Which anti-anxiety medication has lower sexual side effects, particularly on libido?

Anti-Anxiety Medications with Lower Libido Side Effects

Buspirone is the anti-anxiety medication with the lowest impact on libido and should be considered first-line for patients concerned about sexual side effects. 1, 2, 3

Comparison of Anti-Anxiety Medications and Sexual Side Effects

First-Line Option

• Buspirone (BuSpar)
  • Demonstrated normalization of sexual function in 8 of 10 patients with generalized anxiety disorder 1
  • Does not typically cause decreased libido unlike benzodiazepines and SSRIs 2
  • Can actually improve sexual dysfunction when added to SSRI treatment (58% improvement vs 30% with placebo) 3
  • Typical dosage: 20-60 mg/day
  • Common side effects: dizziness, headache, nervousness, nausea (but minimal sexual side effects)

Second-Line Options

• Bupropion (Wellbutrin)
  • Significantly lower rates of sexual adverse events compared to SSRIs like fluoxetine 4
  • Can be used as primary treatment or as augmentation to counteract sexual side effects of other medications
  • Often used to treat both anxiety and depression

Medications to Avoid When Sexual Function is a Priority

• SSRIs (fluoxetine, paroxetine, sertraline)

  • Associated with significant sexual dysfunction including decreased libido, delayed orgasm, and erectile dysfunction 5, 4
  • Paroxetine may have the highest risk of sexual side effects among SSRIs 5

• Benzodiazepines (diazepam, lorazepam, alprazolam)

  • Can cause decreased libido and erectile dysfunction 2
  • Diazepam has been specifically associated with decreased libido 2

Treatment Algorithm for Anxiety with Minimal Sexual Side Effects

1. First attempt: Buspirone

   • Start at 7.5 mg twice daily, titrate up to 20-30 mg/day divided doses
   • Allow 2-4 weeks for full therapeutic effect
   • Monitor for improvement in both anxiety and sexual function

2. If inadequate response to buspirone:

   • Consider bupropion (starting at 150 mg daily, may increase to 300 mg daily)
   • Particularly useful if depression is also present

3. For severe anxiety requiring immediate control:

   • Consider short-term (1-2 weeks) benzodiazepine use while initiating buspirone
   • Taper benzodiazepine as buspirone takes effect

4. For patients already on SSRIs with sexual dysfunction:

   • Consider adding buspirone (20-60 mg/day) as augmentation therapy 3
   • Approximately 58% of patients show improvement in sexual function with this approach

Important Clinical Considerations

• Sexual dysfunction is often multifactorial and requires a comprehensive treatment plan 5
• Assess response to medication changes within 2-4 weeks, evaluating both sexual function and anxiety symptoms 4
• Buspirone may be less effective in patients with previous long-term benzodiazepine exposure 6
• For women with low sexual desire, flibanserin or bremelanotide may be considered as adjunctive treatments if primary anxiety treatment is insufficient 5

Monitoring and Follow-up

• Evaluate sexual function before starting treatment and at each follow-up visit
• Use direct questioning about specific sexual symptoms (desire, arousal, orgasm)
• If sexual side effects emerge, consider dose reduction or medication switch before adding additional agents

Remember that while buspirone is generally effective for generalized anxiety disorder, it may not be as effective for other anxiety disorders such as panic disorder or social anxiety disorder 7, which may require alternative treatment approaches.