Is bupropion (Wellbutrin) 75mg SR effective for improving male libido in a patient with a history of intolerance to higher doses and complex hormonal treatment regimen, including enclomiphene, anastrazole, and cabergoline?

Bupropion 75mg SR for Male Libido in Complex Hormonal Treatment

Bupropion 75mg SR is unlikely to significantly improve libido in your case, and PDE-5 inhibitors would be a more evidence-based first-line approach for sexual dysfunction with your hormonal profile.

Assessment of Current Situation

Your current hormonal profile shows:

• Total testosterone: 542-677 ng/dL (within normal range)
• Estradiol: 50.2-56.3 pg/mL (elevated)
• Prolactin: 13.3 ng/mL (slightly elevated)
• Complex medication regimen including enclomiphene, anastrozole, and cabergoline
• Intolerance to higher doses of bupropion (150mg) with side effects including sweating, constipation, anger, irritability, and insomnia

Evidence-Based Approach

First-Line Treatment Options

1. PDE-5 Inhibitors

   • The American College of Physicians strongly recommends PDE-5 inhibitors as first-line therapy for sexual dysfunction 1
   • These medications have demonstrated statistically significant and clinically relevant improvements in sexual function
   • Choice between sildenafil, vardenafil, or tadalafil should be based on individual preferences, cost, and side effect profile

2. Hormonal Management

   • Your testosterone levels are within normal range (>300 ng/dL), so testosterone therapy is not indicated 2
   • Your current estradiol levels are elevated, which may contribute to libido issues
   • The fluctuations in libido with changes in anastrozole dosing suggest estrogen management is important in your case

Role of Bupropion

• Bupropion has limited evidence for improving libido in men with normal testosterone levels
• The Cochrane review indicates bupropion may be beneficial for SSRI-induced sexual dysfunction, but primarily at higher doses (150mg twice daily) 3
• A placebo-controlled study found that bupropion 150mg daily was not effective for SSRI-induced sexual dysfunction 4
• At your lower dose of 75mg SR, efficacy is likely to be even more limited

Specific Recommendations for Your Case

1. Optimize Hormonal Balance

   • Maintain anastrozole at 0.125mg twice weekly to manage estradiol levels without completely suppressing them
   • Consider reducing cabergoline dose if prolactin normalizes (monitor levels)
   • Maintain enclomiphene at current dose as it appears to be maintaining adequate testosterone levels

2. Consider PDE-5 Inhibitor Trial

   • Add a PDE-5 inhibitor (sildenafil, vardenafil, or tadalafil) as needed before sexual activity 1
   • This approach has stronger evidence than bupropion for improving sexual function

3. Lifestyle Modifications

   • Implement regular exercise, which can improve sexual function and hormonal balance
   • Ensure adequate sleep (7-8 hours)
   • Reduce alcohol consumption
   • Manage stress through appropriate techniques

Potential Pitfalls and Considerations

1. Medication Interactions

   • Monitor for interactions between multiple medications affecting hormonal balance
   • Bupropion can cause increased anxiety and insomnia, which you've already experienced at higher doses

2. Hormonal Fluctuations

   • Rapid changes in estradiol levels (as seen with your anastrozole dose changes) can negatively impact libido
   • More gradual adjustments may be better tolerated

3. Monitoring Requirements

   • Regular monitoring of testosterone, estradiol, and prolactin levels is essential with your complex regimen
   • Adjust medications based on both laboratory values and symptoms

Conclusion

While bupropion 75mg SR is unlikely to significantly improve libido in your case, optimizing your hormonal therapy and adding a PDE-5 inhibitor would be a more evidence-based approach. The evidence for bupropion's efficacy for libido is primarily at higher doses than you can tolerate, making it a poor choice for your specific situation.