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 Follow this and additional works at: https://jdc.jefferson.edu/jeffjpsychiatry Part of the Psychiatry Commons Let us know how access to this document benefits ouy 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.