What are the treatment options for post Selective Serotonin Reuptake Inhibitor (SSRI) sexual dysfunction?

Treatment Options for Post-SSRI Sexual Dysfunction (PSSD)

The most effective approach to managing post-SSRI sexual dysfunction is medication adjustment, including switching to antidepressants with lower sexual side effect profiles such as bupropion or mirtazapine, or adding targeted pharmacological interventions to address specific symptoms. 1

Understanding PSSD

PSSD is characterized by sexual dysfunction that persists after discontinuation of SSRI medications. Common symptoms include:

• Decreased capacity to experience sexual pleasure
• Genital anesthesia/reduced sensitivity
• Reduced libido
• Erectile dysfunction or vaginal dryness
• Ejaculatory disorders
• Orgasmic problems (delayed, weak, or absent)

These symptoms can persist indefinitely after stopping SSRIs and significantly impact quality of life 2, 3.

Evaluation Approach

When evaluating PSSD, consider:

• Timing of symptoms in relation to SSRI use and discontinuation
• Exclusion of other causes of sexual dysfunction (cardiovascular disease, diabetes, hormonal issues)
• Assessment of medication history, particularly other drugs that may affect sexual function
• Evaluation of psychological factors (anxiety, depression, relationship issues)

Treatment Algorithm

First-Line Approaches:

1. Medication Adjustment

   • Switch to antidepressants with lower sexual side effect profiles:

     • Bupropion (has dopaminergic effects)
     • Mirtazapine
     • Moclobemide (MAO inhibitor)
     • Agomelatine 1, 4

   • Avoid abrupt discontinuation of SSRIs to prevent withdrawal syndrome 1

2. Pharmacological Interventions

   • For erectile dysfunction: PDE5 inhibitors (sildenafil, tadalafil) 5
   • For reduced sensitivity/libido: Consider testosterone therapy if hypogonadism is present 5
   • For ejaculatory problems: Adjust dosing of current medications 1

Second-Line Approaches:

1. Augmentation Strategies

   • Cyproheptadine before sexual activity (caution: monitor for serotonin syndrome) 1
   • Dopaminergic agonists may help with orgasmic dysfunction 5, 3

2. Non-Pharmacological Interventions

   • Pelvic floor physical therapy for erectile dysfunction or ejaculatory problems 5
   • Lifestyle modifications: increased physical activity, smoking cessation, weight management, reduced alcohol consumption 5

3. Nutraceutical Approaches

   • Limited evidence supports supplements containing L-citrulline and other aphrodisiacs 6
   • Consider as adjunctive therapy rather than primary treatment

Special Considerations

• For patients on tamoxifen: Avoid strong CYP2D6 inhibitors like paroxetine or fluoxetine; consider citalopram or venlafaxine instead 1
• For men with both anorgasmia and premature ejaculation: Careful dosing adjustment may help balance these opposing conditions 1
• For breast cancer survivors: Venlafaxine may improve libido while treating vasomotor symptoms 1

Treatment Challenges

• PSSD remains poorly understood with limited research on effective treatments 2, 7
• Many proposed mechanisms exist, including epigenetic changes, serotonin receptor downregulation, and hormonal alterations 7, 3
• Treatment response is variable, and some patients may have persistent symptoms despite interventions

Monitoring and Follow-up

• Regular assessment of sexual function during and after SSRI treatment
• Evaluation of treatment efficacy and side effects
• Consideration of psychotherapy or sexual counseling as adjunctive treatment

PSSD is a challenging condition that requires recognition and a systematic approach to management. While complete resolution may not always be achieved, targeted interventions can help improve symptoms and quality of life.