Lexapro and Decreased Libido
Yes, Lexapro (escitalopram) definitively causes decreased libido as a common adverse effect, occurring through increased serotonergic activity with a clear dose-response relationship. 1, 2
Incidence and Clinical Significance
Decreased libido occurs in 3-7% of patients taking escitalopram based on FDA clinical trial data, though this substantially underestimates the true incidence since patients and physicians are often reluctant to discuss sexual side effects. 2
- In major depressive disorder trials, decreased libido occurred in 3% of escitalopram patients versus 1% on placebo 2
- In generalized anxiety disorder trials, decreased libido occurred in 7% of escitalopram patients versus 2% on placebo 2
- Direct physician inquiry reveals the actual incidence exceeds 50% for sexual dysfunction overall with SSRIs, including decreased libido 3
Dose-Dependent Relationship
Sexual side effects, including decreased libido, increase significantly with higher escitalopram doses. 1, 2
- The 20 mg/day dose produces approximately twice the incidence of sexual dysfunction compared to 10 mg/day 2
- All SSRIs, including escitalopram, demonstrate a consistent dose-response relationship for sexual side effects 1
Complete Sexual Dysfunction Profile
Beyond decreased libido, escitalopram causes a spectrum of sexual dysfunction that impacts quality of life:
- Ejaculatory dysfunction (primarily delayed ejaculation): 9-14% in males versus <1-2% on placebo 2
- Anorgasmia: 2-6% in females versus <1% on placebo 2
- Erectile dysfunction: 3% in males versus <1% on placebo 2
Management Strategies
First-Line Approach: Dose Reduction
If clinically appropriate, reduce the escitalopram dose as the first management step, since sexual side effects are dose-dependent. 1
Second-Line Approach: Switch Antidepressants
Switch to antidepressants with lower sexual side effect profiles when dose reduction is insufficient or depression control is inadequate. 1
The following alternatives have substantially lower rates of sexual dysfunction:
- Bupropion: 81% of patients switching from fluoxetine to bupropion experienced "much" or "very much" increased libido, with 94% achieving complete or partial resolution of orgasm dysfunction 4
- Mirtazapine: Lowest among antidepressants to cause sexual dysfunction in comparative studies 1, 5
- Nefazodone: Recommended alternative with lower sexual side effect profile 1
- Vortioxetine: Recommended alternative with lower sexual side effect profile 1
Third-Line Approach: Adjunctive Treatment
Consider adding bupropion or saffron (Crocus sativus) as adjunctive therapy if switching is not feasible. 6
- Bupropion augmentation shows promise for managing SSRI-induced sexual dysfunction 6
- Saffron supplementation demonstrates potential benefit 6
Critical Clinical Pitfalls
Do not assume sexual dysfunction will resolve spontaneously with continued treatment. In prospective studies, only 5.8% of patients experienced complete resolution of sexual dysfunction within 6 months, while 81.4% showed no improvement at all. 7
Always directly inquire about sexual side effects at each visit, as spontaneous reporting captures only 14% of cases versus 58% when physicians ask direct questions. 7
Recognize that sexual dysfunction significantly impacts treatment adherence and quality of life, making early identification and management essential to prevent treatment discontinuation and relapse. 5