Medication-Induced Libido Changes: Amitriptyline, Quetiapine, and Hydroxyzine

Quetiapine is most likely to cause libido changes, followed by amitriptyline, while hydroxyzine has minimal effects on sexual function. 1, 2, 3

Quetiapine and Sexual Dysfunction

Quetiapine has significant effects on sexual function through multiple mechanisms:

Elevates prolactin levels in some patients, which can persist during chronic administration 1
Hyperprolactinemia can suppress hypothalamic GnRH, reducing pituitary gonadotrophin secretion and impairing gonadal steroidogenesis in both males and females 1
Clinical studies show diminished libido is the most frequent sexual dysfunction in both males (31.8%) and females (28.6%) taking quetiapine 3
As an atypical antipsychotic with dopamine antagonist properties, it affects sexual function primarily through decreased libido 4

Amitriptyline has moderate effects on sexual function with notable gender differences:

Overall sexual dysfunction rate is 5.7%, with significantly higher rates in men (11.9%) compared to women (1.7%) 2
In male patients, amitriptyline impacts arousal and libido more than orgasm and ejaculation 2
In female patients, amitriptyline primarily affects libido 2
Sexual dysfunction from amitriptyline is significantly higher in patients with depression (6.9%) compared to non-depressive patients (0.8%) 2
Sexual side effects tend to gradually decrease after 8 weeks of treatment 2

Hydroxyzine has minimal documented effects on sexual function compared to the other medications 5
While listed in a table of drugs that may cause withdrawal symptoms including tremors and irritability, there is no specific mention of sexual dysfunction with hydroxyzine in the available guidelines 5
As an antihistamine without significant dopaminergic or serotonergic activity, it lacks the primary mechanisms that typically cause medication-induced sexual dysfunction 4, 6

Dopamine generally increases sexual behavior, while serotonin typically inhibits it 6
Medications that affect dopamine (like quetiapine) or serotonin (like amitriptyline) are more likely to cause sexual dysfunction 4, 6
Prolactin elevation, which occurs with quetiapine, can lead to decreased libido, galactorrhea, amenorrhea, gynecomastia, and impotence 1
Long-standing hyperprolactinemia when associated with hypogonadism may lead to decreased bone density in both females and males 1

Sexual dysfunction is often underreported in clinical trials that rely on patient self-report 4
Direct inquiry is necessary to accurately assess medication-induced sexual dysfunction 4
Sexual side effects can significantly impact medication adherence and therapeutic success 7
When assessing sexual dysfunction in patients taking psychotropic medications, clinicians should first consider other potential causes 6

Monitor for sexual dysfunction symptoms, particularly in patients taking quetiapine or amitriptyline 1, 2, 3
For amitriptyline, be aware that sexual dysfunction can be predicted by co-existing insomnia, somnolence, or nausea during treatment 2
Consider that sexual dysfunction with amitriptyline may improve after 8 weeks of continued treatment 2
For patients with significant sexual dysfunction on quetiapine, consider alternative medications with less impact on sexual function if clinically appropriate 4, 3