Can spironolactone cause erectile dysfunction?

Spironolactone and Erectile Dysfunction

Yes, spironolactone can cause erectile dysfunction and other sexual side effects in men due to its anti-androgenic properties. 1

Mechanism of Action and Sexual Side Effects

Spironolactone is an aldosterone receptor antagonist that also exhibits potent anti-androgenic activity through several mechanisms:

• Decreases testosterone production
• Competitively inhibits binding of testosterone and dihydrotestosterone to androgen receptors
• May inhibit 5-alpha-reductase enzyme
• Increases steroid hormone-binding globulin 1

These anti-androgenic effects can lead to several sexual side effects in men:

• Erectile dysfunction
• Decreased libido
• Gynecomastia (breast enlargement)
• Reduced sexual function 1, 2

Prevalence and Clinical Evidence

Sexual side effects are well-documented in clinical guidelines and research:

• The Korean Association for the Study of Liver Cirrhosis specifically mentions erectile dysfunction as a side effect of spironolactone 1
• The American Academy of Dermatology acknowledges hyposexuality and erectile dysfunction as recognized side effects 1
• Early research from the 1970s identified the mechanism of spironolactone's anti-androgenic effects, showing it decreases plasma testosterone and inhibits binding of androgens to receptors 2

Risk Factors and Management

The risk and severity of erectile dysfunction with spironolactone may depend on:

1. Dose: Higher doses (>100mg daily) increase the risk of sexual side effects 1
2. Duration: Longer treatment periods may increase likelihood of symptoms
3. Individual sensitivity: Varies between patients
4. Underlying conditions: Pre-existing hormonal imbalances may exacerbate effects

Management options include:

• Dose reduction: Consider using the lowest effective dose
• Medication substitution: For patients with liver cirrhosis requiring diuretics, amiloride (10-40 mg/day) can be substituted for spironolactone in men experiencing sexual side effects 1
• Alternative treatments: For conditions like acne, consider alternative treatments in male patients
• Discontinuation: Sexual side effects often resolve after stopping the medication

Special Considerations

• Gender differences: Spironolactone is commonly used in women for conditions like acne, where its anti-androgenic effects are beneficial rather than problematic 1, 3
• Transgender care: Spironolactone is intentionally used in transgender women as part of feminizing hormone therapy due to its anti-androgenic effects 1
• Rare cases: There have been case reports of more profound effects on sexual identity when combined with other medical conditions and medications 4

Clinical Application

When prescribing spironolactone to male patients:

• Inform patients about potential sexual side effects before initiating treatment
• Monitor for development of erectile dysfunction, decreased libido, or gynecomastia
• Consider alternatives when treating conditions where other options exist
• Weigh benefits against risks, particularly in younger male patients where sexual function may be a priority

In female patients, the anti-androgenic effects are generally beneficial for conditions like acne, though other sexual side effects like decreased libido may still occur 5.