How to treat sexual side effects caused by Zoloft (sertraline)?

Managing Sexual Side Effects of Zoloft (Sertraline)

Bupropion is the most effective treatment for Zoloft-induced sexual dysfunction and should be considered as first-line therapy for patients experiencing these side effects. 1

Understanding Sertraline-Related Sexual Dysfunction

Sertraline (Zoloft) commonly causes sexual side effects, with FDA data showing:

• 14% of male patients experience ejaculation failure (primarily delayed ejaculation)
• 6% of all patients report decreased libido 2

These numbers likely underestimate the true incidence, as patients and physicians may be reluctant to discuss sexual issues. Studies suggest the actual incidence of SSRI-related sexual dysfunction may be as high as 58-73% 3.

Types of Sexual Side Effects

Zoloft can affect all phases of sexual function:

• Desire phase: Decreased libido
• Arousal phase: Erectile dysfunction in men, reduced lubrication in women
• Orgasm phase: Delayed or absent orgasm, ejaculatory problems
• Other: Impotence, priapism (rare) 2

Treatment Options (Algorithm)

First-Line Approaches:

1. Add Bupropion (Wellbutrin)

   • Starting dose: 37.5 mg every morning
   • Titrate by 37.5 mg every 3 days
   • Target dose: 150 mg twice daily
   • Mechanism: Activating effect with minimal sexual side effects 4, 1
   • Note: Should not be used in agitated patients or those with seizure disorders
   • Give second dose before 3 p.m. to minimize insomnia risk

2. Switch to an antidepressant with lower sexual side effect profile:

   • Mirtazapine (Remeron): 7.5 mg at bedtime, up to 30 mg 4, 1
   • Nefazodone: 50 mg twice daily, up to 150-300 mg twice daily 4, 3
   • Bupropion (as monotherapy rather than adjunct) 1, 5

Second-Line Approaches:

1. Dose reduction of sertraline

   • Lower doses may maintain antidepressant efficacy while reducing sexual side effects
   • Must be done gradually under medical supervision 4

2. Timing strategies

   • Taking sertraline after sexual activity
   • Drug holidays (skipping doses on days when sexual activity is planned)
   • Note: This approach may be less suitable for sertraline due to its longer half-life compared to other SSRIs 6

3. Add buspirone

   • 20-60 mg/day as augmentation therapy
   • Approximately 58% of patients show improvement 1

For Specific Sexual Dysfunctions:

• For erectile dysfunction: Consider PDE5 inhibitors (sildenafil, tadalafil) 1
• For women with low sexual desire: Consider flibanserin or bremelanotide as adjunctive treatments 1

Important Considerations

• Do not abruptly discontinue sertraline as this may lead to withdrawal symptoms; taper over 10-14 days if switching medications 4

• Monitor for drug interactions:

  • Sertraline has less effect on metabolism of other medications compared to other SSRIs 4
  • When combining with PDE5 inhibitors, monitor for potential hypotension

• Assess baseline sexual function before starting antidepressants to better evaluate medication effects 1

• Regularly inquire about sexual side effects as patients may not spontaneously report them 2

Caution

• Sexual dysfunction can significantly impact quality of life and medication adherence
• Approximately 40% of patients show low tolerance for sexual dysfunction 3
• Sexual side effects are a common reason for discontinuation of antidepressant treatment
• Men have a higher frequency of sexual dysfunction (62.4%) than women (56.9%), although women report higher severity 3