SSRIs and delayed orgasm

Last reviewed 03/2023

• selective serotonin reuptake inhibitors (SSRIs) are a common cause of drug-induced hyperprolactinaemia
  • SSRIs are associated with an approximate eight-fold increased risk of development of galactorrhoea compared with other antidepressants
    
    
• also delayed orgasm or ejaculation is a possible adverse effect in men treated with SSRIs

• monoamine oxidase inhibitors and tricyclic antidepressants have also been rarely reported to cause galactorrhoea or hyperprolactinaemia

Sexual dysfunction and SSRIs

• sexual dysfunction occurs through several brain pathways involving increases in serotonin (5-HT), decreases in dopamine (DA) and inhibition of nitric oxide synthase
  • increases in cortico-limbic 5-HT result in decreased sexual desire, ejaculation and orgasm selective serotonin reuptake inhibitor (SSRI)-induced sexual dysfunction occurs in 30%-80% of patients and is a main cause of treatment discontinuation
    
    
• management
  • check PRL - SSRIs can cause drug-induced hyperprolactinaemia
    
    
  • seek expert advice
    
    
  • pharmacologic methods to reduce sexual dysfunction involve dose reduction, augmentation, or switching medication
    • since dose reduction is the least disruptive strategy it should be considered first, particularly in a responder (1)
      
      
    • altering 5-HT receptor antagonism and agonism can have favourable sexual effects, but may cause other adverse event
      • mirtazapine antagonizes 5-HT2 and 5-HT3 receptors and it has been successfully used as an add-on therapy for antidepressant-induced sexual dysfunction
        • however associated with a relatively high rate of weight gain
      • other possible augmentation therapies that have been used include cyproheptidine and buspirone
        
        
    • phospho-diesterase inhibitors e.g. sildenafil have demonstrated evidence for the reversal of SSRI-induced sexual side effects in men
      
      
    • DA release enhances sexual function
      • evidence supports adjunctive bupropion XL for reversing SSRI-induced sexual dysfunction in men and women across the domains of desire, arousal and orgasm
        
        
    • several antidepressants, including bupropion, moclobemide, and mirtazapine have little to no effect on sexual function compared with placebo when used as a monotherapy
      
      
    • evidence suggests exercise can improve sexual function in SSRI-induced sexual dysfunction

Reference:

• Rizvi SJ1, Kennedy SH.Management strategies for SSRI-induced sexual dysfunction. J Psychiatry Neurosci. 2013 Sep;38(5):E27-8.