SSRI-induced anorgasmia

[SpiritiualDuck]

I have a patient that had been stable on Sertraline for years, doing well, but now in a new relationship and is struggling with anorgasmia and it's made worse with the addition of a condom.

Treating a primary anxiety disorder, so switching to Welbutrin wouldn't work. I tried mirtazapine with him and he just had multiple complaints, beyond sedation/appetite stuff.

I've thought about a switch to lyrica/neurontin or trying viibryd.

Viagra has helped with his erections, but not the issue of anorgasmia and given the mechanism, I wouldn't anticipate a benefit. Maybe nefazodone.

Maybe adding on welbutrin or buspar.

Has anyone found something that truly works other than switching agents? I suspect lowering dose might help too.

---

Members don't see this ad.

 

[BobA]

I've been trying to get good at handling this SE, with minimal success.

I usually end up prescribing Viagra, and trying some cognitive re-framing around the issue that it's all-important to have an orgasm during sex. Usually, I say something (appropriately!), about how their partner may like it better if they last longer. This only works occasionally.

Next, if the patient is stable on the medication I will recommend taking a drug holiday when they know they will be having sex. For instance, if he knows that he will be going out on a Saturday night, I recommend skipping the Friday and Saturday doses. This usually is quite successful, but isn't the best long term strategy for a number of reasons. They may wish to have sex more frequently than once a week, for instance.

The only real "cure" for this SE I feel I can usually offer is to refer the patient to CBT, and then try to taper off the medication. After all, they know they can go back on it if they need to. The success of this, of course, depends on the availability of CBT, the patient's work schedule/insurance status, and willingness to give it a try.

There's a recent Carlat Report on this particular topic if you are a subscriber.

There's research supporting the use of busiprone and bupropion, but I've never found it clinically useful, and my attendings shy away from using these as well.

Lyrica can also cause loss of libido and erectile dysfunction.

 

[WhoisJohnGalt]

I have a patient that had been stable on Sertraline for years, doing well, but now in a new relationship and is struggling with anorgasmia and it's made worse with the addition of a condom.

Treating a primary anxiety disorder, so switching to Welbutrin wouldn't work. I tried mirtazapine with him and he just had multiple complaints, beyond sedation/appetite stuff.

I've thought about a switch to lyrica/neurontin or trying viibryd.

Viagra has helped with his erections, but not the issue of anorgasmia and given the mechanism, I wouldn't anticipate a benefit. Maybe nefazodone.

Maybe adding on welbutrin or buspar.

Has anyone found something that truly works other than switching agents? I suspect lowering dose might help too.

Though I haven't had the opportunity to follow up a patient that's been started on it yet, there's lots of buzz about the new Viibryd having essentially no sexual side effects. Sounds like a good patient to try it out on.

 

[billypilgrim37]

Treating a primary anxiety disorder, so switching to Welbutrin wouldn't work.

I need to finally hunt down the review someone shared with me recently dispelling that. I avoid wellbutrin in panic disorder, but otherwise find it a really well tolerated med much more effective for GAD and social phobia than we've been taught.

Trazodone blocks 5HT1A as well. You obviously don't want to pop a trazodone right before "going to bed" unless you're going to sleep, it might be a reasonable adjunct, and I'm not sure the benefit would be entirely lost even with HS dosing.

 

[Chrismander]

Though I haven't had the opportunity to follow up a patient that's been started on it yet, there's lots of buzz about the new Viibryd having essentially no sexual side effects. Sounds like a good patient to try it out on.

I swear I looked at the data on the back of one of the ads and saw that sexual side effects were still at least 2-fold greater than placebo. Don't have the numbers in front of me though. Anyone try it on a patient yet? Any news?

 

[BobA]

I swear I looked at the data on the back of one of the ads and saw that sexual side effects were still at least 2-fold greater than placebo. Don't have the numbers in front of me though. Anyone try it on a patient yet? Any news?

Just looking at the prescribing info in males ~10% of the Viibryd group had sexual dysfunction compared to >1% in placebo. And that's in pre-marketing studies. Moreover, the rate of sexual dysfunction in the general population is much higher than 1%, so this must have been a particularly virile study group. In real practice, I would expect the overrall rate of sexual dysfunction to be higher than that seen in the pre-marketing studies.

http://www.frx.com/pi/viibryd_pi.pdf

 

[firedoor]

I agree w billypilgrim not to so readily discount Wellbutrin so long as you're not using it as monotherapy in panic disorder. But even in panic disorder Wellbutrin may be tolerable in combination with an SSRI (my speculation). In fact if the SSRI is working well you might consider keeping it on board and simply adding Wellbutrin...you may be able to get by with a low-dose like 150 mg XR (I've also heard of prescribing 75 mg of immediate-release wellbutrin an hour or so before intercourse, though I've never seen it done). Also as you (the OP) mentioned, lowering the SSRI alone or in combination with the aforementioned strategies may help as well.

From Psychopharmacology Bulletin

A Pilot Controlled Trial of Bupropion XL vs. Escitalopram in Generalized Anxiety Disorder (GAD)

Alexander Bystritsky, M.D.; Lauren Kerwin, B.A.; Jamie D. Feusner, M.D.; Tanya Vapnik, Ph.D.
Authors and Disclosures
Posted: 03/11/2008; Psychopharmacol Bull. 2008;41(1):1-9. © 2008 MedWorks Media Global

Abstract

Objective: To compare the efficacy and safety of bupropion XL (150-300mg/day) with the selective serotonin reuptake inhibitor escitalopram (10-20mg/day) in outpatients diagnosed with generalized anxiety disorder (GAD).
Methods: Twenty-four participants with GAD between the ages 18 and 64 years enrolled in a 12-week, double-blind, randomized, trial. The primary efficacy measures were the Clinical Global Impression of Improvement (CGI-I) and the Hamilton Anxiety Rating Scale (HARS).
Results: Bupropion XL demonstrated comparable anxiolytic efficacy to escitalopram in outpatients with GAD. Both treatments were well-tolerated.
Conclusion: Findings from this pilot project suggest bupropion XL may be useful in treating GAD. These preliminary results warrant further research to explore the use of bupropion XL in the treatment of GAD.


My guess is that the subjects did not have a comorbid mood disorder, as comorbid anxiety & depression may be an entirely different animal than pure GAD.

 

[billypilgrim37]

...so this must have been a particularly virile study group...

For some reason this struck me really really funny and I about spat coffee all over the computer screen.

 

[whopper]

The above study, while intriguing is only 24 people. It's not enough IMHO do to much other than more studies.

If the patient is a male, I'd encourage zinc supplements, and possibly DHEA supplementation. I've had several patients on SSRIs and the above supplements got rid of their sexual side effects.

If the above does not work, consider trying a different SSRI or Effexor or Cymbalta. Another option is to lower the Sertraline, and augment it with Buspirone.

 

[Manicsleep]

The above study, while intriguing is only 24 people. It's not enough IMHO do to much other than more studies.

If the patient is a male, I'd encourage zinc supplements, and possibly DHEA supplementation. I've had several patients on SSRIs and the above supplements got rid of their sexual side effects.

If the above does not work, consider trying a different SSRI or Effexor or Cymbalta. Another option is to lower the Sertraline, and augment it with Buspirone.

I have seen zinc or simply MVI work many times.
Trying cyproheptadine prn at night can work although this would dampen the effect of the SSRI. Yohimbine has been shown to be effective as well.

Viagra, cialis etc cannot be used for anorgasmia and can worsen it. They are for erectile dysfunction.

 

[siked]

Woodrum and Brown did a nice review in "The Annals of Pharmacotherapy," 1998. I and other residents have had good luck with Cyproheptadine.

 

[BobA]

Two more thoughts:
1) Sertraline may be among the worst offenders for SSRIs
2) http://www.medscape.com/viewarticle/430614_5

 

[whopper]

Another option, and I'll just have to be graphic and blunt (but we are doctors, are we not?)...

Several people on SSRIs can still experience orgasm, it just takes a heck of a lot longer. How much? Some of my patients told me they could literally have sex for hours, but eventually they can have it. Strangely, some of them are able to still achieve orgasm without delay while masterbating. The problem for some appears to only happen with sex.

If I have a patient that fits into the above category I recommend they masterbate to the point of near orgasm before the person engages in sex. You'll have to be sure your patient is comfortable about talking about these things before you present this.

 

[Atilla]

Some of the other issues relating to anorgasmia is pt's describing lack of pleasure while having sex, one pt. put it as watching Black and White TV after watching HDTV.
Relationship issues as the partner feels that the pt. does not find them attractive enough to have an orgasm.

Things I have tried and which have worked occasionally-

Adding 100 mg of wellbutrin SR
Skipping the Antidepressant on the day
Lowering the dose
Adding Viagra- more for erectile issues

 

[milesed]

I've had many female patients with this and SSRI's are the only med that will help the mood/anxiety sxs. I end up cycling through them all and can often find one that seems not to cause this SE. I haven't given Viibryd to anyone yet but the studies look better than others for this.

 

[firedoor]

I've had many female patients with this and SSRI's are the only med that will help the mood/anxiety sxs. I end up cycling through them all and can often find one that seems not to cause this SE.

Very helpful to know. I wonder if some of these same patients might respond well to trazodone or remeron as both are also serotonergic AD's essentially devoid of sexual side effects.

 

[9point75]

How about amantadine or a little bit of Ritalin?

 

[firedoor]

I have seen zinc or simply MVI work many times.

Interesting. I wonder if this isn't dopaminergically mediated, as zinc binds the dopamine transporter.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1170760/pdf/004266.pdf

http://cbr.meduniwien.ac.at/fileadmin/db_files/pub_art_176.pdf

 

[firedoor]

How about amantadine or a little bit of Ritalin?

Good thought

 

[whopper]

Zinc, if you remember from biochem, is needed to prevent testosterone from conversion to estrogen. Lower levels of zinc is correlated with less testosterone.

http://www.ncbi.nlm.nih.gov/pubmed/8875519

While the above is only one study, put in "zinc testosterone" into a google scholar search and you will see plenty of other studies that found similar results.

A bit of self-disclosure, I actually tried zinc on myself to see what would happen given that it's a natural supplement and I wouldn't fall into the self-prescribing pitfall. Let's just say that....ahem....my sex drive was through to roof to the point where it was actually uncomfortable.

I have, however, had marginal success with it to treat SSRI induced sexual side effects. It's not going to work with everyone, but given the alternatives such as more prescription meds, male hormone supplementation (which I find risky in women--most women don't respond well to hirsutism, especially when it might not go away when they stop it), I don't mind telling patients to give zinc a try.

 

[kugel]

A) lower the sertraline dose
2) add bupropion
D) talk to the partner - maybe that should be A)

 

[billypilgrim37]

Zinc, if you remember from biochem, is needed to prevent testosterone from conversion to estrogen. Lower levels of zinc is correlated with less testosterone.

http://www.ncbi.nlm.nih.gov/pubmed/8875519

While the above is only one study, put in "zinc testosterone" into a google scholar search and you will see plenty of other studies that found similar results.

A bit of self-disclosure, I actually tried zinc on myself to see what would happen given that it's a natural supplement and I wouldn't fall into the self-prescribing pitfall. Let's just say that....ahem....my sex drive was through to roof to the point where it was actually uncomfortable.

I have, however, had marginal success with it to treat SSRI induced sexual side effects. It's not going to work with everyone, but given the alternatives such as more prescription meds, male hormone supplementation (which I find risky in women--most women don't respond well to hirsutism, especially when it might not go away when they stop it), I don't mind telling patients to give zinc a try.

Zinc was supposedly Peter North's "secret weapon."

If you don't know who he is, I suggest you make no effort to find out.

 

[ResCon]

Ginkgo biloba is one agent that may be worthwhile to explore, although like all agents for this indication, relies on case studies (see Cohen, 1998)

Maca root has also shown some potential, though again the number of subjects is small (see Dording CM et al, 2008).

Your best bet in my opinion though is to add a dopaminergic (amantadine or ritalin) in the smallest effective dose.

 

[8862846]

What zinc dosage is used to treat sexual dysfunction induced by SSRs?

 

[whopper]

There is some debate as to a maximum allowable dosage.

I did find this source...

U.S. National Research Council set a Tolerable Upper Intake of 40 mg/day

From..
Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001). Institute of Medicine, Food and Nutrition Board. http://books.nap.edu/openbook.php?record_id=10026&page=442. Retrieved 2010-03-30.

http://books.nap.edu/openbook.php?record_id=10026&page=442