What medication(s) are appropriate for a postpartum breastfeeding mother on sertraline who is experiencing low libido?

Management of SSRI-Induced Sexual Dysfunction in a Postpartum Breastfeeding Mother

For a postpartum breastfeeding mother on sertraline experiencing low libido, bupropion is the most appropriate medication to add, as it is present in human milk at very low or undetectable levels in infant serum and is specifically useful for treating co-occurring depression with sexual dysfunction. 1, 2

Primary Recommendation: Bupropion

Add bupropion to the current sertraline regimen rather than switching antidepressants, as this addresses the sexual side effects while maintaining mood stability. 1

Dosing Strategy

• Start with 150 mg daily of bupropion extended-release 2
• Bupropion transfers into breast milk in very low concentrations, with infant serum levels often undetectable 1
• The American College of Obstetricians and Gynecologists recommends maintaining therapeutic dose while breastfeeding if needed 1

Safety Profile During Breastfeeding

• Only 21 documented cases of bupropion use during breastfeeding exist, with generally no adverse events reported 3
• Two case reports of seizures in breastfed infants have been documented, though causality remains uncertain 3
• Monitor the infant carefully for vomiting, diarrhea, jitteriness, sedation, and seizures 1

Critical Considerations Before Prescribing

Drug Interaction Alert

Bupropion is a CYP2D6 inhibitor and will increase sertraline levels when used concomitantly. 2 This interaction means:

• The sertraline dose may need to be reduced if side effects emerge
• Monitor for increased serotonergic effects (agitation, tremor, diaphoresis)
• This interaction is manageable but requires awareness

Infant Monitoring Protocol

All breastfed infants exposed to maternal antidepressants require monitoring for: 1

• Irritability and excessive crying
• Poor feeding or decreased appetite
• Unusual drowsiness or sedation
• Sleep disturbances
• Adequate weight gain and developmental milestones

Alternative Consideration: Continue Sertraline Alone

If adding bupropion is not feasible, continuing sertraline alone remains the safest option for both mother and infant. 1, 3

Why Sertraline Should Be Continued

• Sertraline is the first-line antidepressant for breastfeeding mothers, transferring into breast milk in the lowest concentrations and producing undetectable infant plasma levels 1, 3
• Discontinuing effective antidepressant treatment poses significant risks to the mother-infant dyad 3
• Sexual dysfunction from SSRIs is common but typically less harmful than untreated depression 4

What NOT to Do

Do Not Switch to Another SSRI

• All SSRIs cause similar rates of sexual dysfunction 4
• Switching from sertraline (the safest SSRI for breastfeeding) to another SSRI would increase infant risk without addressing libido concerns 1
• Fluoxetine produces the highest infant plasma concentrations and should be avoided 1

Do Not Use Medications Lacking Safety Data

• Avoid medications without established breastfeeding safety profiles
• The limited data on bupropion (21 cases) is still superior to medications with no data 3

Clinical Decision Algorithm

1. Assess severity of sexual dysfunction: If significantly impacting quality of life and relationship → proceed with treatment
2. Verify sertraline is optimally dosed: Ensure patient is on the lowest effective dose (typically 50-100 mg daily) 1
3. Add bupropion 150 mg daily as first-line intervention 1, 2
4. Educate mother about infant monitoring requirements and potential (rare) adverse effects 1
5. Follow-up within 1-2 weeks to assess infant tolerance and maternal response
6. Consider dose adjustment of either medication based on response and tolerability

Common Pitfalls to Avoid

• Do not discontinue sertraline abruptly to switch medications, as this risks maternal relapse 3
• Do not assume sexual dysfunction will resolve spontaneously while continuing SSRI monotherapy 4
• Do not advise discontinuing breastfeeding to allow medication changes, as breastfeeding benefits outweigh theoretical medication risks 1, 3
• Do not overlook non-pharmacological contributors to postpartum low libido (sleep deprivation, relationship stress, hormonal changes)