Can Lexapro (escitalopram) cause decreased libido?

Can Lexapro Cause Decreased Libido?

Yes, Lexapro (escitalopram) definitively causes decreased libido as a documented adverse effect, occurring in 3-7% of patients compared to 1-2% with placebo. 1

FDA-Documented Sexual Side Effects

The FDA drug label for escitalopram clearly establishes decreased libido as a treatment-emergent adverse reaction:

• In Major Depressive Disorder trials: 3% of patients experienced decreased libido vs 1% on placebo 1
• In Generalized Anxiety Disorder trials: 7% experienced decreased libido vs 2% on placebo 1
• Sexual dysfunction is likely underreported because patients and physicians may be reluctant to discuss these symptoms 1

Complete Sexual Dysfunction Profile

Beyond decreased libido, escitalopram causes a spectrum of sexual side effects 1:

In males:

• Ejaculation disorder (primarily delayed ejaculation): 9-14% vs <1-2% placebo 1
• Erectile dysfunction: 3% vs <1% placebo 1
• These rates increase with higher doses 1

In females:

• Anorgasmia: 2-6% vs <1% placebo 1
• Decreased libido: 3-7% vs 1-2% placebo 1

Dose-Dependent Effects

Higher doses of escitalopram produce more sexual side effects. At 20 mg/day, adverse event rates (86%) are substantially higher than at 10 mg/day (66%) or placebo (61%) 1. This dose-response relationship is consistent across all SSRIs 2.

Mechanism and Class Effect

All selective serotonin reuptake inhibitors (SSRIs) cause sexual dysfunction through increased serotonergic activity 3, 4. A systematic review demonstrated that antidepressants as a class significantly increase odds of:

• Decreased libido: OR 1.89 (95% CI: 1.40-2.56) 3
• Erectile dysfunction: OR 2.28 (95% CI: 1.31-3.97) 3
• Ejaculatory dysfunction: OR 7.31 (95% CI: 4.38-12.20) 3

Critical Clinical Considerations

Proactively discuss sexual side effects before initiating treatment 1. The FDA label explicitly states that physicians should routinely inquire about sexual dysfunction, as actual incidence exceeds reported rates 1.

Depression itself causes sexual dysfunction, making attribution complex 5. However, one naturalistic study found that sexual function actually improved as depressive symptoms resolved during escitalopram treatment over 12 weeks 5. This suggests that in some patients, treating the underlying depression may outweigh medication-induced sexual effects.

Persistent sexual dysfunction after discontinuation is possible but rare 6. Case reports document permanent sexual dysfunction following SSRI discontinuation, though the mechanism remains unclear 6.

Management Algorithm

When sexual dysfunction occurs on escitalopram:

1. First, verify the dysfunction is medication-related rather than depression-related by assessing temporal relationship to drug initiation 4

2. Consider dose reduction if clinically appropriate, as sexual side effects are dose-dependent 1

3. Switch to antidepressants with lower sexual side effect profiles: mirtazapine, nefazodone, vortioxetine, or bupropion 4, 7. Bupropion causes significantly less sexual dysfunction than SSRIs 7

4. Add adjunctive treatment: Bupropion augmentation shows promise for managing SSRI-induced sexual dysfunction 4

5. For erectile dysfunction specifically: Sildenafil can temporarily restore erectile function while other symptoms may persist 6

Common Pitfall

Do not dismiss patient reports of sexual dysfunction as "just depression." While depression causes sexual problems, SSRIs independently and significantly worsen sexual function through pharmacologic mechanisms 1, 3. The FDA requires explicit warnings about this adverse effect 1.