Unfortunately, few double-blind placebo-controlled trials exist to guide clinicians in understanding the sexual impact of medications. As a result, much of the information that follows is based on less refined information as, for example, case reports. Caution in interpretation is therefore advisable.
Unless otherwise referenced, information in this section has been taken from Segraves and Balon (22) and Kaufman and Vermeulen (23).
In general, there is often great difficulty in differentiating the sexual consequences of a disorder from side effects of the medication used in treatment. When thinking about a sexual desire problem, attempting this separation requires care in determining that it did not exist before drug treatment began (i.e., making sure that it is, in fact, acquired rather than lifelong). Likewise, one would expect drug-related sexual problems to occur under all circumstances rather than some (i.e., to be generalized rather than situational), and that the desire problem would disappear if the drug is stopped but reappear if resumed. Last, one would want to determine that the diminished sexual desire would not be better explained by the onset of an illness or exposure to an environmental stress.
This group includes those which are "typical" (also called "neuroleptics" and "traditional," for example, phenothiazines, thioxanthenes, and butyrophenones), as well as "atypical" (e.g., risperidone, olanzapine, quetiapine, and clozapine). Men who are taking antipsychotic drugs generally complain of various sexual side effects including loss of sexual desire (although interference with ejaculation seems particularly common). One factor that seems especially noteworthy is that many of the typical antipsychotics, as well as risperidone in the atypical group, result in an elevation in PRL which, in turn, has significant sexual consequences including a lessening of sexual desire (see below).
Alprazolam (Xanax) was reported to sometimes result in diminished sexual desire in both men and women (44). In that SSRIs are often used to treat anxiety, the information on "antidepressants" immediately below is of relevance.
The incidence of sexual dysfunction generally with antidepressants is estimated at 30-50%. All types of antidepressants (TCAs, MAOIs, SSRIs) are linked to decreased sexual desire. Sexual dysfunctions generally are said to be less with bupropion, mirtazapine, moclobemide, and maybe reboxetine.
Lithium may result in diminished sexual desire in a minority of patients.
Finasteride is used in the treatment of benign prostatic hypertrophy (BPH); its mode of action is to block the conversion of T to DHT by inhibiting the enzyme 5-alpha reductase. Diminished sexual desire is commonly reported.
Several drugs are used in the treatment of prostate cancer, a disease which is often androgen-dependent. The treatment strategy is therefore to lower or eliminate the effect of androgens which, in turn, has a predictable markedly negative impact on sexual desire. Flutamide interferes with the binding of T and DHT to the androgen receptor. Flutamide is used both alone and in combination with either leutinizing-hormone releasing hormone (LHRH) or finasteride. Drugs used to treat metastatic prostate cancer include LHRH agonists (synthetic analogues of LHRH including leuprolide, flutamide, nafarelin, and nilutamide), and androgen receptor blockers. LHRH agonists act by blocking the pituitary release of gonadotropins thereby decreasing the production of androgens (Fig. 4.3).
Substances that are known to be associated with lowering of sexual desire include: chlorthalidone, clofibrate, clonidine, gemfibrozil, hydrochlorthiazide, methyldopa, propanolol, reserpine, spironolactone, and timolol.
Cytotoxic drugs often have substantial effects on the gonads. Loss of sexual desire often accompanies their use and may be, at least in part, a result of hormonal changes. The treatment of some cancers in men might involve the use of anti-androgenic drugs resulting in a substantial decrease in T. Bone marrow transplant (BMT) in men may cause a substantially lower level of sexual desire. Androgen replacement therapy is often suggested to men who have received high-dose chemotherapy with BMT.
Carbamazepine, clonazepam, gabapentin, phenobarbital, phenytoin, and primi-done have been linked to sexual dysfunction (including, but not limited to, low sexual desire). The picture is often confounded by the appearance of sexual disorders associated with epilepsy itself as well as with the paucity of published information on this entire subject. Sexual effects seem related to enzyme induction as well as changes in sex hormone levels (via SHBG), and possibly, neurotransmitters.
Recreational drugs include nicotine, marijuana, alcohol, heroin, methadone, and MDMA. Given the connection between cigarette smoking and ED as well as the apparent link between ED and HSDD, nicotine can be considered as an indirect cause of sexual desire disorders in men. Many who use marijuana frequently also report low sexual desire. The sexual effects of chronic use of alcohol are legion and include ED (possibly due to peripheral neuropathy), testicular atrophy, low T, and high SHBH in those with cirrhosis, and hyperestrogenism also associated with alcohol-related liver disease. Any of these difficulties may also result in low sexual desire. Chronic use of heroin and all other opiates results in diminished sexual desire, possibly related to low T levels.
Drugs Used in Gastrointestinal Practice
Cimetidine has been reported to result in diminished libido in men and to have an antiandrogenic effect.
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