. before or tid sex
Dextro-amphetamine Anorgasmia 5-20 mg 2.5-5 mg bid
(Dexedrine) or tid
Yohimbine Anorgasmia 5.4-10.8 mg 5.4 mg tid
Bromocriptine Decreased libido 1/2 tablet (1.25 mg) At bedtime 1st
Cabergoline Decreased libido &
(Dostinex) orgasms in men 1/2-1 tab 1/2-1 tab q 4 days
(Adapted from: Bartlik, Kaplan, & Kaplan, 1995; Gitlin, 1994; Crenshaw & Goldberg, 1996; Ashton & Rosen, 1998; Gutierrez & Stimmel, 1999; Labbate, Croft, & Oleshansky, 2003).