Sexual function SSRIs

Sexual function SSRIs can cause sexual dysfunction, particularly reduced libido, impaired orgasm in women, and inhibition of ejaculation or erectile difficulties in men. There have been two reports of unusual male sexual dysfunction. In two cases of spermatorrhea (excessive emission of semen without orgasm or erection) in men taking fluvoxamine, the problem resolved on drug withdrawal [IS ]. Spontaneous ejaculations occurred daily in a 27-year-old man after he had taken citalopram for 2 weeks [16 ]. They were unrelated to sexual fantasies, arousal, erection, or any sensation of orgasm and resolved on drug withdrawal. They did not recur when he took paroxetine. 

Sexual function One of the potential benefits of hypericum is the apparent reduced or lack of adverse effects upon sexual function, compared to pharmaceutical antidepressants. The SSRIs are particularly notorious for inhibition of sexual function, whereas antidepressants with dopaminergic actions (e.g., bupropion) do not, and may actually enhance sexual function (Rosen et al. 1999 Piazza et al. 1997). Anecdotal reports and the fact that there are no clinical reports of sexual dysfunction with hypericum is encouraging, but it remains to be tested empirically. 

Piazza LA, Markowitz JC, Kocsis JH, Leon AC, Portera L, Miller NL, Adler D. (1997). Sexual functioning in chronically depressed patients treated with SSRI antidepressants a pilot study. Am J Psychiatry. 154(12) 1757-59. 

Rosen RC, Lane RM, Menza M. (1999). Effects of SSRIs on sexual function a critical review. J din Psychopharmacoi. 19(1) 67-85. 

Fluoxetine, along with sertraline, fluvoxamine, and paroxetine, belongs to the more recently developed group of SSRI. The clinical efficacy of SSRI is considered comparable to that of established antidepressants. Added advantages include absence of cardiotoxicity, fewer autonomic nervous side effects, and relative safety with overdosage. Fluoxetine causes loss of appetite and weight reduction. Its main adverse effects include overarousal, insomnia, tremor, akathisia, anxiety, and disturbances of sexual function. 

Bupropion appears to be relatively free of adverse effects on sexual function, in contrast to the SSRIS or venlafaxine (168). 

SSRIs and venlafaxine can cause of variety of sexual dysfunctions including delayed ejaculation, anorgasmia, and decreased libido ( Table 7-24). For two reasons, the adverse effect of these medications on sexual function was underestimated during the early clinical trials. First, such trials rely on spontaneous reporting by participants. Second, these adverse effects appear to take several weeks to develop. These adverse effects develop in approximately 30% to 40% of patients on adequate doses of SSRIs and venlafaxine. Although all manufacturers of these medications endeavor to suggest that their product is less likely to cause these effects, there is no compelling evidence to indicate that is true. Comparisons of rates across studies are not fair comparisons because they may differ based on how these problems were assessed. 

Fluoxetine was the first SSRI to reach general clinical use. Paroxetine and sertraline differ mainly in having shorter half-lives and different potencies as inhibitors of specific P450 isoenzymes. While the SSRIs have not been shown to be more effective overall than prior drugs, they lack many of the toxicities of the tricyclic and heterocyclic antidepressants. Thus, patient acceptance has been high despite adverse effects such as nausea, decreased libido, and even decreased sexual function. 

In my clinical experience, many, and probably most, patients taking SSRIs suffer from drug-induced sexual dysfunction due to suppressed sexual appetite, inhibited sexual function, and emotional withdrawal, but the SSRIs often make them too apathetic or disinterested to complain to their doctors. They are too medication spellbound to care about their sexual and love life or the effects on their loved ones and partners. 

The adverse sexual effects of SSRIs have been reviewed (58). The use of SSRIs is most often associated with delayed ejaculation and absent or delayed orgasm, but reduced desire and arousal have also been reported. Estimates of the prevalence of sexual dysfunction with SSRIs vary from a small percentage to over 80%. Prospective studies that enquire specifically about sexual function have reported the highest figures. Similar sexual disturbances are seen in patients taking SSRIs for the treatment of anxiety disorders (59), showing that SSRI-induced sexual dysfunction is not limited to patients with depression. It is not clear whether the relative incidence of sexual dysfunction differs between the SSRIs, but it is possible that paroxetine carries the highest risk (58). 

In a chart review of 22 adolescents who were taking SSRIs for a variety of indications and who had been systematically questioned about the effect of their illness and its treatment on their sexual function, five reported significant sexual dysfunction (three cases of anorgasmia, and two of reduced libido), probably attributable to the SSRI (60). This small sample suggests that the rate of sexual dysfunction associated with SSRI treatment in adolescents is very similar to that seen in adults. Issues of sexuality are particularly important in adolescence, but may be difficult to discuss. This study shows the importance of tactful and sensitive enquiry and the probable benefit of clear information about the sexual adverse effects of SSRIs. 

In a prospective study, 47 patients who complained of SSRI-induced sexual dysfunction took amfebutamone (bupropion) 75-150 mg 1-2 hours before sexual activity (67). If this was unsuccessful they were titrated to a dosage of 75 mg tds on a regular basis. Amfebutamone improved sexual function in 31 patients (66%). Anxiety and tremor were the most frequently reported adverse events, and seven patients discontinued for this reason. However, it should be noted that more serious adverse events (panic attacks, delirium, and seizures) have been reported when amfebutamone (bupropion) and SSRIs are combined (59). 

There are many other ways in which SSRIs can interfere with sexual function, for example by causing loss of sexual interest and erectile difficulties. In an open, prospective study of 1000 Spanish patients taking a variety of antidepressants, there was an overall incidence of sexual dysfunction of 59% (15). The highest rates, 60-70%, were found with SSRIs (including fluvoxamine) and venlafax-ine. The lowest rates were found with mirtazepine (24%), nefazodone (8%), and moclobemide (4%). Spontaneous resolution of this adverse effect was uncommon - 80% of subjects had no improvement in sexual function over 6 months of treatment. 

In contrast to SSRIs, amfebutamone is believed to have minimal effect on sexual function (SEDA-23, 20). 

Antidepressant drugs can rarely cause priapism. The agent most often implicated has been trazodone, perhaps because of its ai-adrenoceptor antagonist properties. In general venlafaxine has an inhibitory effect on sexual function, but perhaps, like SSRIs, it can rarely cause priapism (23). 

Serotonin reuptake inhibitors (SSRI). These are currently the drugs of choice for the treatment of bulimia nervosa. The most frequently cited adverse effects include nausea, insomnia and diminution of sexual interest and/or impaired sexual function. 

The new wave of safer antidepressants introduced in the 1990s, led by fluoxetine (Prozac),is dominated by drugs that are serotonin-selective reuptake inhibitors (SSRIs). The SSRIs exhibit some adverse side effects, notably in impaired sexual function in both men and women, but because they are relatively safe physicians have been less inhibited about using them. This has extended the clin-... 

Most prominent among the psychotropics that enhance serotonergic transmission are the selective serotonin reuptake inhibitors (SSRIs), which may induce sexual dysfunction in as many as 50-75% of patients, in part by activation of central 5-HT2 receptors. Antidepressants that antagonize the 5-HT2 receptor, such as mirtazapine and trazodone, cause fewer sexual side-effects compared with the SSRIs. Stimulation of the 5-HTia receptor facilitates sexual functioning, while activation of the 5-HTib,id and 5-HTic receptors inhibits... 

Unlike the SSRIs, 5-HTP is not associated with sexual side effects or weight gain. In fact, the supplement may actually improve sexual function while reducing food cravings and binge eating. 

An isolated case describes spontaneous orgasm with the combined use of bupropion and sertraline. Bupropion had been successfully used to treat SSRI-induced impaired sexual function, but after 6 weeks of combined therapy she experienced a sudden-onset, spontaneous orgasm this occurred again on rechallenge with bupropion. ... 

There have been two reports of the management of SSRI-induced sexual adverse effects. First, in an 8-week prospective double-blind placebo-controlled trial of sildenafil 50-100 mg/day in 98 previously sexually functioning premenopausal women whose major depression had remitted on SSRIs, but who were also experiencing sexual dysfunction, sildenafil was associated... 

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