Sexual Side Effects of SSRIs
SSRIs commonly cause sexual dysfunction including decreased libido, delayed ejaculation/orgasm, anorgasmia, and erectile dysfunction, with rates significantly higher than reported in spontaneous patient reports. 1, 2, 3
Prevalence and Reporting
- Sexual side effects occur in up to 80% of patients taking SSRIs but are significantly underreported when not directly asked about by clinicians 1
- Incidence increases from 14.2% (spontaneously reported) to 55.29% when physicians directly question patients 4
- Sexual dysfunction typically begins within the first few weeks of treatment and rarely resolves with continued treatment 1
Specific Sexual Side Effects
Male-Specific Side Effects
- Ejaculatory disturbances: 13-28% (vs 0-2% with placebo) 2
- Primarily manifests as delayed ejaculation
- Paroxetine causes the strongest ejaculation delay (8.8-fold increase in ejaculatory latency) 1
- Erectile dysfunction: 2-9% (vs 0-3% with placebo) 2
- Impotence: Reported in FDA labeling for both paroxetine and sertraline 2, 3
Female-Specific Side Effects
- Orgasmic disturbance: 2-9% (vs 0-1% with placebo) 2
- Women experience more intense sexual dysfunction effects than men 4
Non-Gender Specific Side Effects
- Decreased libido: 6-15% in males, 0-9% in females (vs 0-5% in males and 0-2% in females with placebo) 2
- Genital numbness: Common complaint but not specifically quantified in most studies 5
- Pleasureless or weak orgasm: Frequently reported 5
Mechanisms of Sexual Dysfunction
- Increased serotonin levels directly inhibit the ejaculatory reflex and orgasm 1
- Serotonin modulates sexual desire and arousal centers in the brain 1
- Effects are dose-dependent, with higher doses correlating with increased frequency and severity of sexual side effects 1
- Possible involvement of glutamatergic pathways, with genetic polymorphisms in glutamatergic genes associated with specific sexual dysfunctions 6
Therapeutic Use of Sexual Side Effects
- SSRIs are deliberately used to treat premature ejaculation due to their ejaculation-delaying properties 1
- Paroxetine, sertraline, fluoxetine, and clomipramine are all effective in treating premature ejaculation 1
Post-SSRI Sexual Dysfunction (PSSD)
- Sexual dysfunction can persist indefinitely after discontinuation of SSRIs in some individuals 7
- Characterized by genital numbness, pleasureless orgasm, loss of libido, and erectile dysfunction 5
- Decreased capacity to experience sexual pleasure is the most frequent characteristic 7
- A MedDRA code for PSSD has been introduced but is not yet widely adopted by regulators 5
Management of SSRI-Induced Sexual Dysfunction
- Dose adjustment: Lower doses may reduce sexual side effects while maintaining therapeutic efficacy 1
- Medication switching: Consider alternatives with lower rates of sexual dysfunction 1
- Drug holidays: May provide temporary relief from sexual side effects 8
- Augmentation strategies: Various approaches including 5-HT receptor antagonists and PDE5 inhibitors have been tried 8
Clinical Considerations
- Sexual dysfunction significantly impacts medication adherence and quality of life 8
- Patients show substantial improvement in sexual function when the dose is reduced or the drug is withdrawn 4
- Only about 22.6% of patients report good tolerance of their sexual dysfunction 4
- Clinicians should proactively ask about sexual side effects rather than waiting for patients to report them 1