What medications can cause low libido?

Medications That Cause Low Libido

Selective Serotonin Reuptake Inhibitors (SSRIs) are the most common medications that cause decreased libido, with up to 50% of patients experiencing sexual dysfunction including reduced sexual desire. 1, 2

Common Medication Classes That Reduce Libido

1. Antidepressants

• SSRIs: Paroxetine, sertraline, fluoxetine, citalopram, escitalopram

  • Cause decreased libido in up to 50% of patients 1
  • May persist even after discontinuation in some cases 3
  • Mechanism: Excessive serotonergic activity inhibits dopamine pathways involved in sexual desire 4

• Tricyclic Antidepressants: Clomipramine

  • Associated with reduced libido and other sexual side effects 5
  • Often used to treat premature ejaculation specifically because of these effects

• Lower-risk alternatives:

  • Bupropion (norepinephrine and dopamine reuptake inhibitor) has minimal sexual side effects 4
  • Mirtazapine and nefazodone have lower rates of sexual dysfunction 6

2. Antipsychotics

• Cause hyperprolactinemia which reduces libido
• Examples: Flupenthixol, amisulpride, risperidone
• Aripiprazole and quetiapine may have lower impact on sexual function 5

3. Anxiolytics

• Benzodiazepines can reduce sexual desire 6
• Mechanism: CNS depression and reduced arousal

4. Hormonal Medications

• Androgen deprivation therapies used in prostate cancer
• Hormonal contraceptives containing estrogen/progestin
• Finasteride and other 5-alpha reductase inhibitors

5. Cardiovascular Medications

• Beta-blockers: Particularly older non-selective agents
• Diuretics: Especially thiazides
• Antihypertensives: Centrally-acting agents like clonidine

Mechanism of SSRI-Induced Sexual Dysfunction

1. Serotonergic effects: Increased serotonin inhibits dopaminergic pathways involved in sexual desire 4
2. Neuroanatomical changes: Reduced activation in:
   • Anterior cingulate cortex (emotional processing)
   • Ventral striatum (motivation/reward)
   • Midbrain regions involved in sexual arousal 4
3. Hormonal effects: Potential increases in prolactin levels

Clinical Considerations

Assessment

• Sexual dysfunction from medications includes multiple domains:
  • Decreased libido (desire)
  • Erectile/arousal difficulties
  • Delayed or absent orgasm
  • Ejaculatory problems 1

Management Options for Medication-Induced Low Libido

1. Medication switch to alternatives with lower sexual side effect profiles:

   • Switch from SSRIs to bupropion, mirtazapine, or nefazodone 6
   • Consider alternative antihypertensives if beta-blockers are the cause

2. Dose adjustment:

   • Lower doses of SSRIs may reduce sexual side effects while maintaining efficacy 2
   • Consider intermittent dosing regimens when appropriate

3. Adjunctive treatments:

   • For men with low testosterone (<300 ng/dL), testosterone replacement therapy may help 5
   • PDE5 inhibitors (sildenafil, tadalafil) may help with erectile function but not necessarily libido 5

4. Lifestyle modifications:

   • Increased physical activity
   • Smoking cessation
   • Reduction of alcohol consumption
   • Weight loss if obese 5

Important Caveats

• Sexual dysfunction may persist even after medication discontinuation in some patients (post-SSRI sexual dysfunction) 3
• The underlying condition being treated (e.g., depression) may itself cause sexual dysfunction, complicating assessment 7
• Always consider the risk-benefit ratio of changing medications that are effectively treating the primary condition

Special Considerations

• Cancer survivors: Follow NCCN guidelines for addressing medication-related sexual dysfunction 5
• Alcohol dependence treatment: Medications like acamprosate have lower sexual side effect profiles than many antidepressants 5
• Premature ejaculation: SSRIs are sometimes deliberately used for their sexual side effects 5

When evaluating patients with low libido, always obtain a complete medication history, including over-the-counter medications, as medication-induced sexual dysfunction is both common and frequently underreported by patients.