SSRI sexual dysfunction: a female perspective

Current Opinions about the Use of Duloxetine: Results from a Survey Aimed at Psychiatrists

Major depressive disorder (MDD) is a complex psychiatric disorder that, presented alone or with other comorbidities, requires different adjustments of antidepressant treatments. Some investigations have demonstrated that psychoactive drugs, such as serotonin and norepinephrine reuptake inhibitors (SNRIs), can exert more effective and faster antidepressant effects than other common medications used, such as serotonin selective reuptake inhibitors (SSRIs), although these differences are still controversial. During the last five years, the SNRI duloxetine has shown favorable results in clinical practice for the treatment of MDD, anxiety, and fibromyalgia. Through an online self-completed survey, in the present article, we collected information from 163 psychiatrists regarding the use of duloxetine and its comparison with other psychiatric drugs, concerning psychiatrists' knowledge and experience, as well as patients' preferences, symptoms, and well-being. We discussed and contrasted physicians' reports and the scientific literature, finding satisfactory concordances, and finally concluded that there is agreement regarding the use of duloxetine, not only due to its tolerability and effectiveness but also due to the wide variety of situations in which it can be used (e.g., somatic symptoms in fibromyalgia, diabetes) as it relieves neuropathic pain as well.

The antidepressant fluoxetine (Prozac®) modulates estrogen signaling in the uterus and alters estrous cycles in mice

Selective serotonin reuptake inhibitors (SSRI) are the most used antidepressants. However, up to 80% of women taking SSRI suffer from sexual dysfunction. We investigated the effects of fluoxetine (Prozac®) (low and high dose, n = 6-7/group) on reproductive function and the regulation of the estrous cycle. All mice treated with high dose of fluoxetine had interruption of estrous cycles within a few days after onset of treatment. When treated for 14 days, mice in the high dose group had fewer CL, often lack of any CL, and antral follicles. Uterine expression of estrogen receptor alpha, G-protein coupled estrogen receptor, and steroidogenesis enzymes were upregulated in the high dose group. Nevertheless, decreased expression of connexin 43 and alkaline phosphatase and increased expression of insulin-like growth factor-binding protein 3 and monoamine oxidase A are consistent with decreased estrogen signaling and the decreased uterine weight. Taken together, fluoxetine modulates estrogen synthesis/signaling and dysregulates estrous cycles.

Males and females differ in reported sexual functioning with escitalopram treatment for major depressive disorder: A CAN-BIND-1 study report

BACKGROUND

Antidepressant use for major depressive disorder (MDD) is frequently associated with sexual dysfunction.

AIMS

Cross-sectional and longitudinal relationships between antidepressant treatment outcomes and sexual functioning (SF) were evaluated separately for males and females receiving escitalopram. We further assessed the association between pre- and posttreatment SF.

METHODS

In all, 208 of the 211 CAN-BIND-1 trial participants (77 males and 131 females) with MDD and detectable drug blood levels were eligible for the analyses. All received escitalopram (10-20 mg) for 8 weeks. At baseline and Week 8, participants completed the Montgomery-Åsberg Depression Rating Scale (MADRS) and the SexFx scale, which measures sexual satisfaction and SF frequency. Mixed-model repeated measures assessed baseline to Week 8 SF changes among participants with different response/remission statuses. Multiple linear regression analyses examined SF differences between treatment outcomes at Week 8 as well as associations between pretreatment and eventual SF.

RESULTS

For both sexes, overall sexual satisfaction improved among responders but not among nonresponders (p < 0.05). For females, overall SF frequency did not change significantly over time regardless of response status. For males, overall SF decreased significantly among nonresponders; orgasm decreased significantly among nonresponders and, to a lesser extent, among responders (p < 0.05). For both sexes, pretreatment SF was significantly associated with SF at Week 8 across all domains (p < 0.05).

CONCLUSION

For both sexes, sexual satisfaction improves with response to escitalopram. For females, the response does not correspond to improvements in SF frequency. For males, SF frequency, particularly that of orgasm, declines regardless of response/nonresponse.ClinicalTrials.gov identifier: NCT01655706.

An experimental test of the ovulatory homolog model of female orgasm

The ovulatory homolog model of female orgasm posits that the neuro-endocrine mechanisms underlying female orgasm evolved from and are homologous to the mechanisms mediating copulation-induced ovulation in some mammals. This model predicts that pharmacological agents that affect human orgasm, such as fluoxetine, should also affect ovulation in animals with copulation-induced ovulation, such as rabbits. We tested this prediction by treating rabbits with daily doses of fluoxetine for 2 wk and found that fluoxetine treatment reduces the number of ovulations postcopulation by 30%. In a second experiment we tested whether this result was mediated by an effect on the brain or via peripheral serotonin functions. We treated animals with fluoxetine and induced ovulation with a single injection of human chorionic gonadotropin. In this experiment ovulation rate was nominally reduced by only 8%, which is statistically not significant. We conclude that the effect of fluoxetine on copulation-induced ovulation rate supports the ovulatory homolog model of female orgasm, suggesting that female orgasm has very deep evolutionary roots among the early eutherian mammals.

Saffron for treatment of fluoxetine-induced sexual dysfunction in women: randomized double-blind placebo-controlled study

OBJECTIVE

Saffron (Crocus sativus L.) has shown beneficial aphrodisiac effects in some animal and human studies. The aim of the present study was to assess the safety and efficacy of saffron on selective serotonin reuptake inhibitor-induced sexual dysfunction in women.

METHODS

This was a randomized double-blind placebo-controlled study. Thirty-eight women with major depression who were stabilized on fluoxetine 40 mg/day for a minimum of 6 weeks and had experienced subjective feeling of sexual dysfunction entered the study. The patients were randomly assigned to saffron (30 mg/daily) or placebo for 4 weeks. Measurement was performed at baseline, week 2, and week 4 using the Female Sexual Function Index (FSFI). Side effects were systematically recorded.

RESULTS

Thirty-four women had at least one post-baseline measurement and completed the study. Two-factor repeated measure analysis of variance showed significant effect of time × treatment interaction [Greenhouse-Geisser's corrected: F(1.580, 50.567) = 5.366, p = 0.012] and treatment for FSFI total score [F(1, 32) = 4.243, p = 0.048]. At the end of the fourth week, patients in the saffron group had experienced significantly more improvement in total FSFI (p < 0.001), arousal (p = 0.028), lubrication (p = 0.035), and pain (p = 0.016) domains of FSFI but not in desire (p = 0.196), satisfaction (p = 0.206), and orgasm (p = 0.354) domains. Frequency of side effects was similar between the two groups.

CONCLUSIONS

It seems saffron may safely and effectively improve some of the fluoxetine-induced sexual problems including arousal, lubrication, and pain.

Effect of saffron on fluoxetine-induced sexual impairment in men: randomized double-blind placebo-controlled trial

RATIONALE

Saffron (Crocus sativus L.) has shown aphrodisiac effects in some animal and human studies.

OBJECTIVES

To assess the efficacy and tolerability of saffron in fluoxetine-related sexual dysfunction.

METHODS

This was a 4-week randomized double-blind placebo-controlled study. Thirty-six married male patients with major depressive disorder whose depressive symptoms had been stabilized on fluoxetine and had subjective complaints of sexual impairment entered the study. The patients were randomly assigned to saffron (15 mg twice per day) or placebo for 4 weeks. International Index of Erectile Function scale was used to assess sexual function at baseline and weeks 2 and 4.

RESULTS

Thirty patients finished the study. Baseline characteristics as well as baseline and final depressive symptoms scores were similar between the two groups. Effect of time × treatment interaction on the total score was significant [Greenhouse-Geisser-corrected, F (1.444, 40.434) = 6.154, P = 0.009]. By week 4, saffron resulted in significantly greater improvement in erectile function (P < 0.001) and intercourse satisfaction domains (P = 0.001), and total scores (P < 0.001) than the placebo group. Effect of saffron did not differ significantly from that of placebo in orgasmic function (P = 0.095), overall satisfaction (P = 0.334), and sexual desire (P = 0.517) domains scores. Nine patients (60%) in the saffron group and one patient (7%) in the placebo group achieved normal erectile function (score > 25 on erectile function domain) at the end of the study (P value of Fisher's exact test = 0.005). Frequency of side effects were similar between the two groups.

CONCLUSIONS

Saffron is a tolerable and efficacious treatment for fluoxetine-related erectile dysfunction.

Social relationships and activities among married psychiatric inpatients with sexual difficulties

This study examined the social relationships and activities of married adults with sexual difficulties receiving inpatient psychiatric care in Ontario, Canada. The authors conducted secondary analysis of population-level data on 11,982 married inpatients who were assessed with the Resident Assessment Instrument Mental Health. The authors used descriptive statistics, chi-square analyses, and multivariate logistic regression techniques. Results indicated that 10.7% experienced sexual difficulties, which were related to higher likelihood of dysfunctional social relationships and to lower likelihood of social contact, especially among married women. These findings suggest that assessment of sexual function should be seen as part of comprehensive psychiatric care to support recovery.

Sexual assault in the military and its impact on sexual satisfaction in women veterans: a proposed model

AIMS

Sexual assault in the military (SAIM) is associated with decreased sexual satisfaction. However, mediators of this association have not been fully described.

METHODS

Using a retrospective analysis of cross-sectional data collected for the national Veterans Affairs (VA) Women's Health Survey, we propose a mediator model to explain the association between SAIM and decreased sexual satisfaction among women veterans. Four mediators of the association between SAIM and decreased sexual satisfaction are tested: (1) emotional health-related quality of life, (2) physical health-related quality of life, (3) lack of a close partner, and (4) gynecological illness. These mediators were chosen to encompass independent domains potentially relevant to sexual satisfaction, including emotional, physical, and relational.

RESULTS

Of 3161 women (87%) who answered the sexual satisfaction question, the mean age was 45 (SD 15) years; 85% were white. Twenty-four percent reported a history of SAIM, and 39% reported sexual dissatisfaction. In age-adjusted logistic regression analyses, both SAIM and sexual dissatisfaction were strongly associated with each of the proposed mediators. However, of the four mediators, emotional health-related quality of life most strongly attenuated the association between SAIM and sexual dissatisfaction. After including all mediators, the association between SAIM and decreased sexual satisfaction was markedly attenuated.

CONCLUSIONS

SAIM's negative impact on sexual satisfaction in women veterans operates both directly and through its physical and mental health sequelae. Of the proposed mediators in this association, the most prominent is mental health-related quality of life; the other proposed mediators were minimally related.

A population-based survey of sexual activity, sexual problems and associated help-seeking behavior patterns in mature adults in the United States of America

To study sexual activity, the prevalence of sexual dysfunction and related help-seeking behaviors among mature adults in the United States of America, a telephone survey was conducted in 2001-2002. A total of 1491 individuals (742 men/749 women) aged 40-80 years completed the survey. Overall, 79.4% of men and 69.3% of women had engaged in sexual intercourse during the 12 months preceding the interview. Early ejaculation (26.2%) and erectile difficulties (22.5%) were the most common male sexual problems. A lack of sexual interest (33.2%) and lubrication difficulties (21.5%) were the most common female sexual problems. Less than 25% of men and women with a sexual problem had sought help for their sexual problem(s) from a health professional. Many men and women in the United States report continued sexual interest and activity into middle age and beyond. Although a number of sexual problems are highly prevalent, few people seek medical help.

Correlates of sexual satisfaction among sexually active postmenopausal women in the Women's Health Initiative-Observational Study

BACKGROUND

Satisfaction with sexual activity is important for health-related quality of life, but little is known about the sexual health of postmenopausal women.

OBJECTIVE

Describe factors associated with sexual satisfaction among sexually active postmenopausal women.

DESIGN

Cross-sectional analysis.

PARTICIPANTS

All members of the Women's Health Initiative-Observational Study (WHI-OS), ages 50-79, excluding women who did not respond to the sexual satisfaction question or reported no partnered sexual activity in the past year (N = 46,525).

MEASUREMENTS

PRIMARY OUTCOME

dichotomous response to the question, "How satisfied are you with your sexual activity (satisfied versus unsatisfied)?" Covariates included sociodemographic factors, measures of physical and mental health, and gynecological variables, medications, and health behaviors related to female sexual health.

RESULTS

Of the cohort, 52% reported sexual activity with a partner in the past year, and 96% of these answered the sexual satisfaction question. Nonmodifiable factors associated with sexual dissatisfaction included age, identification with certain racial or ethnic groups, marital status, parity, and smoking history. Potentially modifiable factors included lower mental health status and use of SSRIs. The final model yielded a c-statistic of 0.613, reflecting only a modest ability to discriminate between the sexually satisfied and dissatisfied.

CONCLUSIONS

Among postmenopausal women, the variables selected for examination yielded modest ability to discriminate between sexually satisfied and dissatisfied participants. Further study is necessary to better describe the cofactors associated with sexual satisfaction in postmenopausal women.

Sexual difficulties and help-seeking among mature adults in Australia: results from the Global Study of Sexual Attitudes and Behaviours

Background: The Global Study of Sexual Attitudes and Behaviours was a survey of 27 500 men and women in 29 countries. Here we report the sexual activity, the prevalence of sexual difficulties and related help-seeking behaviour among participants in Australia. Methods: A telephone survey was conducted in Australia in 2001–2002, with interviews based on a standardised questionnaire. A total of 1500 individuals (750 men and 750 women) aged 40 to 80 years completed the survey. The questionnaire covered demographic information, overall health, and sexual behaviours, attitudes and beliefs. Results: Overall, 83% of men and 74% of women had engaged in sexual intercourse during the 12 months preceding the interview, and 38% of all men and 29% of all women engaged in sexual intercourse more than once a week. Early ejaculation (23%), erectile difficulties (21%) and a lack of sexual interest (18%) were the most common male sexual difficulties. The most frequently reported female sexual difficulties were: lack of sexual interest (33%), lubrication difficulties (26%) and an inability to reach orgasm (25%). Older age was a significant predictor of male erectile difficulties and of lubrication difficulties in women. Only a minority of men and women had sought help for their sexual difficulty(ies) from a health professional. Conclusions: Many middle-aged and older adults in Australia report continued sexual interest and sexual activity. Several sexual difficulties are highly prevalent in this population, but those experiencing these difficulties rarely seek medical help. This may be because they do not perceive such difficulties as serious or sufficiently upsetting.

Prevalence and predictors of sexual dysfunction in psychiatric inpatients

The authors examined the prevalence and predictors of sexual dysfunction in a sample of 3,717 psychiatric inpatients assessed with the Minimum Data Set-Mental Health Version 1 (MDS-MH 1.0). Sexual dysfunction was found to be less prevalent in inpatient psychiatry (17%) than is typically reported in community settings. Severe depression symptoms, use of antidepressants, and cardiopulmonary conditions emerged as powerful predictors of sexual dysfunction. More research is needed on the assessment and treatment of sexual dysfunction in psychiatric inpatients, particularly focusing on attitudes of assessors, patients, and interactions between medical, psychiatric, and medication characteristics.

Gender differences in efficacy and sexual function in long-term trazodone treatment (preliminary results)

Objects. To evaluate the effect of trazodone on depressive or anxiety symptoms and sexual function depending on patient gender. Method. A total of 111 patients (59 men, 52 women) subjected to long-term treatment with trazodone were studied. The effect of the therapy was recorded according to the Clinical Global Impression - Severity of Illness (CGI-S) scale. The incidence of sexual dysfunction was assessed on the Utvalg for Kliniske Undersogelser (UKU) scale. Results. The effect of the therapy was similar in both genders. The incidence of diminished sexual desire was low and comparable in both genders; orgasmic dysfunctions were present only in women at the level of statistical significance. A positive correlation between the severity of the illness and the occurrence of diminished sexual desire and orgasmic dysfunction was found in women but not in men. Conclusion. The occurrence of sexual dysfunctions in trazodone therapy was lower than in population. It seems that trazodone is an effective therapy of depressive and anxiety symptoms in both genders and it is convenient for sexually active patients, because the occurrence of sexual dysfunctions was present the general to a low degree.

Depression and sexual functioning in minority women: current status and future directions

Despite the increasing number of non-Caucasians in the United States, the overwhelming majority of research into both depression and sexuality has been conducted with European-American (Caucasian) samples. Sexual dysfunction and depression often co-occur, impacting relationship satisfaction, quality of life, and treatment adherence. These issues may be particularly salient for African-American, Hispanic, and Asian-American women, yet this area of research has been relatively unexplored. Cultural factors may shape women's response to sexual dysfunction, resulting from the depression itself as well as antidepressant medication. Further research emphasizing gender and culture is needed to elucidate the prevalence, impact, and treatment of sexual dysfunction in specific groups of depressed minority women.

Prevalence of sexual problems and related help-seeking behaviors among mature adults in Brazil: data from the global study of sexual attitudes and behaviors

CONTEXT AND OBJECTIVE

Relatively little is known about the usual frequency of sexual activity and how older individuals cope with sexual problems. The objective was to study sexual activity, prevalence of sexual problems and related help-seeking behaviors among middle-aged and older men and women in Brazil.

DESIGN AND SETTING

Population survey, by Fundação Oswaldo Cruz.

METHODS

Interviews were held with 1,199 Brazilians aged 40-80 years (471 men and 728 women). The standardized questionnaire investigated demographics, general health, sexual behavior, attitudes and beliefs.

RESULTS

Overall, 92.6% of men and 58.3% of women had had sexual intercourse during the preceding year. More than half of the men and women had done so more than once a week. Early ejaculation (30.3%) was the commonest male sexual problem, followed by inability to reach orgasm (14.0%), erectile difficulties (13.1%) and lack of sexual interest (11.2%). For women, the commonest sexual problems were lubrication difficulties (23.4%) and lack of sexual interest (22.7%). Depression was a significant correlate of sexual problems, for men and women. More women than men had sought help for sexual problem(s) from a healthcare professional.

CONCLUSIONS

The findings highlight the importance of encouraging greater use of available healthcare services, including consultation with a medical doctor regarding sexual health. This should not only enable men and women to maintain satisfactory sexual function well into their later years, but may also result in overall improvement in the quality of healthcare.

ORIGINAL RESEARCH—PATHOPHYSIOLOGY: Clinical Biologic Pathophysiologies of Women's Sexual Dysfunction

INTRODUCTION

Data concerning the biologic pathophysiology of desire, arousal, and orgasm in women are limited.

AIM

To gain knowledge of biologic pathophysiology of female sexual function. METHODS. To provide state-of-the-art knowledge concerning female sexual dysfunction, representing the opinions of seven experts from five countries developed in a consensus process over a 2-year period.

MAIN OUTCOME MEASURE

An International Consultation in alliance with key urological and sexual medicine societies convened over 200 multidisciplinary specialists from 60 countries into 17 consultation committees. The aims, goals and intentions of each committee were defined. Expert opinion was based on grading of evidence-based medical literature, extensive internal committee dialogue, open presentation, and debate.

RESULTS

Three critical physiologic requirements, including intact sex steroids, autonomic/somatic nerves, and arterial inflow/perfusion pressure to women's genital organs play fundamental roles in maintaining women's sexual function. Despite this, there are nominal data supporting a direct pathophysiologic involvement of abnormal sex steroid values, and/or damage/injury to neurologic and/or blood flow integrity in women with problems in sexual desire, arousal, and/or orgasm. This summary details the available literature concerning hormonal, neurologic, and vascular organic pathophysiologies of women's sexual dysfunctions.

CONCLUSIONS

Additional research on clinical pathophysiologies in women's sexual dysfunction is needed. This chapter encompasses data presented at the 2nd International Consultation on Sexual Medicine in Paris, France, June 28-July 1, 2003.

A randomized, placebo-controlled, crossover study of ephedrine for SSRI-induced female sexual dysfunction

The objective of this study was to determine whether ephedrine, an alpha- and beta-adrenergic agonist previously shown to enhance genital blood flow in women, has beneficial effects in reversing antidepressant-induced sexual dysfunction. Nineteen sexually dysfunctional women receiving either fluoxetine, sertraline, or paroxetine participated in an eight-week, double-blind, placebo-controlled, cross-over study of the effects of ephedrine (50 mg) on self-report measures of sexual desire, arousal, orgasm, and sexual satisfaction. Although there were significant improvements relative to baseline in sexual desire and orgasm intensity/pleasure on 50 mg ephedrine 1-hr prior to sexual activity, significant improvements in these measures, as well as in sexual arousal and orgasmic ability also were noted with placebo. These findings highlight the importance of conducting placebo-controlled trials for this condition.

Zaprinast, a phosphodiesterase 5 inhibitor, overcomes sexual dysfunction produced by fluoxetine, a selective serotonin reuptake inhibitor in hamsters

A high incidence of sexual dysfunction among women is reported in the clinical literature. Little experimental investigation has been initiated on the ability of phosphodiesterase (PDE) inhibitors to overcome deficits in sexual functioning because of selective serotonin reuptake inhibitors (SSRIs). The effects of fluoxetine, an SSRI, and zaprinast, a PDE-5 inhibitor, on the lateral displacement response (used as a measure of sensitivity to reproductively relevant stimuli) of hamsters in behavioral estrus were investigated. In Experiment 1, hamsters that were maximally sensitive to reproductively relevant stimuli because they were at the peak of behavioral estrus were administered fluoxetine (10 mg/kg, i.p.); they had significantly decreased lateral displacement responses compared to vehicle-administered hamsters. In Experiment 2, hamsters that were relatively less sensitive to sexual stimuli because they were at the termination of behavioral estrus were administered zaprinast (3 mg/kg; i.p.); they had significantly enhanced lateral displacement responses compared to responses seen following vehicle administration. In Experiment 3, fluoxetine-induced deficits in the lateral displacement of hamsters at the peak of behavioral estrus were overcome by the coadministration of zaprinast. These data confirm previous findings that sexual dysfunction can be induced by SSRIs and extend the current knowledge to suggest that administration of a PDE-5 inhibitor can override SSRI-induced deficits in sexual functioning.