Q: What kinds of sexual side effects are possible with SSRIs?

A: Almost every aspect of sexual functioning can be affected by SSRIs.  It is not uncommon for people to complain of decreased libido (sexual desire).  Both men and women may notice their genital response decreases while on these medicines, meaning weaker erections or even inability to have an erection for men and decreased engorgement and lubrication for women.  The amount of sensation or the pleasure in the sensation that is felt during sexual touching may be less.  Individuals might find that the time it takes to reach orgasm is prolonged.  This can reach the point where orgasm is impossible to attain at all while on these medications.  The sensation of orgasm might be diminished.  In summary, every step along the cycle of desire, physical response, and orgasm may be affected by SSRIs.

Q: Are some SSRIs better than others in terms of sexual side effects?

A: Although some people may notice that their symptoms are better with one medication and worse with another, overall these medications seem to have about the same likelihood of causing sexual side effects.  The one exception to this might be Paroxetine (Paxil), which may be slightly worse than the rest.

Q: How likely am I to get these problems if I take an SSRI?

A: The likelihood that a person taking these medications will get sexual side effects of some sort is between 50-70%.  That means just over half the people who take these have at least one of the problems listed in the previous answer.  Of course, the good news is that between a third and half the people taking them have no sexual side effects at all.

Q: Will these side effects go away when I stop the medications?

A: As far as we know, these SSRIs do not cause any permanent changes.  Usually once people stop taking them, they return to their previous state.  There have been rare cases where people have complained of persistent changes in their sexual functioning after taking SSRIs.  Because they are so infrequent it is difficult to know whether these changes occurred because of the medicines or some other, co-incidental reason.

Q: I have mood problems that really interfere with my life and I’d like to try medications.  Are there any that don’t have these side effects?

A: There are a number of medications that help mood similar ways to SSRIs that don’t have as many or as bothersome sexual side effects.  Unfortunately, each of these has different side effects of it’s own.  I have listed them below.

● Bupropion (Wellbutrin) – This medication is often used for depression and has been found to be as effective as SSRIs.  It is used widely and is generally safe.  Of all the anti-depressants it appears to have the lowest incidence of sexual side effects.  In fact, in most studies it had no more of these effects than a sugar pill (placebo.)  Unfortunately, it can be associated with an increase in anxiety which, for many patients with mood disorders, is a difficulty they already have and do not want to get worse.  Other side effects include sleep difficulties and increase in blood pressure.

● Mirtazapine (Remeron) – Another good anti-depressant.  It also seems to work as well as SSRIs.  With respect to its sexual profile, in one large study about one quarter of all patients taking Mirtazapine experienced sexual side effects.  Two other drawbacks to this medicine are that it causes drowsiness and weight gain.

● Duloxetine (Cymbalta) – This is a newer medication used to treat depression.  It’s manufacturers have touted it as having fewer sexual side effects than other, similar medications.  As more information becomes available, this seems less promising.  The most recent study found that about half of all patients taking Duloxetine experienced sexual side effects, only slightly less than the percentage with SSRIs.

● Nefazadone (Serzone) – This was an anti-depressant that worked well for mood problems, but was associated with rare occurrences of liver failure (fewer than 1/10,000 cases).  For this reason physicians tend not to use it as a first-line agent.  However, it is still prescribed and works as well as the SSRIs.

Q: I’m on an SSRI and it’s working well, so I don’t want to stop it.  Is there anything I can do to get rid of the sexual side effects I’m having?

A: The sexual side effects of SSRIs are difficult, but not impossible, to treat.  What can be done depends on which difficulties a person is experiencing.  Many treatments have been tried, with varying degrees of success.  The most commonly used ones are listed below.

Decrease in physical response (arousal)
◦ For men, drugs specifically designed to treat erectile dysfunction (ED) appear to work well.  These include Sildenafil (Viagra), Tadalafil (Cialis), and Vardenafil (Levitra).

◦ Women may also get some benefit from Viagra, especially if they are experiencing decreased arousal and difficulty achieving orgasm.

◦ Yohimbine has been suggested as helpful for men, but the evidence for this is minimal.  Side effects include high blood pressure, tremor, and irritability.

◦ There are other methods that have been found to be effective.  However, many people find them undesirable because they are either cumbersome or uncomfortable.  These include a vacuum suction device to increase blood flow to the penis and Caverject, a device that injects a medication at the base of the penis that leads to erection.

Decrease in sexual desire
◦ Switching antidepressants – Changing to another SSRI may be a good strategy, especially if you are getting a good antidepressant effect from the one you are on now.  Alternatively, you might switch to another type of antidepressant, such as Bupropion or Mirtazapine.

◦ Dosage adjustment – Generally, this means dosage decrease.  Some people find that their sexual side effects diminish or disappear altogether on lower doses.  On the other hand, lower doses may not treat mood symptoms as well.

◦ “Drug holiday” – this is a term used to indicate taking a break from your medication.  Occasionally, just being off the medication for a few days is enough to reverse some of the unwanted side effects.

◦ Adding Bupropion – This approach was previously thought to be very effective.  In fact, the more information we get, the less this seems to be helpful.
 

A word of caution: although these problems can be very distressing and sometimes hard to talk about, it is important that you not make any changes in you medication regimen without first talking to your doctor.  Don't be shy about bringing up these problems, if you have them.  Your doctor has discussed them with hundred of patients before you and will be more than willing to talk about your sexual side effects in way that makes you comfortable.

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