Which pharmacologic sleep aids are appropriate for a man and have no impact on libido or risk of erectile dysfunction?

Sleep Medications Without Libido or Erectile Dysfunction Effects

For men concerned about sexual function, first-line sleep medications—including ramelteon, low-dose doxepin, and orexin receptor antagonists (suvorexant, lemborexant, daridorexant)—do not cause erectile dysfunction or decreased libido and should be prioritized over alternatives.

Recommended Sleep Medications (No Sexual Side Effects)

First-Line Options

• Ramelteon 8 mg is a melatonin receptor agonist with no reported effects on libido or erectile function, carries no abuse potential, and is particularly appropriate for sleep-onset insomnia 1, 2
• Low-dose doxepin 3–6 mg for sleep maintenance has minimal anticholinergic effects at hypnotic doses and does not impair sexual function, unlike higher antidepressant doses 1, 2
• Orexin receptor antagonists (suvorexant 10 mg, lemborexant, daridorexant) work through a distinct mechanism and have no documented sexual side effects, making them excellent alternatives for sleep maintenance 1, 3

Alternative Benzodiazepine Receptor Agonists

• Zolpidem 10 mg (5 mg if elderly) has no direct effects on testosterone or sexual function and is effective for both sleep onset and maintenance 1
• Zaleplon 10 mg (5 mg if elderly) has an ultrashort half-life with no reported sexual dysfunction 1
• Eszopiclone 2–3 mg does not affect libido or erectile function and addresses both sleep onset and maintenance 1

Critical: Medications to AVOID

Agents That Impair Sexual Function

• Benzodiazepines (lorazepam, clonazepam, temazepam) are CNS depressants that can decrease libido and impair erectile function through dopamine blockade and sedation 4, 5
• Trazodone is a sedating antidepressant that commonly causes erectile dysfunction and decreased libido through serotonergic mechanisms, despite frequent off-label use for sleep 1, 5
• SSRIs and other antidepressants at therapeutic doses frequently cause sexual dysfunction (20–80% of patients), though low-dose doxepin (3–6 mg) avoids this effect 5
• Antihistamines (diphenhydramine, doxylamine) have anticholinergic effects that can impair erectile function and should not be used 1, 2

Essential Treatment Framework

Behavioral Therapy First

• Cognitive Behavioral Therapy for Insomnia (CBT-I) must be initiated before or alongside any medication, as it provides superior long-term outcomes without any sexual side effects 1
• CBT-I includes stimulus control, sleep restriction, relaxation techniques, and cognitive restructuring, all of which can be delivered via individual, group, telephone, or web-based formats 1

Implementation Algorithm

1. Start CBT-I immediately for all patients with chronic insomnia, incorporating behavioral interventions that have no impact on sexual function 1

2. Add first-line pharmacotherapy if CBT-I insufficient after 4–8 weeks:

   • Sleep-onset difficulty → ramelteon 8 mg or zaleplon 10 mg 1, 2
   • Sleep-maintenance difficulty → low-dose doxepin 3–6 mg or suvorexant 10 mg 1, 3
   • Combined difficulty → eszopiclone 2–3 mg or zolpidem 10 mg 1

3. Reassess after 1–2 weeks to evaluate sleep parameters, daytime functioning, and any adverse effects 1

4. If first-line agent fails, switch to alternative within same class rather than adding multiple agents 1

Special Considerations

Drug Interactions and Safety

• All recommended agents (ramelteon, doxepin 3–6 mg, orexin antagonists, Z-drugs) have minimal drug interactions and do not affect testosterone levels or sexual hormone pathways 1, 2
• Use lowest effective dose for shortest duration, typically ≤4 weeks for acute insomnia, with periodic reassessment 1
• Monitor for complex sleep behaviors (sleep-driving, sleep-walking) with all benzodiazepine receptor agonists, though these do not affect sexual function 1

Dose Adjustments for Older Men

• Men ≥65 years require reduced doses: zolpidem ≤5 mg, eszopiclone ≤2 mg, zaleplon ≤5 mg, doxepin ≤6 mg 1
• Ramelteon 8 mg and suvorexant 10 mg do not require age-based dose reduction 1, 2

Common Pitfalls to Avoid

• Prescribing trazodone for sleep despite its high rate of sexual dysfunction (erectile dysfunction in up to 20% of men) and lack of guideline support 1, 5
• Using benzodiazepines which impair sexual function through CNS depression and can decrease libido 1, 4
• Failing to implement CBT-I before starting medication, which provides durable benefits without any sexual side effects 1
• Combining multiple sedating agents which increases risk of cognitive impairment and may compound sexual dysfunction 1
• Using over-the-counter antihistamines which have anticholinergic effects that can impair erectile function 1, 2