Enduring sexual dysfunction after treatment with antidepressants, 5α-reductase inhibitors and isotretinoin: 300 cases

Frequency of self-reported persistent post-treatment genital hypoesthesia among past antidepressant users: a cross-sectional survey of sexual and gender minority youth in Canada and the US

PURPOSE

Persistent post-treatment genital hypoesthesia (PPTGH) is a primary symptom of post-SSRI sexual dysfunction (PSSD), an iatrogenic syndrome characterized by enduring sexual dysfunction following the discontinuation of some antidepressants. We aimed to estimate the frequency of PPTGH among past users of psychiatric treatments, particularly antidepressants.

METHODS

We used a subsample of UnACoRN, a US/Canada survey of sexual and gender minority youth aged 15 to 29. We included participants with a history of psychiatric drug use. We excluded individuals with genital surgeries or without sexual experience. The analysis involved chi-square tests for initial group comparisons, post hoc tests for multiple comparisons, and logistic regression among those who had stopped taking medication. We exponentiated the regression to estimate the odds of PPTGH by drug type, adjusting for age, sex-assigned-at-birth, hormone treatment, and depression severity in three nested models.

RESULTS

574 of 2179 survey participants reported genital hypoesthesia. They were older and more likely to report male sex assignment at birth, hormonal therapy history, and psychiatric drug history. The frequency of PPTGH among antidepressant users was 13.2% (93/707) compared to 0.9% (1/102) among users of other medications; adjusted odds ratio: 14.2 (95% CI: 2.92 to 257).

CONCLUSION

Antidepressant discontinuation is strongly associated with PPTGH in the US and Canada where SSRI/SNRI medications account for 80% of antidepressant prescriptions. We call for standardized international warnings and transparent, informed consent. Future research should expand upon our efforts to estimate the risk of PSSD by including all the proposed diagnostic criteria, including documentation of temporal changes in PSSD-related symptoms before and after treatment (≥3 months).

Post-SSRI sexual dysfunction: barriers to quantifying incidence and prevalence

While sexual dysfunction is a well-known side effect of taking selective serotonin reuptake inhibitors (SSRIs), in an undetermined number of patients, sexual function does not return to pre-drug baseline after stopping SSRIs. The condition is known as post-SSRI sexual dysfunction (PSSD) and is characterised most commonly by genital numbness, pleasureless or weak orgasm, loss of libido and erectile dysfunction. This article provides a commentary on the incidence and prevalence of PSSD based on a combination of academic literature as well as clinical and research experience. A number of obstacles to quantifying the occurrence of PSSD are outlined including difficulty in designing a suitable study method. Other contextual obstacles include patient embarrassment at raising sexual concerns, the response of healthcare professionals, inability to stop an antidepressant due to withdrawal issues in a proportion of patients and patient unawareness that their sexual difficulties are linked to prior medication compounded by variability of online information and a lack of information aimed at public education. A definition of PSSD with diagnostic criteria has been published. A MedDRA code for PSSD has also been introduced, but this is yet to be adopted by regulators.

Self-reported male genital side-effects in a UK cohort taking isotretinoin

The prescribing of isotretinoin in male patients has become a hot topic of debate in the UK after an independent report from the UK Commission on Human Medicines in October 2023, which resulted in new safety guidance to encourage stricter monitoring of this cohort. We reviewed patients in a tertiary hospital in the UK where an online system has been monitoring genital side-effects and mood for the past 3 years, before this new safety guidance.

A clinical guide to rare male sexual disorders

Conditions referred to as 'male sexual dysfunctions' usually include erectile dysfunction, ejaculatory disorders and male hypogonadism. However, some less common male sexual disorders exist, which are under-recognized and under-treated, leading to considerable morbidity, with adverse effects on individuals' sexual health and relationships. Such conditions include post-finasteride syndrome, restless genital syndrome, post-orgasmic illness syndrome, post-selective serotonin reuptake inhibitor (SSRI) sexual dysfunction, hard-flaccid syndrome, sleep-related painful erections and post-retinoid sexual dysfunction. Information about these disorders usually originates from case-control trials or small case series; thus, the published literature is scarce. As the aetiology of these diseases has not been fully elucidated, the optimal investigational work-up and therapy are not well defined, and the available options cannot, therefore, adequately address patients' sexual problems and implement appropriate treatment. Thus, larger-scale studies - including prospective trials and comprehensive case registries - are crucial to better understand the aetiology, prevalence and clinical characteristics of these conditions. Furthermore, collaborative efforts among researchers, health-care professionals and patient advocacy groups will be essential in order to develop evidence-based guidelines and novel therapeutic approaches that can effectively address these disorders. By advancing our understanding and refining treatment strategies, we can strive towards improving the quality of life and fostering healthier sexual relationships for individuals suffering from these rare sexual disorders.

Post-Finasteride Syndrome And Post-Ssri Sexual Dysfunction: Two Clinical Conditions Apparently Distant, But Very Close

Post-finasteride syndrome and post-SSRI sexual dysfunction, are two poorly explored clinical conditions in which men treated for androgenetic alopecia with finasteride or for depression with SSRI antidepressants show persistent side effects despite drug suspension (e.g., sexual dysfunction, psychological complaints, sleep disorders). Because of some similarities in the symptoms, common pathological mechanisms are proposed here. Indeed, as discussed, clinical studies and preclinical data obtained so far suggest an important role for brain modulators (i.e., neuroactive steroids), neurotransmitters (i.e., serotonin, and cathecolamines), and gut microbiota in the context of the gut-brain axis. In particular, the observed interconnections of these signals in these two clinical conditions may suggest similar etiopathogenetic mechanisms, such as the involvement of the enzyme converting norepinephrine into epinephrine (i.e., phenylethanolamine N-methyltransferase). However, despite the current efforts, more work is still needed to advance the understanding of these clinical conditions in terms of diagnostic markers and therapeutic strategies.

Clinical characterisation of women with persistent genital arousal disorder: the iPGAD-study

Persistent Genital Arousal Disorder (PGAD) is a rare condition-mostly in women-where patients perceive prolonged genital arousal without any sexual desire or stimulation. Etiopathological considerations reach from peripheral to central issues over local disturbance of the pudendal nerve to neuropathy, psychosocial, and pharmacological theories. Since well controlled clinical studies about PGAD in conjunction with a mental and somatic health status are missing, this study is a detailed clinical investigation of PGAD patients compared to healthy controls. 26 women who fulfilled diagnostic criteria for PGAD were compared to 26 age matched healthy controls. Investigations included comparison of vegetative, gynaecological and sexual history, psychiatric features as well as a (neuro-)radiological, neurophysiological and gynaecological examination. Moreover, a detailed clinical characterisation of PGAD symptoms was performed. PGAD symptoms were mostly characterised as tingling or prickling and were permanently present. In over 80%, PGAD symptoms were located in the clitoris. Almost 70% reported radiations to other regions of the body. Most frequent trigger factors were tight clothes, mental stress, driving a car/bus/bicycle and sexual intercourse. Relieving factors were mainly distraction, relaxation, physical exercise, masturbation and swimming. In group comparisons, PGAD presented with significant higher rates of sexual dysfunctions, spontaneous orgasms, swelling of the genitals, extraordinary lubrication as well as higher rates in depression, agoraphobia, generalized anxiety disorder and lifetime panic disorder. Significantly more PGAD patients were diagnosed with restless legs symptoms. In contrast childhood traumatization, somatization disorder, suicidality, gynaecological as well as neurophysiological examination of the pudendal nerve were not different between the groups. MRI of the brain, pelvis and spinal cord was unsuspicious and incidental findings - including Tarlov cysts or pelvic venous congestion - were equally distributed among the groups. In summary, our study provides a careful characterization of women with PGAD highlighting a serious mental burden, most probably as a consequence of PGAD. With the current set of clinical investigations there was no evidence of a clear causal relationship to a specific clinical finding as it has been previously discussed. Future studies and additional techniques will have to further explore where and how in the peripheral or central nervous systems PGAD develops.

Selective serotonin reuptake inhibitors, post-treatment sexual dysfunction and persistent genital arousal disorder: A systematic review

PURPOSE

Adverse effects of selective serotonin reuptake inhibitors (SSRIs) on sexual function have been an important area of research for many years. However, the duration of SSRI-associated sexual adverse effects, and their possible persistence after treatment discontinuation, is still uncertain. The aims of the current systematic review were first to identify existing evidence of sexual dysfunction following SSRI discontinuation, and to provide an account of reported symptoms and proposed treatment options; and second, to establish whether current literature allows accurate estimates of the prevalence of such sexual dysfunction.

METHODS

A systematic review was conducted on PubMed, Embase, and Google Scholar; papers with clinical data regarding patients with persistent sexual dysfunction after SSRI treatment suspension were included.

RESULTS

Overall, two retrospective interventional studies, six observational studies and 11 case reports were judged eligible for inclusion. It was not possible to determine reliable estimates of prevalence. Similarly, a cause-effect relationship between SSRI exposure and persistent sexual impairment could not be ascertained. Nonetheless, the potential for continued sexual disturbances despite discontinuation could not be entirely ruled out.

CONCLUSIONS

There is a need to investigate a possible dose-response relationship between SSRI exposure and persistent sexual adverse effects. Treatment options for persistent dysfunctions remain limited, but novel therapeutic approaches may be required in order to address an otherwise neglected need for sexual well-being.

The post-finasteride syndrome: possible etiological mechanisms and symptoms

Finasteride and dutasteride, synthetic 5α-reductase inhibitors (5ARIs) are recommended in many guidelines for the treatment of benign prostatic hyperplasia/lower urinary tract symptoms and alopecia despite a variety of side effects like sexual, neurological, psychiatric, endocrinological, metabolic and ophthalmological dysfunctions and the increased incidence of high grade prostate cancer. The sexual side effects are common during the use of the drug but in a small subgroup of patients, they can persist after stopping the drug. This so-called post-finasteride syndrome has serious implications for the quality of life without a clear etiology or therapy. Three types of 5α-reductases are present in many organs in- and outside the brain where they can be blocked by the two 5ARIs. There is increasing evidence that 5ARIs not only inhibit the conversion of testosterone to 5α-dihydrotestosterone (DHT) in the prostate and the scalp but also in many other tissues. The lipophilic 5ARIs can pass the blood-brain barrier and might block many other neurosteroids in the brain with changes in the neurochemistry and impaired neurogenesis. Further research and therapeutic innovations are urgently needed that might cure or relieve these side effects. More awareness is needed for physicians to outweigh these health risks against the benefits of 5ARIs.

Exploring the link between eating disorders and persistent genital arousal disorder/genito-pelvic dysesthesia: first description and a systematic review of the literature

BACKGROUND

Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD) characterized by recurrent physiological genital without corresponding psychological arousal is a poorly understood and researched condition. Based on the first two case descriptions of eating disorders directly linked to PGAD/GPD the aim of this paper was to systematically review the literature on possible associations between eating disorders and PGAD/GPD.

METHOD

A systematic literature search on eating disorders and PGAD/GPD was conducted in PubMed, PsycINFO, and Scopus, complemented by Google Scholar. We included case reports, case series, cross-sectional studies and review articles published in peer-reviewed journals written in English or German-language.

RESULTS

The included original papers described a total of 2078 cases with PGAD/GPD symptomatology. Of these, 892 participants fulfilled all five PGAD/GPD core criteria. The aetiology of PGAD/GPD is unknown. Multifactorial genesis of PGAD/GPD is presumed including neurological, pharmacological, hormonal, vascular and psychological causes. A high degree of psychological comorbidity is reported. No study was found that drew a direct link between eating disorders and PGAD/GPD. Although PGAD/GPD symptoms also occur in adolescents, there are no findings in this regard. However, we found a gap in data collection: eating disorders as potential psychiatric comorbidities were systematically recorded in only a few studies.

CONCLUSION

The existing literature have not yet considered a possible link between eating disorders and PGAD/GPD so far. According to the authors' knowledge, this work is the first review to systematically explore the associations. We suspect underreporting of PGAD/GPD cases in eating disorders and particularly during adolescence. We argue that there are several common factors that appear to be important in the etiology, course, and treatment of both disorders (e.g. hormonal dysregulation or sensory sensitivity and avoidance), warranting future research on the possible comorbidity of these disorders.

Cutting the First Turf to Heal Post-SSRI Sexual Dysfunction: A Male Retrospective Cohort Study

Post-SSRI sexual dysfunction (PSSD) is a set of heterogeneous sexual problems, which may arise during the administration of selective serotonin reuptake inhibitors (SSRIs) and persist after their discontinuation. PSSD is a rare clinical entity, and it is commonly associated with non-sexual concerns, including emotional and cognitive problems and poor quality of life. To date, however, no effective treatment is available. The aim of this study was to retrospectively evaluate the potential efficacy of the different treatments used in clinical practice in improving male PSSD. Of the 30 patients referred to our neurobehavioral outpatient clinic from January 2020 to December 2021, 13 Caucasian male patients (mean age 29.53 ± 4.57 years), previously treated with SSRIs, were included in the study. Patients with major depressive disorder and/or psychotic symptoms were excluded a priori to avoid overlapping symptomatology, and potentially reduce the misdiagnosis rate. To treat PSSD, we decided to use drugs positively affecting the brain dopamine/serotonin ratio, such as bupropion and vortioxetine, as well as other compounds. This latter drug is known not to cause or reverse iatrogenic SD. Most patients, after treatment with vortioxetine and/or nutraceuticals, reported a significant improvement in all International Index of Erectile Function-(IIEF-5) domains (p < 0.05) from baseline (T0) to 12-month follow-up (T1). Moreover, the only patient treated with pelvic muscle vibration reached very positive results. Although our data come from a retrospective open-label study with a small sample size, drugs positively modulating the central nervous system serotonin/dopamine ratio, such as vortioxetine, could be used to potentially improve PSSD. Large-sample prospective cohort studies and randomized clinical trials are needed to investigate the real prevalence of this clinical entity and confirm such a promising approach to a potentially debilitating illness.

Review of Dermatologic Medications and Impact on Male Fertility, Sexual Dysfunction and Teratogenicity

BACKGROUND

Dermatologic medications have been linked to issues with safety during pregnancy and lactation. Despite this, limited research, often with conflicting findings, has been published on the association between dermatologic medications, male infertility, sexual dysfunction, and teratogenicity following paternal exposure.

OBJECTIVE

This review seeks to provide evidence-based guidance for physicians who are prescribing dermatologic medications to male patients who are trying to conceive.

METHODS

Common medications used in the largest outpatient specialist dermatologic centre in Singapore were the focus of this review. A PubMed search using MeSH terms from inception to April 22, 2021, was conducted. A secondary search was conducted to include common non-dermatologic medications. Drug information from various online clinical resources and the Tenth Edition of Drugs in Pregnancy and Lactation were also used as a reference.

RESULTS

In this review of 234 studies, 131 medications were covered. A total of 34 medications were associated with male infertility and sexual dysfunction, while 16 medications were implicated with concerns of teratogenicity.

DISCUSSION AND CONCLUSION

Physicians are advised to discuss the potential impact on male fertility and teratogenicity with males who are trying to conceive, while taking into consideration the clinical efficacy and tolerability of these medications and alternative treatments. This article is protected by copyright. All rights reserved.

Medications Most Commonly Associated With Erectile Dysfunction: Evaluation of the Food and Drug Administration National Pharmacovigilance Database

Background

Erectile dysfunction (ED) is an adverse effect of many medications.

Aim

We used a national pharmacovigilance database to assess which medications had the highest reported frequency of ED.

Methods

The Food and Drug Administration Adverse Event Reporting System (FAERS) was queried to identify medications with the highest frequency of ED adverse event reports from 2010 to 2020. Phosphodiesterase-5 inhibitors and testosterone were excluded because these medications are often used as treatments for men with ED. The 20 medications with the highest frequency of ED were included in the disproportionality analysis.

Outcomes

Proportional Reporting Ratios (PRRs) and their 95% confidence intervals were calculated.

Results

The 20 medications accounted for 6,142 reports of ED. 5-α reductase inhibitors (5-ARIs) and neuropsychiatric medications accounted for 2,823 (46%) and 2,442 (40%) of these reports respectively. Seven medications showed significant levels of disproportionate reporting with finasteride and dutasteride having the highest PRRs: 110.03 (103.14–117.39) and 9.40 (7.83–11.05) respectively. The other medications are used in a wide variety of medical fields such as cardiology, dermatology, and immunology.

Clinical Implications

Physicians should be familiar with these medications and understand their respective mechanisms of action, so that they may counsel patients appropriately and improve their quality of life.

Strengths and Limitations

The strength of the study is its large sample size and that it captures pharmacologic trends on a national level. Quantitative and comparative “real-world” data is lacking for the most common medications associated with ED. The limitation is that the number of reported events does not establish causality and cannot be used to calculate ED incidence rates.

Conclusion

In a national pharmacovigilance database, 5-ARIs and neuropsychiatric medications had the highest reports of ED adverse effects. There were many other medications used in a variety of medical fields that were also associated with ED.

Kaplan-Marans E, Sandozi A, Martinez M, et al. Medications Most Commonly Associated With Erectile Dysfunction: Evaluation of the Food and Drug Administration National Pharmacovigilance Database. Sex Med 2022;10:100543.

Individualized identification of sexual dysfunction of psychiatric patients with machine-learning

Sexual dysfunction (SD) is prevalent in patients with mental health disorders and can significantly impair their quality of life. Early recognition of SD in a clinical setting may help patients and clinicians to optimize treatment options of SD and/or other primary diagnoses taking SD risk into account and may facilitate treatment compliance. SD identification is often overlooked in clinical practice; we seek to explore whether patients with a high risk of SD can be identified at the individual level by assessing known risk factors via a machine learning (ML) model. We assessed 135 subjects referred to a tertiary mental health clinic in a Western Canadian city using health records data, including age, sex, physician's diagnoses, drug treatment, and the Arizona Sexual Experiences Scale (ASEX). A ML model was fitted to the data, with SD status derived from the ASEX as target outcomes and all other variables as predicting variables. Our ML model was able to identify individual SD cases-achieving a balanced accuracy of 0.736, with a sensitivity of 0.750 and a specificity of 0.721-and identified major depressive disorder and female sex as risk factors, and attention deficit hyperactivity disorder as a potential protective factor. This study highlights the utility of SD screening in a psychiatric clinical setting, demonstrating a proof-of-concept ML approach for SD screening in psychiatric patients, which has marked potential to improve their quality of life.

Delayed ejaculation in men with depressive disorders

Delayed ejaculation belongs to the group of sexual disorders in men. The causes of delayed ejaculation or anejaculation are not exactly known. It is assumed that it can be caused by psychogenic or organic influences or their combinations. One of the causes of delayed ejaculation may be elevated prolactin levels, which may be increased by psychosocial stress, pituitary disorders or also treatment with selective serotonin reuptake inhibitors in the treatment of depression. We tested a selected group of 50 men who were diagnosed with a depressive disorder and whose antidepressant treatment lasted for at least 24 weeks. These patients reported long-term delayed ejaculation or, in some cases, anejaculation as comorbidity. The results showed significant Spearman's correlation between elevated prolactin levels and intravaginal ejaculation latency values (R = 0.45), as well as between Beck's Depression-II inventory and intravaginal ejaculation latency and latency values (R = 0.48).

Persistent sexual dysfunction after SSRI withdrawal: a scoping review and presentation of 86 cases from the Netherlands

BACKGROUND

Sexual dysfunction is highly prevalent worldwide. A specific form is persistent sexual dysfunction after SSRI withdrawal. We conducted a systematic literature review in order to characterize factors related to post SSRI sexual dysfunction (PSSD) and analyzed spontaneous reports of persistent sexual dysfunction reported to the Netherlands Pharmacovigilance Center Lareb.

RESEARCH DESIGN AND METHODS

A systematic literature review was conducted following the PRISMA-ScR guidelines. In addition, reports of PSSD submitted to the Netherlands Pharmacovigilance Center Lareb between 1992 and 2021 were analyzed.

RESULTS

A total of 237 articles were retrieved through the search and 33 articles were selected for inclusion in this review, in accordance with the inclusion criteria. Information regarding the characteristics of the condition, its clinical management, patient characteristics, and impact of PSSD is presented. A total of 86 reports of persistent sexual dysfunction were analyzed. The longest case being a patient with PSSD for 23 years. The main symptoms were: loss or decreased libido (n = 53), erectile dysfunction (n = 23) and anorgasmia (n = 5).

CONCLUSIONS

PSSD impact includes sexual, psychological, and social consequences. Little is known about the mechanisms underlying PSSD and no effective treatment exists. It is necessary to increase recognition of PSSD among prescribers and improve its management at the clinical level.

Diagnostic criteria for enduring sexual dysfunction after treatment with antidepressants, finasteride and isotretinoin

BACKGROUND:

A set of enduring conditions have been reported in the literature involving persistent sexual dysfunction after discontinuation of serotonin reuptake inhibiting antidepressants, 5 alpha-reductase inhibitors and isotretinoin.

OBJECTIVE:

To develop diagnostic criteria for post-SSRI sexual dysfunction (PSSD), persistent genital arousal disorder (PGAD) following serotonin reuptake inhibitors, post-finasteride syndrome (PFS) and post-retinoid sexual dysfunction (PRSD).

METHODS:

The original draft was designed using data from two published case series (Hogan et al., 2014 and Healy et al., 2018), which represent the largest public collections of data on these enduring conditions. It was further developed with the involvement of a multidisciplinary panel of experts.

RESULTS:

A set of criteria were agreed upon for each of the above conditions. Features of PSSD, PFS and PRSD commonly include decreased genital and orgasmic sensation, decreased sexual desire and erectile dysfunction. Ancillary non-sexual symptoms vary depending on the specific condition but can include emotional blunting and cognitive impairment. PGAD presents with an almost mirror image of unwanted sensations of genital arousal or irritability in the absence of sexual desire. A new term, post-SSRI asexuality, is introduced to describe a dampening of sexual interest and pleasure resulting from a pre-natal or pre-teen exposure to a serotonin reuptake inhibitor.

CONCLUSIONS:

These criteria will help in both clinical and research settings. As with all criteria, they will likely need modification in the light of developments.

Post-SSRI Sexual Dysfunction (PSSD): Biological Plausibility, Symptoms, Diagnosis, and Presumed Risk Factors

INTRODUCTION

Post-SSRI sexual-dysfunction (PSSD) is an iatrogenicsyndrome, the underlying neurobiological mechanisms of which areunclear. Symptom onset follows cessation of serotonergicantidepressants i.e. Selective Serotonin and Norepinephrine ReuptakeInhibitors (SSRI's, SNRI's), and Tricyclic antidepressants (TCA's). PSSDsymptoms include genital anesthesia, erectile dysfunction andorgasmic/ejaculatory anhedonia, and should be differentiated fromdepression-related sexual-dysfunction. Recently, accumulated data of numerous case-reports suggest additional non-sexual symptoms including, anhedonia, apathy, and blunted affect. PSSD gained official recognition after the European medical agency concluded that PSSD is a medical condition that persists after discontinuation of SSRI's and SNRI's.

OBJECTIVE

To review possible underlying neurobiological mechanisms ofthis syndrome, update information on the pathophysiology, present a listof potential risk-factors and discuss potential management options forPSSD.

METHODS

Extensive literature review on the main symptom-patterns ofthis disorder was undertaken using PubMed. It includes introductoryexplications of relevant neurobiology with the objective of generatinghypothesis.

RESULTS

Precipitating factors for PSSD include previous exposure to certain drugs, genetic predisposition, psychological stress or chemical stressful reaction to antidepressants along pre-existing medical conditions affecting neuroplasticity. Different theories have been proposed to explain the pathophysiology of PSSD: epigenetic gene expression, dopamine-serotonin interactions, serotonin neurotoxicity and hormonal changes. The diagnosis of PSSD is by excluding all other etiologies of sexual-dysfunction. Treatment is challenging, and many strategies have been suggested without definitive outcomes. We offerthe contours of a future neurobiological research agenda, and propose several underlying mechanisms for the various symptoms of PSSD which could be the foundation for a future treatment algorithm.

CONCLUSION

There is a need for well-designed neurobiological research in this domain, as well as in the prevalence, pathophysiology, and treatment of PSSD. Practitioners should be alert to the distinctive features of PSSD. Misdiagnosing this syndrome might lead to harmful Sexual Medicine Reviews. Peleg LC, Rabinovitch D, Lavie Y, et al. Post-SSRI Sexual Dysfunction (PSSD): Biological Plausibility, Symptoms, Diagnosis, and Presumed Risk Factors. Sex Med Rev 2021;XX:XXX-XXX.

Effects of paroxetine treatment and its withdrawal on neurosteroidogenesis

Selective serotonin reuptake inhibitors (SSRI) show high efficacy in treating depression, however during treatment side effects, like for instance sexual dysfunction, may appear, decreasing compliance. In some cases, this condition will last after drug discontinuation, leading to the so-called post-SSRI sexual dysfunction (PSSD). The etiology of PSSD is still unknown, however a role for neuroactive steroids may be hypothesized. Indeed, these molecules are key physiological regulators of the nervous system, and their alteration has been associated with several neuropathological conditions, including depression. Additionally, neuroactive steroids are also involved in the control of sexual function. Interestingly, sexual dysfunction induced by SSRI treatment has been also observed in animal models. On this basis, we have here evaluated whether a subchronic treatment with paroxetine for two weeks and/or its withdrawal (i.e., a month) may affect the levels of neuroactive steroids in brain areas (i.e., hippocampus, hypothalamus, and cerebral cortex) and/or in plasma and cerebrospinal fluid of male rats. Data obtained indicate that the SSRI treatment alters neuroactive steroid levels and the expression of key enzymes of the steroidogenesis in a brain tissue- and time-dependent manner. Indeed, these observations with the finding that plasma levels of neuroactive steroids are not affected suggest that the effect of paroxetine treatment is directly on neurosteroidogenesis. In particular, a negative impact on the expression of steroidogenic enzymes was observed at the withdrawal. Therefore, it is possible to hypothesize that altered neurosteroidogenesis may also occur in PSSD and consequently it may represent a possible pharmacological target for this disorder.

Simultaneous Quantification of Four Ginsenosides in Rat Plasma and Its Application to a Comparative Pharmacokinetic Study in Normal and Depression Rats Using UHPLC-MS/MS

A sensitive method has been developed for simultaneous determination of ginsenoside Rh₁ (G-Rh₁), ginsenoside Rb₁ (G-Rb₁), ginsenoside Rc (G-Rc), and ginsenoside Rd (G-Rd) in rat plasma of normal and depression model group after oral administration of their solutions by using Ultra-High-Performance Liquid Chromatography-Tandem Mass Spectrometry (UHPLC-QQQ-MS). The biological samples were prepared by protein precipitation. Ginsenoside Rg₃ (G-Rg₃) was used as an internal standard (IS). MS analysis was performed under the multiple reaction monitoring (MRM) with electron spray ionization (ESI) operated in the negative mode. The method showed good linearity over a wide concentration range (R ² > 0.999) and obtained lower limits of quantification (LLOQ) of 5 ng/mL. The whole analysis procedure could be completed in as short as 16.5 min. The intraday precisions, interday precisions, and stabilities were less than 10%. The extraction recoveries from rat plasma were exceeded 86.0%. The results indicated that there were significant differences between the two groups on pharmacokinetics parameters; the absorptions of four analytes in the depression group were higher than those in the normal group because the liver metabolism and internal environment of the model rats had been affected.

Exposure to serotonin selective reuptake inhibitors or serotonin noradrenaline reuptake inhibitors and sexual dysfunction: Results from an online survey

BACKGROUND: Post-SSRI Sexual Dysfunction (PSSD) is characterized by sexual and emotional symptoms associated to the exposure to Selective Serotonin Reuptake Inhibitors (SSRI) or Serotonin Noradrenaline Reuptake Inhibitors (SNRI). OBJECTIVE: The present study provides a comprehensive picture on demographic and clinical characteristics associated to PSSD. METHODS: An online survey was run on subjects self-declaring as affected by PSSD. The survey collected socio-demographic and clinical data via questions created ad hoc and three standardized scales (Arizona Sexual Experiences Scale, Hospital Anxiety and Depression Scale, World Health Organization Wellbeing Index). RESULTS: A total of 135 subjects (115 males; mean age 31.9 ± 8.9 years) was analysed. The syndrome was more represented among young, heterosexual males after the exposure to SSRI/SNRI at relatively high doses. The major findings involved the temporal sequence of symptoms: 118 subjects had symptoms both during and after SSRI/SNRI administration, and 17 only after, thus deposing for a iatrogenic action of SSRI/SNRI. Different variables, represented by both emotional and sexual symptoms, accounted for the variability of the severity of the sexual dysfunction as well as of wellbeing. CONCLUSIONS: Based on the present results, PSSD is a complex iatrogenic syndrome in need of being further studied and understood.

Charactarizing Post-SSRI sexual dysfunction and its impact on quality of life through an international online survey

BACKGROUND

Post-SSRI sexual dysfunction (PSSD) is an underrecognized and poorly understood medical condition characterized by sexual dysfunction that persists despite SSRI discontinuation.

OBJECTIVE

We conducted a survey of individuals with PSSD to better characterize this condition and its impact on various quality of life concerns.

METHODS

Surveys were distributed to an online support group for individuals with PSSD. Surveys assessed medications suspected of causing PSSD and symptoms experienced during and after treatment. Respondents reported the trajectory of their condition, the efficacy of different treatments, and the impact of PSSD on their quality of life.

RESULTS

239 survey responses were included in this study. A majority of respondents had a history of SSRI use (92%) compared to only SNRI or atypical antidepressant use (8%). The overall severity of symptoms improved for 45% and worsened or remained the same for 37% of respondents after discontinuing treatment with serotonin reuptake inhibitors. Only 12% of respondents reported being counseled regarding potential sexual dysfunction while taking antidepressants. The majority rated the effect of PSSD on their quality of life as extremely negative (59%) or very negative (23%).

CONCLUSION

PSSD can have an overwhelmingly negative impact on quality of life. Currently, it is unclear why certain individuals develop PSSD and there are no definitive treatments for this condition. Further research of PSSD and greater awareness of this condition is needed among prescribers of serotonin reuptake inhibitors to improve patient care. Abstract goes.

Development and persistence of patient-reported visual problems associated with serotonin reuptake inhibiting antidepressants

BACKGROUND

The majority of antidepressants inhibit serotonin reuptake and include the selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and the serotonin reuptake inhibiting tricyclic antidepressants.

OBJECTIVE

The objective of this study was to investigate and describe the range and impact of reported adverse visual effects linked to serotonin reuptake inhibiting antidepressants.

METHODS

Using data from a global database of patient spontaneous reports of drug adverse events, we systematically identified eligible reports of visual problems linked to the use of serotonin reuptake inhibiting antidepressants. We analyzed these data using simple descriptive statistics to present the range and impact.

RESULTS

We identified 124 reports of visual problems. Reports originate from 18 countries and involve 11 different drugs. The most commonly reported symptoms were vision blurred/visual acuity reduced (n = 79, 63.7%), night blindness (n = 22, 17.7%), vitreous floaters (n = 21, 16.9%), photophobia (n = 19, 15.3%), diplopia (n = 15, 12.1%), palinopsia (n = 13, 10.5%), visual field defect (n = 12, 9.7%), photopsia (n = 11, 8.9%) and visual snow syndrome (n = 11, 8.9%). 74 patients indicated that the side effect was bad enough to affect everyday activities, 62 had sought health care, and 50 indicated that their work had been affected. 49 patients reported an enduring vision problem after discontinuation of treatment.

CONCLUSIONS

The data suggest that serotonin reuptake inhibiting antidepressants can produce a range of adverse effects on vision that in some cases can be long-lasting after discontinuation of the drug. Further efforts are needed to understand the mechanisms involved, the incidence among those prescribed these medications, and identify any risk or mitigation factors.

Acute and Persistent Withdrawal Syndromes Following Discontinuation of Psychotropic Medications

Studies on psychotropic medications decrease, discontinuation, or switch have uncovered withdrawal syndromes. The present overview aimed at analyzing the literature to illustrate withdrawal after decrease, discontinuation, or switch of psychotropic medications based on the drug class (i.e., benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonists, antidepressants, ketamine, antipsychotics, lithium, mood stabilizers) according to the diagnostic criteria of Chouinard and Chouinard [Psychother Psychosom. 2015;84(2):63-71], which encompass new withdrawal symptoms, rebound symptoms, and persistent post-withdrawal disorders. All these drugs may induce withdrawal syndromes and rebound upon discontinuation, even with slow tapering. However, only selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, and antipsychotics were consistently also associated with persistent post-withdrawal disorders and potential high severity of symptoms, including alterations of clinical course, whereas the distress associated with benzodiazepines discontinuation appears to be short-lived. As a result, the common belief that benzodiazepines should be substituted by medications that cause less dependence such as antidepressants and antipsychotics runs counter the available literature. Ketamine, and probably its derivatives, may be classified as at high risk for dependence and addiction. Because of the lag phase that has taken place between the introduction of a drug into the market and the description of withdrawal symptoms, caution is needed with the use of newer antidepressants and antipsychotics. Within medication classes, alprazolam, lorazepam, triazolam, paroxetine, venlafaxine, fluphenazine, perphenazine, clozapine, and quetiapine are more likely to induce withdrawal. The likelihood of withdrawal manifestations that may be severe and persistent should thus be taken into account in clinical practice and also in children and adolescents.

The effect of paternal exposure to immunosuppressive drugs on sexual function, reproductive hormones, fertility, pregnancy and offspring outcomes: a systematic review

BACKGROUND

Information regarding the possible influence of immunosuppressive drugs on male sexual function and reproductive outcomes is scarce. Men diagnosed with immune-mediated diseases and a wish to become a father represent an important neglected population since they lack vital information to make balanced decisions about their treatment.

OBJECTIVE AND RATIONALE

The aim of this research was to systematically review the literature for the influence of paternal immunosuppressive drug use on many aspects of male sexual health, such as sexual function, fertility, pregnancy outcomes and offspring health outcomes.

SEARCH METHODS

A systematic literature search was performed in the bibliographic databases: Embase (via Elsevier embase.com), MEDLINE ALL via Ovid, Cochrane Central Register of Trials (via Wiley) and Web of Science Core Collection. Additionally, Google Scholar and the Clinical trial registries of Europe and the USA were searched. The databases were searched from inception until 31 August 2019. The searches combined keywords regarding male sexual function and fertility, pregnancy outcomes and offspring health with a list of immunosuppressive drugs. Studies were included if they were published in English and if they included original data on male human exposure to immunosuppressive drugs. A meta-analysis was not possible to perform due to the heterogeneity of the data.

OUTCOMES

A total of 5867 references were identified, amongst which we identified 161 articles fulfilling the eligibility criteria. Amongst these articles, 50 included pregnancy and offspring outcomes and 130 included sexual health outcomes. Except for large Scandinavian cohorts, most of the identified articles included a small number of participants. While a clear negative effect on sperm quality was evident for sulfasalazine and cyclophosphamide, a dubious effect was identified for colchicine, methotrexate and sirolimus. In three articles, exposure to tumour necrosis factor-α inhibitors in patients diagnosed with ankylosing spondylitis resulted in improved sperm quality. The information regarding pregnancy and offspring outcomes was scant but no large negative effect associated with paternal immunosuppressive drug exposure was reported.

WIDER IMPLICATIONS

Evidence regarding the safety of immunosuppressive drugs in men with a wish to become a father is inconclusive. The lack of standardisation on how to evaluate and report male sexual function, fertility and reproduction as study outcomes in men exposed to immunosuppressive drugs is an important contributor to this result. Future research on this topic is needed and should be preferably done using standardised methods.

International Society for the Study of Women's Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD)

BACKGROUND

Persistent genital arousal disorder (PGAD), a condition of unwanted, unremitting sensations of genital arousal, is associated with a significant, negative psychosocial impact that may include emotional lability, catastrophization, and suicidal ideation. Despite being first reported in 2001, PGAD remains poorly understood.

AIM

To characterize this complex condition more accurately, review the epidemiology and pathophysiology, and provide new nomenclature and guidance for evidence-based management.

METHODS

A panel of experts reviewed pertinent literature, discussed research and clinical experience, and used a modified Delphi method to reach consensus concerning nomenclature, etiology, and associated factors. Levels of evidence and grades of recommendation were assigned for diagnosis and treatment.

OUTCOMES

The nomenclature of PGAD was broadened to include genito-pelvic dysesthesia (GPD), and a new biopsychosocial diagnostic and treatment algorithm for PGAD/GPD was developed.

RESULTS

The panel recognized that the term PGAD does not fully characterize the constellation of GPD symptoms experienced by patients. Therefore, the more inclusive term PGAD/GPD was adopted, which maintains the primacy of the distressing arousal symptoms and acknowledges associated bothersome GPD. While there are diverse biopsychosocial contributors, there is a common underlying neurologic basis attributable to spontaneous intense activity of the genito-pelvic region represented in the somatosensory cortex and its projections. A process of care diagnostic and treatment strategy was developed to guide the clinician, whenever possible, by localizing the symptoms as originating in any of five regions: (i) end organ, (ii) pelvis/perineum, (iii) cauda equina, (iv) spinal cord, and (v) brain. Psychological treatment strategies were considered critical and should be performed in conjunction with medical strategies. Pharmaceutical interventions may be used based on their site and mechanism of action to reduce patients' symptoms and the associated bother and distress.

CLINICAL IMPLICATIONS

The process of care for PGAD/GPD uses a personalized, biopsychosocial approach for diagnosis and treatment.

STRENGTHS AND LIMITATIONS

Strengths and Limitations: Strengths include characterization of the condition by consensus, analysis, and recommendation of a new nomenclature and a rational basis for diagnosis and treatment. Future investigations into etiology and treatment outcomes are recommended. The main limitations are the dearth of knowledge concerning this condition and that the current literature consists primarily of case reports and expert opinion.

CONCLUSION

We provide, for the first time, an expert consensus review of the epidemiology and pathophysiology and the development of a new nomenclature and rational algorithm for management of this extremely distressing sexual health condition that may be more prevalent than previously recognized. Goldstein I, Komisaruk BR, Pukall CF, et al. International Society for the Study of Women's Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD). J Sex Med 2021;18:665-697.

Persistent Genital Arousal Disorder: A Study on an Italian Group of Female University Students

There are very few studies in literature about Persistent Genital Arousal Disorder (PGAD) prevalence to date, and no one has ever been done in Italy. This study replicated the earlier Canadian research in order to investigate the prevalence of PGAD diagnostic criteria in an Italian group of 679 female university students and to compare the results with those obtained in the Canadian group. In addition, the research aimed at verifying if the type or number of PGAD criteria met and the intensity of symptoms are associated with more negative emotions, and if they can be related to age and sexual orientation. The results confirm that some women can experience spontaneous genital sensations that can vary in intensity and duration, and can be associated with a wide range of emotions. However, the results seem to suggest the importance of other factors in the evaluation of the symptoms, rather than factors related to their nature and intensity or age and sexual orientation. Moreover, 2 participants (0.29%) met all five criteria and reported high distress, confirming that there is a potential clinical condition called PGAD, in which the hypertrophic, intense and intrusive spontaneous genital arousal might determine the presence of extremely negative emotions.

Post-finasteride syndrome: a surmountable challenge for clinicians

Post-finasteride syndrome (PFS) is a constellation of serious adverse side effects manifested in clinical symptoms that develop and persist in patients during and/or after discontinuing finasteride treatment in men with pattern hair loss (androgenetic alopecia) or benign prostatic hyperplasia. These serious adverse side effects include persistent or irreversible sexual, neurological, physical and mental side effects. To date, there are no evidence-based effective treatments for PFS. Although increasing number of men report persistent side effects, the medical community has yet to recognize this syndrome nor are there any specific measures to address this serious and debilitating symptoms. Here we evaluate the scientific and clinical evidence in the contemporary medical literature to address the very fundamental question: Is PFS a real clinical condition caused by finasteride use or are the reported symptoms only incidentally associated with but not caused by finasteride use? One key indisputable clinical evidence noted in all reported studies with finasteride and dutasteride was that use of these drugs is associated with development of sexual dysfunction, which may persist in a subset of men, irrespective of age, drug dose or duration of study. Also, increased depression, anxiety and suicidal ideation in a subset of men treated with these drugs were commonly reported in a number of studies. It is important to note that many clinical studies suffer from incomplete or inadequate assessment of adverse events and often limited or inaccurate data reporting regarding harm. Based on the existing body of evidence in the contemporary clinical literature, the author believes that finasteride and dutasteride induce a constellation of persistent sexual, neurological and physical adverse side effects, in a subset of men. These constellations of symptoms constitute the basis for PFS in individuals predisposed to epigenetic susceptibility. Indeed, delineating the pathophysiological mechanisms underlying PFS will be of paramount importance to the understanding of this syndrome and to development of potential novel therapeutic modalities.

Post-finasteride syndrome

Finasteride is a 5α-reductase enzyme inhibitor that has been approved for the treatment of male androgenic alopecia since 1997. Over time, it has been considered a safe and well-tolerated drug with rare and reversible side effects. Recently there have been reports of adverse drug-related reactions that persisted for at least three months after discontinuation of this drug, and the term post-finasteride syndrome arose. It includes persistent sexual, neuropsychiatric, and physical symptoms. Studies to date cannot refute or confirm this syndrome as a nosological entity. If it actually exists, it seems to occur in susceptible people, even if exposed to small doses and for short periods, and symptoms may persist for long periods. Based on currently available data, the use of 5α-reductase inhibitors in patients with a history of depression, sexual dysfunction, or infertility should be carefully and individually assessed.

Antidepressant-induced sexual dysfunction

Sexual dysfunction is a frequent, potentially distressing, adverse effect of antidepressants and a leading cause of medication non-adherence. Sexual function should be actively assessed at baseline, at regular intervals during treatment, and after treatment cessation. Trials comparing the risk of sexual dysfunction with individual antidepressants are inadequate, but it is reasonable to conclude that the risk is greatest with selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs), less with tricyclic antidepressants (except clomipramine) and mirtazapine, and least with moclobemide, agomelatine, reboxetine and bupropion. Management of antidepressant-induced sexual dysfunction requires an individualised approach (eg, considering other causes, dose reduction, addition of medication to treat the adverse effect, switching to a different antidepressant). Post-SSRI sexual dysfunction has been recently identified as a potential, although rare, adverse effect of SSRIs and SNRIs. Consider the possibility of post-SSRI sexual dysfunction in patients in whom sexual dysfunction was absent before starting antidepressants but develops during or soon after antidepressant treatment and still persists after remission from depression and discontinuation of the drug.

Post-SSRI sexual dysfunction: Patient experiences of engagement with healthcare professionals

OBJECTIVE

A petition to the European Medicines Agency provided an opportunity to collect reports of a specific adverse event from patients and healthcare professionals, along with details of clinicians' attitudes when asked to endorse patient reports.

METHODS

We approached a cohort of patients reporting post-SSRI sexual dysfunction (PSSD) to an adverse event reporting website, RxISK.org. The responses of patients on their interactions with healthcare professionals were subject to a qualitative analysis.

RESULTS

A total of 62 participants from 23 countries provided details of their experiences. While some had received support and validation of their condition, many described a number of difficulties including a lack of awareness or knowledge about PSSD, not being listened to, receiving unsympathetic or inappropriate responses, and a refusal to engage with the published medical literature.

CONCLUSIONS

Healthcare professionals are nervous about or reluctant to engage with novel problems on a treatment. This is not widely appreciated and the reasons for this concern are not understood.

Post-SSRI Sexual Dysfunction: A Bioelectric Mechanism?

Selective serotonin reuptake inhibitor (SSRI) drugs, targeting serotonin transport, are widely used. A puzzling and biomedically important phenomenon concerns the persistent sexual dysfunction following SSRI use seen in some patients. What could be the mechanism of a persistent physiological state brought on by a transient exposure to serotonin transport blockers? In this study, we briefly review the clinical facts concerning this side effect of serotonin reuptake inhibitors and suggest a possible mechanism. Bioelectric circuits (among neural or non-neural cells) could persistently maintain alterations of bioelectric cell properties (resting potential), resulting in long-term changes in electrophysiology and signaling. We present new data revealing this phenomenon in planarian flatworms, in which brief SSRI exposures induce long-lasting changes in resting potential profile. We also briefly review recent data linking neurotransmitter signaling to developmental bioelectrics. Further study of tissue bioelectric memory could enable the design of ionoceutical interventions to counteract side effects of SSRIs and similar drugs.

Low dose of isotretinoin: A comprehensive review

Isotretinoin is a first-generation retinoid initially approved for the treatment of severe cases of acne vulgaris (nodulocystic acne). Because of its broad anti-inflammatory and immunomodulatory properties, it has been used beyond its initial approval in a myriad of other indications. Adverse effects of isotretinoin vary from xerosis to teratogenicity. Herein, we reviewed the literature, through date-unlimited PubMed search, from inception till December 2019, using the following search terms: "low-dose isotretinoin" and "dermatology," "isotretinoin and safety," "isotretinoin, off-label uses," "isotretinoin and male fertility," "isotretinoin, iPLEDGE system," aiming to deliver a therapeutic update relevant to clinical practice. All English-language articles were considered with no limitation based on the articles' type. Low-dose isotretinoin is not limited to old and novel dermatological conditions, but also showed promising results in the field of infertility and safety in the field of gastroenterology. We also highlight on the safety profile of the drug and experts' recommendations to enhance safety measures to decrease fetal risk while on isotretinoin.

The Pharmacotherapy of Persistent Genital Arousal Disorder

Purpose of Review

Persistent genital arousal disorder (PGAD) is a rare, yet debilitating, disease, which was first described at the beginning of this century and has not yet been considered by the ICD-10 or DSM-5. Since affected subjects usually suffer tremendously, this review aims at offering an overview of pharmacological approaches to treat this disorder.

Recent Findings

Until now, no randomised placebo-controlled clinical trials have been conducted on PGAD, and the international registries have not recorded any ongoing trials. Current knowledge on pharmacological options for the treatment of PGAD relies mainly on case reports/case series. Most importantly, there is evidence that some drugs such as SSRIs and SNRIs might induce or worsen PGAD.

Summary

Knowledge on pharmacological treatment options for PGAD is not yet evidence-based, while some reports even assume an induction of PGAD by serotonergic antidepressants. Nevertheless, practitioners should be aware of PGAD and carefully discuss with the patient an individual treatment trial by considering the experience up to now.

Persistent genital arousal disorder: a special sense neuropathy

Introduction

Persistent genital arousal (PGAD) is a syndrome of unprovoked sexual arousal/orgasm of uncertain cause primarily reported in female patients. Most patients are referred for mental-health treatment, but as research suggests associations with neurological symptoms and conditions, there is need to analyze cases comprehensively evaluated by neurologists.

Methods

The IRB waived consent requirements for this retrospective university-hospital study. We extracted and analyzed neurological symptoms, test, and treatment results from all qualifying participants' records and recontacted some for details.

Results

All 10 participants were female; their PGAD symptoms began between ages 11 to 70 years. Two patterns emerged: 80% reported daily out-of-context sexual arousal episodes (≤30/day) that usually included orgasm and 40% reported lesser, often longer-lasting, nonorgasmic arousals. Most also had symptoms consistent with sacral neuropathy-70% had urologic complaints and 60% had neuropathic perineal or buttock pain. In 90% of patients, diagnostic testing identified anatomically appropriate and plausibly causal neurological lesions. Sacral dorsal-root Tarlov cysts were most common (in 4), then sensory polyneuropathy (2). One had spina bifida occulta and another drug-withdrawal effect as apparently causal; lumbosacral disc herniation was suspected in another. Neurological treatments cured or significantly improved PGAD symptoms in 4/5 patients, including 2 cures.

Conclusions

Although limited by small size and referral bias to neurologists, this series strengthens associations with Tarlov cysts and sensory polyneuropathy and suggests new ones. We hypothesize that many cases of PGAD are caused by unprovoked firing of C-fibers in the regional special sensory neurons that subserve sexual arousal. Some PGAD symptoms may share pathophysiologic mechanisms with neuropathic pain and itch.

Post-finasteride syndrome: An emerging clinical problem

The presence of side effects during pharmacological treatment is unfortunately a quite common problem. In this review, we focused our attention on adverse events related to 5 alpha-reductase (5α-R) inhibitors (i.e., finasteride and dutasteride), approved for the treatment of benign prostatic hyperplasia and androgenetic alopecia (AGA). Although these drugs are generally well tolerated, many reports described adverse effects in men during treatment, such as sexual dysfunction and mood alteration. In addition, it has been also reported that persistent side effects may occur in some AGA patients. This condition, termed post-finasteride syndrome (PFS) is characterized by sexual side effects (i.e., low libido, erectile dysfunction, decreased arousal and difficulty in achieving orgasm), depression, anxiety and cognitive complaints that are still present despite drug withdrawal. Indeed, some national agencies (e.g., Swedish Medical Products Agency, the Medicines and Healthcare Products Regulatory Agency of UK and the U.S. Food and Drug Administration) required to include multiple persistent side effects within the finasteride labels. As here reported, these observations are mainly based on self-reporting of the symptomatology by the patients and few clinical studies have been performed so far. In addition, molecular mechanisms and/or genetic determinants behind such adverse effects have been poorly explored both in patients and animal models. Therefore, results here discussed indicate that PFS is an emerging clinical problem that needs to be further elucidated.

Persistent Genital Arousal Disorder: Review of Pertinent Peripheral Nerves

INTRODUCTION

Persistent genital arousal disorder (PGAD) is a condition that is still poorly understood. Etiologies reported for PGAD are vascular, neurological, pharmacological, and psychological. Determining the neurophysiological etiology of PGAD began with developing an understanding of the underlying biomechanics of the pudendal nerve and the female sexual response.

AIM

To summarize the anatomy, physiology, etiologies, diagnostics, and treatments of the pertinent peripheral nerves involved in the pathology of PGAD.

METHODS

We performed a PubMed, Cochrane, Embase, Web of Science, and Google Scholar search for English-language articles in peer-reviewed journals with no predefined time period for inclusion. Terms included "humans"[All Fields] AND "persistent"[All Fields] AND/OR ("genitalia"[All Fields] OR "genital"[All Fields]) AND/OR "arousal"[All Fields] AND/OR ("disease"[All Fields] OR "disorder"[All Fields]) AND/OR "nerve"[All Fields]. The main outcomes of the papers were reviewed.

MAIN OUTCOME MEASURE

The main outcome measures were the anatomy and physiology, etiologies, history and physical examination, diagnostic imaging, and current evidence for the treatment of PGAD related to the peripheral nervous system.

RESULTS

Most of the literature for PGAD originates from case studies. The diagnosis of PGAD itself is still a debated topic of discussion. More recent data published indicate that this disease affects males, as well.

CONCLUSION

Nerve entrapment may be a source of continuous arousal. Associated PGAD symptoms would depend on the segment of the nerve involved. Unwelcomed or unwanted arousal has been observed as the most common detrimental symptom. Pelvic 3-tesla magnetic resonance imaging is recommended in all patients with suspected nerve entrapment. Lumbosacral 3-tesla magnetic resonance imaging is recommended if a Tarlov cyst or a herniated intervertebral disc is suspected. If the peripheral nerve is the source of the pathology, surgical intervention may be curative. A multidisciplinary team approach consisting of a medical provider, pelvic floor physical therapist, and sex therapist has demonstrated benefits. There are currently no Food and Drug Administration-approved evidenced-based treatments for PGAD. Klifto KM, Dellon AL. Persistent Genital Arousal Disorder: Review of Pertinent Peripheral Nerves. Sex Med Rev 2020;8:265-273.

Mechanisms of Panax ginseng action as an antidepressant

OBJECTIVES

Panax ginseng, a well-known traditional Chinese medicine with multiple pharmacological activities, plays a crucial role in modulating mood disorders. Several recent studies have identified an underlying role of Panax ginseng in the prevention and treatment of depression. However, the cellular and molecular mechanisms remain unclear.

MATERIALS AND METHODS

In this review, we summarized the recent progress of antidepressant effects and underlying mechanisms of Panax ginseng and its representative herbal formulae.

RESULTS

The molecular and cellular mechanisms of Panax ginseng and its herbal formulae include modulating monoamine neurotransmitter system, upregulating the expression of neurotrophic factors, regulating the function of HPA axis, and anti-inflammatory action.

CONCLUSIONS

Therefore, this review may provide theoretical bases and clinical applications for the treatment of depression by Panax ginseng and its representative herbal formulae.

Long-term use of antipsychotics and antidepressants is not evidence-based

BACKGROUND

The widespread use of psychiatric drugs does not appear to be evidence-based but seems to be driven mainly by commercial pressures. I studied whether two widely differing drug classes, antipsychotics and antidepressants, showed similar patterns in long-term usage.

METHODS

I constructed usage curves over a ten-year period, from 2006 to 2016, based on data from Statistics Denmark.

RESULTS

In 2006, a total of 110,235 patients deemed a prescription for an antipsychotic and 395,018 for an antidepressant, corresponding to 2.0% and 7.3% of the Danish population. Only 21,846 vs. 79,030 of these were first-time users (19.8% vs. 20.0%). The percentage of current users who redeemed a prescription for the same or a similar drug in each of the following years was remarkably similar for the two classes of drugs, and after ten years, it was 35% vs. 33%.Using the requirement that the patients identified in 2006 needed to redeem the prescription only once during the next ten years, 42% vs. 43% were taking a drug in 2016. This suggests that most patients identified at any given point in time as drug users continue taking such drugs for many years, with little or no interruption in drug intake.For first-time users, the drop in usage was much quicker. The percentage of first-time users who redeemed a prescription for the same or a similar drug in each of the following years fell to about one-third (29% vs. 36%) already after two years.Using 2011 as the starting year yielded similar results.

CONCLUSIONS

If we accept the evidence-based premises that antipsychotics and antidepressants do not have clinically relevant effects and that the patients dislike them, the data suggest massive overuse of the drugs, to a remarkably similar degree. We need to focus on helping patients withdraw slowly and safely from the drugs they are on instead of telling them that they need to stay on them.

Post-SSRI sexual dysfunction & other enduring sexual dysfunctions

Enduring sexual difficulties following treatment with selective serotonin reuptake inhibitor antidepressants have been reported to regulators since 1991, but it was only in 2006 that a formal post-SSRI sexual dysfunction syndrome was reported. The clinical, research and regulatory implications of this syndrome are considerable and researchers using epidemiological methods are well placed to map out the contours of the problem and perhaps pinpoint possible treatments.

Finasteride for androgenetic alopecia is not associated with sexual dysfunction: a survey-based, single-centre, controlled study

BACKGROUND

The occurrence of sexual dysfunction side-effects associated with finasteride use in men with androgenetic alopecia (AGA) is thought to be less prevalent than is publicized. There is a need to investigate sexual dysfunction among finasteride users with population-based controls.

OBJECTIVE

To evaluate the presence of sexual dysfunction in men using finasteride or not using finasteride.

METHOD

Adult men visiting a dermatologist's office for any reason were asked to complete a survey including a modified version of the Arizona Sexual Experience Scale (ASEX) to assess the presence of sexual dysfunction with and without finasteride use.

RESULTS

Data from 762 men aged 18-82 were collected: 663 finasteride users and 99 non-finasteride users. There were no significant differences between finasteride users and non-user controls in reporting sexual dysfunction using the ASEX. Regression analysis indicated that self-reporting libido loss and reduced sexual performance, not finasteride use, predict a higher ASEX score.

CONCLUSION

The use of finasteride does not result in sexual dysfunction in men with AGA. These data are consistent with other large survey-based controlled studies.

Long-term harms from previous use of selective serotonin reuptake inhibitors: A systematic review

BACKGROUND

Millions of people are treated with antidepressants like selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). This clinical practice is based on short-term trials that have exaggerated the benefits and underestimated the harms. We also know too little about long-term harms.

AIM

To assess harms of SSRIs and SNRIs that persist after end of drug intake.

METHODS

Systematic review of placebo-controlled randomised trials of any length in patients with a psychiatric diagnosis and a follow-up of at least six months. Our primary outcomes were mortality, functional outcomes, quality of life and core psychiatric events. We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials and checked the references for eligible articles. One researcher extracted data and another checked the data extraction.

RESULTS

Our searches returned 9,153 unique records. We included 22 papers for 12 trials on SSRIs. Median intervention and follow-up periods were 15 and 52 weeks, respectively. Median number of randomised participants was 51; only two trials had a drop-out rate below 20%.Outcome reporting was less thorough during follow-up than for the intervention period and only two trials maintained the blind during follow-up. All authors concluded that the drugs were not beneficial in the long term.All trials reported harms outcomes selectively or did not report any. Only two trials reported on any of our primary outcomes (school attendance and number of heavy drinking days).

CONCLUSION

The randomised trials currently available cannot be used to investigate persistent harms of antidepressants.