Can fluoxetine (Prozac) cause ejaculatory dysfunction?

From the Guidelines

Yes, Prozac (fluoxetine) can cause problems with ejaculation, as it is a common side effect of selective serotonin reuptake inhibitors (SSRIs) like Prozac, affecting approximately 30-60% of men who take these medications. The most common ejaculation problems include delayed ejaculation, difficulty ejaculating, or inability to ejaculate (anorgasmia) 1. These sexual side effects typically begin within the first few weeks of starting the medication and often persist throughout treatment. The mechanism behind this involves increased serotonin levels, which can inhibit the ejaculation reflex by affecting nerve signals between the brain and reproductive organs.

Key Points to Consider

• The incidence of sexual dysfunction, including ejaculatory problems, is a significant concern with SSRI use, with paroxetine having higher rates of sexual dysfunction than fluoxetine, fluvoxamine, nefazodone, or sertraline 1.
• Bupropion has been shown to have a significantly lower rate of sexual adverse events than fluoxetine or sertraline, making it a potential alternative for patients experiencing sexual side effects 1.
• If you experience these side effects, don't stop taking Prozac abruptly, but discuss them with your healthcare provider. They might adjust your dosage (typically 20-80 mg daily), suggest taking the medication at a different time of day, recommend a brief medication holiday under supervision, or consider switching to an antidepressant with fewer sexual side effects, such as bupropion (Wellbutrin) or mirtazapine (Remeron) 1.

Clinical Recommendations

• Clinicians should be aware of the potential for SSRI-induced sexual dysfunction, including ejaculatory problems, and discuss this with patients before initiating treatment.
• Patients should be advised to report any changes in sexual function or ejaculatory ability to their healthcare provider, who can then consider adjustments to the treatment plan.
• The use of SSRIs, including fluoxetine, should be carefully considered in patients with a history of sexual dysfunction or those who are concerned about the potential impact of treatment on their sexual health.

From the Research

Sexual Dysfunction Associated with Fluoxetine

• Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has been associated with sexual dysfunction, including delayed ejaculation, in several studies 2, 3, 4.
• A study published in the Journal of Clinical Psychopharmacology found that SSRIs, including fluoxetine, can cause delayed ejaculation and absent or delayed orgasm 2.
• Another study published in the Journal of Sex & Marital Therapy found that fluoxetine, along with other SSRIs, can cause sexual dysfunction, including delayed ejaculation, in a significant proportion of patients 3.
• A randomized, placebo-controlled study published in The Journal of Sexual Medicine found that fluoxetine can delay ejaculation in healthy men, but does not affect sexual desire 4.

Mechanism and Management

• The exact mechanism of SSRI-induced sexual dysfunction is not fully understood, but it is thought to be related to the serotonin and dopamine reuptake mechanisms, induction of prolactin release, anticholinergic effects, inhibition of nitric oxide synthetase, and propensity for accumulation over time 2.
• Management of SSRI-induced sexual dysfunction can include waiting for tolerance to develop, dosage reduction, drug holidays, substitution of another antidepressant drug, and various augmentation strategies 2, 5.
• Sildenafil has been shown to be helpful in the treatment of SSRI-induced sexual dysfunction, including delayed ejaculation 5.

Prevalence and Correlates

• The prevalence of sexual dysfunction associated with fluoxetine and other SSRIs can vary widely, depending on the study and the population being studied 2, 6, 3.
• Men are more likely to experience sexual dysfunction, including delayed ejaculation, than women, but women's sexual dysfunction can be more intense 3.
• Sexual dysfunction can be positively correlated with dose, and patients may experience substantial improvement in sexual function when the dose is diminished or the drug is withdrawn 3.