What are the treatment options for hypersexuality?

Treatment Options for Hypersexuality

Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological treatment for hypersexuality, with paroxetine, sertraline, fluoxetine, or citalopram being the most effective options. 1

Diagnostic Evaluation

A thorough assessment should include:

• Screening for underlying medical conditions that may cause hypersexuality
• Evaluation of medication side effects (particularly hormone therapy or opioids)
• Assessment of psychological factors (anxiety, depression, relationship issues)
• Screening for substance use disorders
• Physical examination to rule out endocrine disorders

Treatment Algorithm

First-Line Treatments

1. SSRIs:

   • Start with low doses and titrate slowly
   • Monitor for side effects including serotonin syndrome
   • Avoid in patients with bipolar disorder due to risk of mania 1
   • Options include paroxetine, sertraline, citalopram, and fluoxetine dosed daily

2. Psychological interventions:

   • Cognitive-behavioral therapy
   • Sexual counseling
   • Couples therapy when relationship issues contribute to the condition

Second-Line Treatments

1. Hormonal therapy:

   • Testosterone evaluation if levels are low (<300 ng/dL) 2
   • Anti-androgen therapy may be considered in severe cases
   • Estrogen therapy (including Premarin) for cases resistant to other treatments 1
     • Requires cardiovascular risk assessment
     • Monitor for feminizing effects

2. Other pharmacological options:

   • Clomipramine dosed on demand 2
   • Mood stabilizers if hypersexuality is associated with bipolar disorder

Special Considerations

Cardiovascular Risk Assessment

Before initiating hormonal treatments:

• Assess if patient can perform exercise equivalent to walking 1 mile in 20 minutes or climbing 2 flights of stairs in 20 seconds 1
• Patients who cannot perform these exercises without symptoms should be referred to a cardiologist 2

Monitoring Requirements

• Regular assessment of behavior changes
• Cardiovascular monitoring with hormonal therapies
• Monitoring for medication side effects
• Follow-up to assess treatment efficacy

Caution Regarding Unproven Therapies

Several newer interventions lack FDA approval and sufficient clinical evidence:

• Intercavernosal stem cell therapy
• Low-intensity shock wave therapy
• Platelet-rich plasma therapy 2

Treatment Based on Underlying Causes

Hypersexuality may be a symptom of other conditions that require specific treatment:

• Bipolar disorder: Mood stabilizers (lithium, valproate)
• Medication-induced: Adjustment of causative medications (e.g., dopamine agonists)
• Substance-induced: Substance use disorder treatment
• Neurological disorders (e.g., frontal lobe syndrome): Targeted neurological treatment

The principle of "de causa effectu evanescent" applies—treating the underlying cause may resolve hypersexuality 3.