How to taper Prozac (fluoxetine) 20mg to improve sexual side effects while managing Premenstrual Dysphoric Disorder (PMDD) in conjunction with Wellbutrin (bupropion) 300mg?

Tapering Fluoxetine for PMDD While Managing Sexual Side Effects

For PMDD management with sexual side effects on fluoxetine 20mg plus bupropion 300mg, switch to intermittent (luteal-phase only) fluoxetine dosing at 20mg daily for 14 days premenstrually, which maintains PMDD efficacy while substantially reducing sexual dysfunction exposure. 1, 2

Recommended Tapering Strategy

Transition to Intermittent Dosing (Preferred Approach)

• Switch from continuous daily fluoxetine to luteal-phase only dosing (14 days before expected menses through onset of menstruation), maintaining the 20mg dose during treatment days 1, 2

• Intermittent fluoxetine dosing shows 75% response rates for PMDD and is specifically designed to minimize side effect burden while maintaining therapeutic efficacy 1

• This approach eliminates 14+ days of monthly SSRI exposure, directly reducing the duration of sexual side effects while preserving PMDD control 2

• No discontinuation syndrome has been reported with intermittent fluoxetine regimens for PMDD, making this transition safer than with other SSRIs 2

If Dose Reduction is Preferred Instead

• Reduce fluoxetine to 10mg daily during luteal phase only (not continuous dosing), which has demonstrated efficacy for premenstrual emotional symptoms with even lower side effect burden 2

• Taper slowly over 2-4 weeks when reducing dose or switching regimens to avoid SSRI discontinuation syndrome (dizziness, fatigue, myalgias, nausea, anxiety, irritability) 3

• Never abruptly stop or rapidly reduce fluoxetine, as this precipitates withdrawal symptoms despite the long half-life 4, 3

Optimizing the Current Regimen

Bupropion's Role

• Continue bupropion 300mg throughout the cycle as it provides antidepressant coverage without sexual side effects and may partially counteract SSRI-induced sexual dysfunction 5

• Bupropion augmentation of SSRIs specifically improves sexual desire when used as an antidote strategy for SSRI-related sexual dysfunction 5

Monitoring Requirements

• Track PMDD symptoms prospectively for 2-3 cycles after switching to intermittent dosing to confirm maintained efficacy 6

• Assess sexual function parameters specifically: sex drive, arousal, ability to achieve/maintain arousal, ease of reaching orgasm, and orgasm satisfaction 7

• Use standardized rating scales to monitor both PMDD symptom control and sexual function objectively 3

Critical Safety Considerations

Contraindications and Warnings

• Screen for bipolar disorder before any medication adjustments, as SSRIs (including fluoxetine) risk precipitating mania in undiagnosed bipolar patients 4, 3

• Monitor for suicidality closely during the first months after any dosage change, particularly in patients under age 24 or with comorbid depression 4, 3

• Avoid combining with other serotonergic agents (tramadol, other antidepressants, certain migraine medications) due to serotonin syndrome risk 4, 3

Serotonin Syndrome Recognition

• Watch for clonus, tremor, hyperreflexia, agitation, mental status changes, diaphoresis, and fever as signs of serotonin syndrome requiring immediate cessation of serotonergic agents 4

Alternative Strategies if Intermittent Dosing Fails

Dose Reduction Approach

• Reduce to the minimum effective fluoxetine dose (potentially 10mg luteal phase only), though this risks inadequate PMDD control and requires close monitoring 3, 5

Switching Antidepressants

• Consider switching to fluvoxamine if orgasm delay/anorgasmia is the primary sexual complaint, as it has a different sexual side effect profile among SSRIs 5

• Switching to non-serotoninergic antidepressants is generally not recommended for PMDD, as SSRIs remain first-line treatment with the strongest evidence base 6

Common Pitfalls to Avoid

• Do not use progestin-only contraceptives (progestin-only pills, levonorgestrel IUD, etonogestrel implant, DMPA) in PMDD patients, as these can worsen mood symptoms 8

• Avoid "weekend holidays" with fluoxetine due to its long half-life making this strategy ineffective, unlike shorter-acting SSRIs 5

• Do not assume sexual dysfunction will resolve spontaneously—proactive management is essential for treatment adherence and requires direct discussion 3, 5

• Recognize that 40% of patients discontinue SSRIs due to concerns about side effects, making early intervention on sexual dysfunction critical for long-term PMDD management 3