Decreased Libido on Spironolactone: Clinical Significance
Yes, decreased libido is a clinically significant and well-documented side effect of spironolactone, occurring due to its potent anti-androgenic activity. This effect is particularly relevant in men and should be discussed with all patients before initiating therapy.
Mechanism and Frequency
Decreased libido is among the most frequent side effects of spironolactone, directly related to its anti-androgenic properties. 1 The medication works by:
- Competitively inhibiting binding of testosterone and dihydrotestosterone to androgen receptors in tissues 1
- Decreasing testosterone production 1
- Potentially inhibiting 5-alpha-reductase activity 1
The anti-androgenic effects manifest as decreased libido alongside other sexual side effects including impotence in men and menstrual irregularities in women 1
Clinical Context by Population
In Men with Cirrhosis and Ascites
The British Society of Gastroenterology explicitly identifies decreased libido as one of the "most frequent side effects" when using spironolactone for ascites management 1. These anti-androgenic effects occur alongside:
- Impotence
- Gynecomastia (can be managed with tamoxifen 20 mg twice daily if needed) 1
In Women Treated for Acne
While the American Academy of Dermatology guidelines acknowledge spironolactone's anti-androgenic mechanism, decreased libido is not prominently featured in the acne literature's side effect profiles 1. The focus in dermatology guidelines is primarily on:
However, emerging evidence suggests sexual dysfunction may be underreported in women. A 2019 case series documented that spironolactone can cause hormonally-associated vestibulodynia and female sexual arousal disorder, with patients experiencing dyspareunia and decreased arousal that resolved after discontinuation 2
In Ophthalmology (CSC Treatment)
When treating central serous chorioretinopathy, decreased libido is listed among the most common side effects (reported in >10% of patients) alongside headache, diarrhea, fatigue, gynecomastia, and menstrual disruption 1
Dose-Dependency
The severity and frequency of anti-androgenic side effects, including decreased libido, are dose-dependent 1, 3. Research demonstrates:
- At 50 mg/day: 6.9% incidence of gynecomastia 3
- At 150 mg/day or more: 52.2% incidence of gynecomastia 3
- Higher doses (200 mg/day) carry significantly increased risk of hormonal side effects 1
Clinical Management Strategies
Prevention and Mitigation
Start with the lowest effective dose to minimize anti-androgenic effects 3. Studies show 75-100 mg daily is as effective for blood pressure control as 150-300 mg daily, but with substantially fewer sexual side effects 3
Consider alternative aldosterone antagonists if sexual side effects are problematic:
- Eplerenone has reduced affinity for androgen and progesterone receptors, resulting in decreased incidence of sexual side effects compared to spironolactone 1, 4, 5
- Potassium canrenoate (where available) significantly reduces gynecomastia and may have fewer sexual side effects 1
Patient Counseling
Counsel all patients—both men and women—about potential sexual side effects before initiating spironolactone 4, 5, 2. This is particularly important because:
- Sexual dysfunction may be underreported, especially in women 2
- The effects are reversible upon discontinuation 2
- Patients may not spontaneously report these symptoms without direct questioning
Common Pitfalls to Avoid
- Don't dismiss sexual complaints in women taking spironolactone—emerging evidence shows these effects occur in both sexes but may be underrecognized in women 2
- Don't use unnecessarily high doses—sexual side effects are dose-dependent, and lower doses are often equally effective 3
- Don't forget to discuss this side effect preemptively—patients are more likely to report symptoms when they know they're expected 2