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Side Effects A-Z: Minimizing Sexual Dysfunction (Anorgasmia)

Posted Aug 27 2009 11:38pm 1 Comment
The selective serotonin reuptake inhibitors (SSRIs, such as Prozac and Zoloft) are the safest and most widely prescribed antidepressant and anti-anxiety medications available and a real boon to millions of patients worldwide. They are highly effective, non-addictive, and they save lives. Unfortunately, among the most common of side effects induced by these medications are those that typically prove to be among the most recalcitrant: sexual dysfunction, in the form of 1) a relative inability to climax (delayed orgasm or complete anorgasmia) and/or 2) decreased sexual arousal, including in a minority of males, erectile dysfunction.

While other side effects caused by these medications, such as queasiness, headaches and diarrhea, resolve rapidly and, for all intents and purposes, completely with continued use, sexual dysfunction is one of those side effects that can persist for many months, or even indefinitely, with little or no improvement (like weight gain, temperature dysregulation and disruptions in the sleep-wake cycle--see my other articles).

Sexual dysfunction as a side effect is one of the leading reasons people who are otherwise benefitting from treatment with psychotropic medications seek to discontinue them. For others, who recognize that they need treatment with psychotropic medications to function, sexual dysfunction is something they "learn to live with." This article addresses how to avoid or at least minimize sexual dysfunction, when treatment with these types of medications is deemed valuable and necessary.

Don't take an SSRI. If you require treatment with psychotropic medication, one obvious strategy is avoiding those antidepressants that are known to cause sexual dysfunction. The problem is that most of them cause it. While it is true that Wellbutrin, for example, does not cause sexual side effects, Wellbutrin is not an SSRI; Wellbutrin does not act on the serotonin system. It is by increasing the neurotransmission of serotonin that sexual dysfunction is induced. However, it is also by increasing the availability of serotonin that we get effects such as protecting a person from crying spells, decreasing irritability and blocking panic attacks. So, while Wellbutrin is a good antidepressant for some individuals who are not particularly anxious or irritable, it doesn't do much for these symptoms in others, and can actually make anxiety and irritability worse in some cases. So, while avoiding manipulating serotonin levels is one certain way to avoid sexual dysfunction, there are relatively few available medications that work this way, and the ones that do often are not indicated.

Wait for it to get better. This is obviously the easiest thing to do, and sometimes it even works! Almost all side effects do improve over time, most fairly rapidly and significantly, if not completely. Unfortunately, sexual dysfunction tends to persist, often indefinitely. It does get somewhat better for most people given enough time, however, so a conservative "wait and see" strategy is not entirely unreasonable, especially for those patients who are suffering fairly serious mood problems for whom sexual health can wait. For those individuals who are severely depressed, sexual arousal actually often improves with treatment of their depression; anorgasmia (the inability to climax) is usually the complaint among most patients who are experiencing sexual dysfunction due to medications. The good news is that all sexual dysfunction side effects are reversible with discontinuation of the offending medication, no matter how severe they are and no matter how long they have been going on. Even after months or years of sexual dysfunction due to treatment with medication, a person will revert to his or her baseline upon discontinuation. Always, always confer with your prescribing physician, however, BEFORE you adjust your psychotropic medication, especially discontinuing it.

Lower the dose. All side effects are more-or-less dose-dependent. That is, they are first noticeable when medication levels reach a certain threshold, and then they intensify with increasing doses beyond that. In general, the greater the dosage, the greater the potential for the side effect, and the more intense the side effect is likely to be when it occurs. For example, in a person taking it for the first time, a very low dose of Prozac may not cause any unpleasant GI effects; a higher dosage may lead to queasiness; a much higher dosage will induce vomiting. One way to avoid vomiting is to begin at a low dose and increase gradually over time. If they continue taking it regularly, eventually most people become more or less immune to the nauseating effect of this drug.

Similarly, we can expect sexual dysfunction to get worse with escalating doses. The difference is that sexual dysfunction often becomes "complete" at fairly low doses: an individual can lose her sex drive altogether or an individual becomes completely anorgasmic sometimes with the very first dose. Lowering the dosage isn't an option, and since the side effect may not improve appreciably over time, the "start low, go slow" strategy that works so well with other side effects, such as queasiness and diarrhea, just doesn't apply.

Try a different SSRI. If you're on the lowest effective dose and you've waited long enough and your doctor doesn't feel that you can or should avoid an SSRI altogether, know that different SSRIs will tend to cause varying levels of sexual dysfunction among different people, so if one medication is causing severe problems for you in this area, discuss switching to a different medication with your doctor. Among SSRIs, paroxetine (Paxil) is the most potent inhibitor of serotonin reuptake in vitro, which, milligram-per-milligram, translates into some of the most impressive, and problematic, sexual dysfunction clinically. In my experience, it's the worst one; I avoid prescribing it when sexual dysfunction is a key concern. On the other end of the spectrum, citalopram and escitalopram (Celexa and Lexapro) seem to be among the least problematic in this area, which is not to say that they don't generate complaints as well.

The choice of antidepressant is a complex one. There are many factors that need to be considered, including target symptoms, personal and family history and the potential for other side effects, so you should always confer with your treating physician in choosing the medication trial that is right for you, but know that not all of these medications are created equal when it comes to inducing sexual dysfunction.

Timing. The SSRIs are taken daily, sometimes in divided doses and, when suitable blood levels are reached and a person has been taking the medication for long enough for certain physiological changes to take place in the brain, the beneficial effects of these medications on a person's mood last all day. Like the effect on a person's mood, sexual dysfunction will also tend to occur at a more or less constant level while a person is taking the medication. However, with regard to difficulty achieving an orgasm--which, again, is by far the most common complaint among patients taking these medications--timing can actually make a difference.

Although it may always be more challenging to achieve an orgasm while taking an SSRI, there are times when it will be virtually impossible, and one of those times is immediately after dosing with the medication, when the level of the medication in the bloodstream is essentially peaking. If you take 200mg of Zoloft, for example, and then attempt to climax half an hour or an hour or two later, you will experience monumental difficulty doing so, and will probably quit trying, very frustrated. If, on the other hand, you attempt to climax as far removed in time from your last dose, you will have a significantly improved chance of succeeding (there is no guarantee that you will succeed, of course, but your chances will be much greater).

Because of the dose-dependent aspect, one strategy for the person who otherwise needs 200mg of Zoloft a day is to divide the dosage into 100mg twice a day. In general, it will be much easier to climax after 100mg than after 200mg. On the other hand, someone else may find it best to take their 200mg in the morning as usual and attempt to climax either first thing in the morning (before that dose) or at the very end of the day. Check with your doctor, adjust your dosing schedule and do what works best for you. Obviously, having to schedule times for sexual activity may not be convenient or feasible for a lot of people, but at least knowing that there are zones of time during which you are more or less likely to be able to climax can save you a lot of frustration and also help you to be more patient while you wait the weeks or months it can take to see some spontaneous improvement of this bothersome side effect.

Antidotes. There are various other prescription medications that can be added to your SSRI by your doctor for the specific purpose of reversing sexual dysfunction. Wellbutrin is one medication that can be added for this purpose, Buspar is another, and there are others. This is a hit-or-miss strategy; the addition of these adjunct medications can significantly improve sexual dysfunction in some individuals while making no difference at all for others. The downside is that it involves taking yet another medication, with all of the cost and inconvenience and potentially new side effects taking a prescription medication can entail, but when it works to reverse the dysfunction, most people feel that it's worth it.

A note on erectile dysfunction (ED). Men who experience ED as a result of treatment with these types of antidepressants and anti-anxiety agents are almost always men who have either previously experienced ED or who are otherwise at risk for it: older gentlemen with histories of high blood pressure, high cholesterol and/or diabetes, for example. Because SSRIs can diminish the libido (sex drive), lowered arousal can contribute to some degree of ED, but the fact is that most males will not experience a complete loss of their sex drives (that effect is more common in females, especially older, postmenopausal women). Even older men with established ED will rarely complain that SSRIs have completely deprived them of their interest in sex or that, as a result, their ED is noticeably worse; rather, these men are likely to complain about what almost all individuals experiencing medication-induced sexual side effects complain about: the decreased ability or relative inability to climax.

Of course, for those few individuals for whom ED does seem to be a consequence of treatment with an SSRI, any of the above strategies apply, but if there are no other medical contraindications, using medications approved for the treatment of ED is certainly worth considering, and the success rate is likely to be greater than using adjunctive medications in an attempt to reverse anorgasmia.
Comments (1)
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"The good news is that all sexual dysfunction side effects are reversible with discontinuation of the offending medication, no matter how severe they are and no matter how long they have been going on. Even after months or years of sexual dysfunction due to treatment with medication, a person will revert to his or her baseline upon discontinuation"

This is absolutely not true. Many, many people have suffered from antidepressant-induced sexual dysfunction for months or YEARS after stopping this medication. I know, because it happened to me. Within 3 hours of taking Zoloft my genitals became completely numb. I was on these drugs for 6 days. A year and a half after stopping the drugs, I am still numb, unable to orgasm, and have no sex-drive to speak of. It's as if my physical and emotional responses have been shut off. 

If my doctor had told  there was even a slight possibililty of this happening, I would never have taken these drugs. Anti-depressants can save lives, but they can utterly destroy them as well and people need to be fully warned. 

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