Jefferson Journal of Psychiatry
Volume 12 Issue 1 Article 11
January 1994
Sexual Side Effects of Psychiatric Medications in Women: A Clinical Review
Laura L. Post, MD, FAACS University of California at San Francisco
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Recommended Citation Post, MD, FAACS, Laura L. (1994) "Sexual Side Effects of Psychiatric Medications in Women: A Clinical Review," Jefferson Journal of Psychiatry: Vol. 12 : Iss. 1 , Article 11. DOI: https://doi.org/10.29046/JJP.012.1.008 Available at: https://jdc.jefferson.edu/jeffjpsychiatry/vol12/iss1/11
This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Jefferson Journal of Psychiatry by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: [email protected]. Sexual Side Effects ofPsychiatric Medications in Women: A Clinical Review
Laura L. Post, MD , FAACS
Abstract
Sexual side dficts ofpsychiatric medications have been estimated to occur in 60% ofmale clients (1) and 30%offemale clients (2). Despite a bodyofliterature relating individual medications to specific sexual side dficts, fe to studies have satisfactorily addressed the psychotropic-induced sexual dysfunctions in women. The spectrum ofknoton sexual sidedficts resultingfrompsychophar macologic interventions will be reviewed. GuidelinesJOr appropriately addressing the possibility qf sexual side effects within a therapeutic relationship.for maximizing reporting ofsexual side dficts, andforpossible treatment approaches to sexual sidedficts will be described.
INTRODUCTION
The pa st twenty years have shown a dramat ic surge in the a pproaches to and tools of bio logical psychi atry. Concomitant with th ese advances has eme rge d aware ness of psychotropic-induced se xual side effects. These side effects may con tribute to physiological morbidity, to e mba rrassme nt and sh ame, to non complian ce, to stress induced sym ptom exace rba tion, and, argu ably, to mistrust of psychi at ric pr actit io ners.Representa tives ofseveral classes of psychiatric medi cations- including bcn zo diaz epines, beta-blockers, lit hium, monoamine oxidase inhibitors, neu rol ep tics, and tri- and tetra-cyclic a ntide pressa nts- ha ve been reported to ca use so me form of se xua l impairment. Kn own sexua l side effects associated with psych otropi cs include anorgasmia (3) , un satisfyin g or painful or gasm (4), alte re d libid o or sex ua l willing ness, erectile failure, priapi sm (5), menstrual irregul arities, delayed or ret rograd e ejacula tion (6) , a nd alte red sexual se nsation and se nsitivity (7,8).Yet , th e se xual side effects of psych o-pharmaceuticals are still a mo ng th e most subtle, least discu ssed , and poorly understood conseq ue nce s of modern medi cal treatments. The psychiatric lit erature contains numerous case reports but few well-designed research studies addressing sexual side effec ts (9). This knowl ed ge ga p may reflect widespread erotophobic attitudes, skewed funding a nd educational prio rit ies around th e importan ce of human se xuality, or inad equa te training of pr escribers in eliciting sexua l side effec ts from clients.
Laura L. Post , M.D. , recently complete d her res ide ncy in Psychi at ry at th e Langley Porter Psych iatric Institute of th e University ofCalifornia in Sa n Francisco.
75 76 JEffERSON JO URNAL OF PSYCHIATRY
In add ition, very few of th e existing studies include fe male subjects (10,11,1 2); those that do oft en fail to separat e outcomes by ge nde r, rendering problematic th e drawing of conclus ions relevant to wom en clients. The lack ofa tt en tion to incid en ces a nd expe riences of psych otropi c-gen erat ed sexual side effec ts in wom en may occur for several reason s. First , th e ease of measurement of ma le se xual arousal (e rec tio n) an d orgasm (ejacula tion) , a nd th e rela tive simplicity of male e ndocrine fun ction s, may have contributed to a research bias towa rd male subjects, Second, th e sexual emo tions, respon ses, a nd beh aviors of wome n a re fre que ntly constrained by cult ur ally based and se xist crite ria; th e sa me cult ura l se xism may reduce t he mo tivation for th e compre he ns ive examina tion of th e pot ential ac tio ns of psychiatric medication s on female sex ua lity. (T his hypothesis is somewha t supporte d by the dearth of publish ed information on ge neral female sexua l function). Third, th e na rrow definiti on s of fe male sexual dysfunction may result in incon sist ent re po rt ing or inap propriat e dat a analysis. For example, qu eryin g lesbia n clients abo ut int ercourse may be irrelevant; not qu erying wom en specificall y about fantasy, a bout lubrication, abo ut ejacula tion, or abo ut th e size, shape, sensitivity, and se nsation of br east s, vagina, and clitoris may lead to om ission of vit al informa tion. Finally, th e subjectivity inh erent in t he determi na tion and describing of sex ua l impai r ment may lead to variations between studies, introducing difficulty in com pil ing dat a: there is a difference bet wee n libido and orgasm. Nevertheless, th e available reports do suggest so me ge neral patterns of sexual sid e effec ts, in wom en , from psych ot ropics.
SUMMARY OF PSYCH OTROPI C-IND UCED SEXUAL DYSFUNCTIO NS IN WO~IE N
In female patients, several psychopharmacologic agents have been implicat ed as causative of sexual side effects. Alprazolam (13), amoxapine (14) , clomipramine (15,16, 17), diazepa m ( 18), fluphenazine ( 19), flurazepam (20) , imipramine (21,22), MAGIs (2 1,23,24,25,26), thiorid azin e (27) , a nd t rifluoroperazine (27) hav e all been spec ifica lly rep ort ed to inhibit orgasm . Fenflura mine has been reported to enha nce orgasm (28). Howeve r, th e story is not so st raightforward. Desipra mine has been rep orted to ca use anorgasmia (29) and not to cause anorgasmia (22) . Fluox etine has been reported to in hib it orgasm (30,3 1,26) and to e nha nce orgasm (32) . Simila rly, trazod one has been re ported to increase (33) and decrease (34) libido.
PERSPECTI VES ON PHARMACOSEXO LOGY
T he rela tionship between psychiatric medi cations and resultant se xua l dysfunc tion is complex. Animal models suggest that sexual fun ction is dep endent upon ce ntrally-acting dopa mi ne agonists and is inhibited by th e se ro tone rgic syste m (35). In hu man males, decr eases in libido have been attributed to anti-dopam inergic and se ro to nergic effec ts (36), as well as to limbic fluctua tion s and to decreased levels of endogeno us opioids and test ost erone (37). Hu ma n male erec tion, medi at ed SEX UAL SIDE EFFE CTS OF PSYCHIATRIC MEDI CATIONS IN WOM EN 77 principally by autonomic neurons, may be diminish ed: a) by interferen ce with central dopaminergic output (38) ; b) by interferen ce with bet a-adren ergic ac tivity or by enha nceme nt of a lphaj-ad rc ne rg ic transmission (39); c) by int erferen ce with th e choline rg ic spinal reflex es necessary for erection; or d) by interruption of th e neuronal-hematological fillin g of the co rpora. Human male ejacula tion, m ediat ed by alpha I-ad re ne rg ic receptors, may be a n tagonized by alphaI-ad re ne rgic blo ckade. Human mal e orgasm [which is no t neces sarily identical with ej ac ula tion], thought to be ce nt ra l in origin, may be elim ina te d by serotonergic age nts (40). Cl early, th e se ro to ne rg ic agonism, th e dopaminergic a nd cholinergic blo ckade, and alphaI-ad re ne rg ic effec ts res ult ing from some psychiat ric medications might aIte r sexual function in ma le clients (41) . Though anatomic analogies m ay be made between male a nd fe male libido, between male erection and female lubrication/labi al swelling, between m ale ejacula tion and female ejaculation, and between male and female orgasm , th e neu rophysiol ogy of female sexuality-animal or human-is less com plete ly understood th an the male counterpart. Conclusions about effe cts, on women , of a n ti-do pamine rgic , anti-a lpha r-adre nc rgic, anticholinergic, and serotonergic effec ts remain th eoret ical a nd sp eculative.
CLINICAL DISCUSSION AND GUIDELINES
Psychotropic-induced sexual sid e effec ts may be ameli orat ed with bioch em icall y informed interventions. Nevertheless, ad equate identification and treat ment of psychotropi c-induced se x ual side effec ts require a n informed , di scerning, and sensi tive psychiatric practitioner, since m any patients will not spo ntaneously rep ort such co ncerns. What follow a re some suggestions for a ppro pria te ly add ressing th e possibil ity of sex ua l sid e effec ts within a th erapeutic relation ship, for max imi zing report ing ofsexua l sid e effec ts, and for a ppro ac hing treatment of sexual side effec ts. When a patient expe riences a se xual dysfuncti on relat ed to a psychiatric m edication, the initial priority is to det ermine wh ether th e dysfunct ion is me d ication induced. This may be done, with some ce rtain ty, by retracing sym pto m developm ent in relation to m edication dosing, in the abse nce of ot he r prescribed or ove r- the cou n te r medications and in th e absence of co ncom itan t emotional stress. If an etiologica l con nection between psychiatric m edication a nd se xual side effec t appears likely, then the next st ep is to as sess the ex te nt of di scomfort expe rience d by the patient, since the patient who is substantially bothered by th e dysfuncti on will participate most cooperatively in treating th e sid e effec t. The sim ples t trea tm en t approach to psychotropic-induced sexual sid e effec ts is to make only a psych ological intervention. In certain inst ances, suc h an ac tion might be indicat ed ; anorgasmia induced by MAGIs has been reported to remit naturall y (42) . An add itiona l psycho logical intervention mi ght be referral to cou ples or individual sex therapy or psychotherapy, wh en relevant. However, sexual side effec ts must be monit ored, and this minimalistic strat egy must be full y ex plaine d to th e client. Another approach might be to reduce the dose of th e putatively offending 78 JEFFERSON JOUR AI. OF PSYCHIATRY
psychiatric medi cation . If dose re duc tion fails to allevia te th e sexual symptom s, or if th e primary psychiatric sym ptoms return, th en th e clinician might consider drug substitution from a different che mica l class. Combination th erap y, with two psych ot ropi c agents be lieved to produce antago nistic sex ual side effects, might minimize the sexual side effect of each while maximizin g th e syne rgistic psych iatric effect. For instance , th e coupling oftrazodone which has been rep orted to increase libido in wome n-and fluoxetine-which has been reported to decrease libido in women-might prove useful. The selec tive utilization of psych opharmacolo gic agents not associated with se xual dysfuncti on may reduce th e incid ence of suc h ia trogenic morbidit y. Specifi ca lly, no publish ed report exis ts, as of this wr it ing, link ing buproprion or bu spi ron e wit h sex ual side effects . In fact, busp iron e has been reported to reverse ge ne ra lized sexual dysfun cti on related to a nxie ty (43). Prescription of a medi cation used in treatment of endogenous sexual dysfun c tion mi ght ass ist in returning th e patient's sex ual funct ion to baseline. Yohimbine (44), naltrexon e, a nd apomorphine ca n each allegedly elicit penile erec tions (45); it is unknown what influence th ey would exert up on wome n. Addition of a second me dica tion, aimed a t addressing th e psych otropic-induced sex ual dysfun ct ion, may have benefit. Seve ral reports have implied that libid o has been enhanced by the choline rgic agent betha nechol (46,47) and by th e dopamine agonist bromocripti ne (48) . Several mixed-gender reports have suggested tha t a no rgasmia induced by MAGIs (49), fluoxet in e (50), a nd m ulticyclic antidepressants (29,26,5 1) might be reduced by th e se ro to nin an tagonist cyproheptadine. How ever, it is important to keep in mind that , j ust as primary psychiatric medications ca n elicit sid e effects, so can adjunct ive medications. Cyproheptadine has been associated wit h anticholinergic crisis in conjunction with treatment of t ricyclic-induced ano rgasmia (29) . A helpful ove rarching strategy is to develop a solid, mutually trusting clini cal re lations hip with each pa ti ent a nd to ro utine ly obtain a com plet e sexua l history before prescribing a ny psych ot ropi c me dica tions. Not only does t he sexual informa tion gathered es tablish a baseline against which to detect future cha nges in th e patient's sexual fun ction, bu t directly bringing th e client's sexual history into th e patient-practitioner interaction also increases the likel ihood th at th e client will fee l welcomed to discuss subjectively perceived changes in sexual fun cti on whic h may arise. Asking about specific practices, about partners and relationships, and ab out th e importance of sexua lity in t he client's overall functioning will be more useful than simply querying broadly about sexua l orientation, partnership st atus, age a t pubert y, or history oforgasm. Practitioners' com for t discussing issues of client sexuality, practition ers' sexual knowledge, and practitioners' sex-positive attitudes are a ll responsibl e for obtaining thorough sexual histories a nd for eliciting, following up on , a nd for ed ucating about psychotropic-ind uce d sexual side effects. Sex-positive at titudes will a lso permit clinic ian-researc he rs to add to psychi a try's un derstan ding of the possible insidi ou s outcomes of prescr ibed medica tions. In the long run, psychiatric clients will ben efit SEX UAL SIDE EFFECTS OF PSYCHIATRI C MEDICATIONS IN WOME T 79 directly from sex-positive attitudes , from op enness to a nd em pathy toward clients' sexual conce rn s, and from application of the mo st co m plete ava ilable dat a about sexual side effec ts.
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