Treatment of Sexual Dysfunction

Introduction to Treatment

• The American College of Psychiatry recommends an initial dose of 5 mg per day of aripiprazol to treat sexual dysfunction induced by sertralina, which can be adjusted according to clinical response 1

Treatment Outcomes

• Continuous therapy for sexual dysfunction is likely to be necessary, as problems often return after discontinuation, according to the American Urological Association 2
• The American College of Physicians recommends PDE-5 inhibitors as the first-line treatment for erectile dysfunction, with medication optimization to reduce sedative burden and address underlying factors contributing to sexual dysfunction 3, 4
• High-quality evidence shows PDE-5 inhibitors improve successful sexual intercourse in approximately 69% of patients, with tadalafil 5mg daily preferred for continuous coverage and fewer timing restrictions 3, 4

Medication Considerations

• The following medications have notable sexual side effects and drug interactions:

2, 5, 6

• The American Academy of Family Physicians recommends adding Bupropion (Wellbutrin) as a first-line therapy for patients experiencing sexual dysfunction due to sertraline, starting with a dose of 37.5 mg every morning and titrating up to a target dose of 150 mg twice daily 7
• Buspirone is recommended as a first-line treatment for patients concerned about sexual side effects, due to its low impact on libido, and bupropion has significantly lower rates of sexual adverse events compared to SSRIs, as supported by the American Urological Association and the American College of Physicians 2, 5

Assessment and Monitoring

• Assessing baseline sexual function before starting antidepressants is crucial to better evaluate medication effects 7
• Regularly inquiring about sexual side effects is necessary, as patients may not spontaneously report them 7
• Baseline sexual function should be assessed before starting medications known to cause sexual side effects, as sexual dysfunction is often underreported unless specifically asked about 8
• Sexual function should be evaluated before starting treatment and at each follow-up visit, using direct questioning about specific sexual symptoms (desire, arousal, orgasm), and if sexual side effects emerge, consideration should be given to dose reduction or medication switch before adding additional agents, as recommended by the National Comprehensive Cancer Network and the American College of Obstetricians and Gynecologists 9, 5

Special Considerations

• Men tend to have a higher frequency of sexual dysfunction compared to women when taking antidepressants, although women report higher severity 8
• Antihypertensive classes such as beta blockers (e.g., atenolol, metoprolol, propranolol) and thiazide diuretics can cause sexual dysfunction 8
• Centrally acting drugs like methyldopa and reserpine can also affect sexual function 8
• The American College of Cardiology suggests that ARBs may have fewer sexual side effects than other antihypertensives 10
• For women with low sexual desire, flibanserin or bremelanotide may be considered as adjunctive treatments if primary anxiety treatment is insufficient, as recommended by the National Comprehensive Cancer Network 9

Treatment Adjustments

• Effectiveness of medication changes should be reviewed in 4 weeks, and hormonal status reassessed after 6 weeks, with improvement in sexual function evaluated using validated questionnaires such as the International Index of Erectile Function 3, 4
• Patients should be monitored for withdrawal symptoms from sedative tapering, mood changes when switching antidepressants, and assessed for drug interactions between PDE-5 inhibitors and other medications 4, 11
• Adding buspirone (20-60 mg/day) as augmentation therapy may improve sexual function in patients already on SSRIs with sexual dysfunction, with approximately 58% of patients showing improvement, as recommended by the National Comprehensive Cancer Network 9
• Switching to an antidepressant with a lower sexual side effect profile, such as Mirtazapine (Remeron) or Nefazodone, is an alternative treatment strategy, as suggested by the American Academy of Family Physicians and the American College of Cardiology 7, 12
• Gradual dose reduction of sertraline may maintain antidepressant efficacy while reducing sexual side effects, and must be done under medical supervision 7
• The American Academy of Family Physicians recommends against abrupt discontinuation of sertraline, and instead suggests tapering over 10-14 days if switching medications 7
• Combination therapy with mirtazapine and bupropion may double the likelihood of remission compared to monotherapy, although the specific evidence strength is not provided 7