What medications can cause sexual dysfunction or decreased libido?

Medications That Can Cause Sexual Dysfunction or Decreased Libido

Many medications can cause sexual dysfunction or decreased libido, with antidepressants (particularly SSRIs), antihypertensives, and certain psychotropic drugs being the most common culprits.

Antidepressants

SSRIs (Selective Serotonin Reuptake Inhibitors)

• Sertraline (Zoloft): Causes sexual dysfunction in 59.1% of patients, including ejaculation failure (14% vs 1% placebo), decreased libido (6% vs 1% placebo), and impotence 1
• Paroxetine: Highest rate of sexual dysfunction among SSRIs at 70.7% 2
• Citalopram: 72.7% incidence of sexual dysfunction 2
• Fluoxetine: 57.7% incidence of sexual dysfunction 2
• Fluvoxamine: 62.3% incidence of sexual dysfunction 2

Other Antidepressants

• Venlafaxine (SNRI): 67.3% incidence of sexual dysfunction 2
• Mirtazapine: Lower incidence at 24.4% 2
• Bupropion: Significantly lower rates of sexual adverse events compared to SSRIs 3
• Nefazodone: Very low incidence at 8% 2
• Moclobemide: Minimal sexual side effects at 3.9% 2

Antihypertensive Medications

Beta-Blockers

• Associated with sexual dysfunction 4
• Examples include:
  • Atenolol
  • Metoprolol
  • Propranolol
  • Nadolol
  • Timolol 5

Diuretics

• Thiazide diuretics can cause sexual dysfunction 5
• However, the VA Cooperative study did not document significant differences in sexual dysfunction with diuretics compared to other antihypertensives 5

Other Antihypertensives

• Centrally acting drugs like methyldopa and reserpine can affect sexual function 5

Psychotropic Medications

• Antipsychotics: Particularly haloperidol can cause sexual dysfunction 4
• Benzodiazepines: Can contribute to sexual dysfunction 4
• Stimulants: May cause sexual side effects 4

Mechanisms of Sexual Dysfunction

Different medications affect sexual function through various mechanisms:

1. SSRIs: Primarily affect ejaculation and orgasm through serotonergic effects 6

   • Delayed ejaculation and absent/delayed orgasm are most common
   • Decreased desire and arousal difficulties also frequently reported
   • Effects are dose-related

2. Antihypertensives: May affect sexual function through:

   • Decreased blood flow
   • Effects on the autonomic nervous system
   • Hormonal changes

3. Other mechanisms:

   • Anticholinergic effects
   • Dopamine inhibition
   • Prolactin elevation
   • Inhibition of nitric oxide synthetase 6

Gender Differences

• Men tend to have a higher frequency of sexual dysfunction (62.4%) compared to women (56.9%) with antidepressants, although women report higher severity 2
• In men, ejaculatory problems and erectile dysfunction are common
• In women, decreased desire and difficulty achieving orgasm are more common

Clinical Considerations

Assessment

• Sexual dysfunction is often underreported unless specifically asked about
• Patients are often reluctant to discuss sexual problems
• Baseline sexual function should be assessed before starting medications known to cause sexual side effects 6

Management Options

For antidepressant-induced sexual dysfunction:

• Switching to medications with lower sexual side effect profiles (bupropion, mirtazapine, nefazodone) 4
• Dose reduction when possible
• Drug holidays (though not always recommended)
• Adjunctive medications like PDE5 inhibitors for erectile dysfunction 5
• Adding buspirone (20-60 mg/day) may improve sexual function in patients on SSRIs 3

For antihypertensive-induced sexual dysfunction:

• Consider alternative antihypertensive classes
• ARBs may have fewer sexual side effects than other antihypertensives 5

Common Pitfalls and Caveats

1. Failure to assess baseline sexual function: Sexual dysfunction may be present before medication initiation, particularly in depression 7

2. Underestimation of prevalence: Sexual side effects are often underreported in product labeling and require direct questioning 1

3. Attributing all sexual problems to medication: Multiple factors may contribute to sexual dysfunction, including:

   • The underlying condition (e.g., depression)
   • Psychosocial factors
   • Other medical conditions
   • Other medications 4

4. Ignoring the impact on adherence: Sexual dysfunction can lead to medication non-compliance and increased risk of disease recurrence 7

5. Not discussing potential sexual side effects: Patients should be informed about potential sexual side effects before starting medications to improve adherence and satisfaction

By understanding which medications commonly cause sexual dysfunction and how to manage these side effects, clinicians can help improve medication adherence and quality of life for their patients.