Does Cymbalta (duloxetine) cause fewer sexual side effects than Lexapro (escitalopram)?

Comparing Sexual Side Effects: Cymbalta vs. Lexapro

Cymbalta (duloxetine) causes fewer sexual side effects than Lexapro (escitalopram). This conclusion is supported by the FDA drug labels and clinical guidelines showing significant differences in the incidence of sexual dysfunction between these medications.

Evidence-Based Comparison

Sexual Side Effect Profiles

• Lexapro (escitalopram): FDA drug label data shows high rates of sexual dysfunction 1:

  • Ejaculation disorder: 14% (vs. 2% with placebo)
  • Decreased libido: 7% in men (vs. 2% with placebo)
  • Anorgasmia: 6% in women (vs. <1% with placebo)

• Cymbalta (duloxetine): FDA drug label shows lower rates of sexual dysfunction 2:

  • Erectile dysfunction: 4% (vs. <1% with placebo)
  • Ejaculation disorder: 2% (vs. <1% with placebo)

Mechanism and Class Differences

Lexapro is a Selective Serotonin Reuptake Inhibitor (SSRI), while Cymbalta is a Serotonin-Norepinephrine Reuptake Inhibitor (SNRI). The additional norepinephrine effect in SNRIs may partially counteract some of the serotonergic sexual side effects.

Clinical Implications

When Sexual Function Is a Priority

For patients where preserving sexual function is a priority, the evidence suggests:

1. First consideration: Cymbalta has a more favorable sexual side effect profile than Lexapro
2. Alternative options: If sexual dysfunction is a major concern, bupropion (Wellbutrin) has even lower rates of sexual dysfunction (22-25%) compared to both medications 3

Assessment of Sexual Function

• Sexual side effects are often underreported unless specifically asked about
• Physicians consistently underestimate the prevalence of antidepressant-associated sexual dysfunction 3
• Use direct questioning about specific sexual symptoms (desire, arousal, orgasm)

Important Caveats

• Individual variation: While population data shows Cymbalta has fewer sexual side effects than Lexapro, individual responses may vary
• Dose-dependent effects: Higher doses of Lexapro (20mg vs. 10mg) show significantly increased rates of sexual side effects 1
• Gender differences: Men report higher frequency of sexual dysfunction (62.4%) than women (56.9%), though women report higher severity 4
• Underreporting: Sexual side effects are likely underestimated in clinical trials due to reluctance of patients to discuss them 1

Clinical Decision Algorithm

1. For patients with history of sexual dysfunction or where sexual function is a priority:

   • Choose Cymbalta over Lexapro
   • Consider bupropion if sexual function is the highest priority

2. For patients already on Lexapro experiencing sexual side effects:

   • Consider switching to Cymbalta if depression control is adequate
   • Avoid abrupt discontinuation; taper over 10-14 days

3. For patients requiring an SSRI specifically:

   • Be aware that Lexapro has higher rates of sexual dysfunction (similar to other SSRIs)
   • Discuss potential sexual side effects before initiating treatment

The evidence clearly demonstrates that when sexual function is a significant concern for patients requiring antidepressant therapy, Cymbalta is preferable to Lexapro due to its lower incidence of sexual side effects.