Evidence-Based Reviews

Female sexual dysfunction: Don’t assume it’s a side effect

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Watch for medical, psychiatric causes.


 

References

Antidepressants are one of many possible causes of sexual dysfunction in women. Sifting through the medical, psychological, and gynecologic possibilities can be daunting, but missing the cause can aggravate the sexual disorder and—worse—delay appropriate treatment.

To help you zero in more quickly, this article explains how to:

  • accurately classify the sexual disorder based on presenting complaints
  • perform a targeted yet thorough medical, gynecologic, and psychiatric history
  • determine which lab and medical tests to order and where to refer the patient.

Case: Depressed with sexual problems

Ms. S, age 42, has major depressive disorder. Her medical history is unremarkable and menstruation is regular, but she reports discord with her husband.

The patient had been taking paroxetine, 40 mg/d for 2 years, but stopped taking it 6 months ago because she thought she no longer needed it. During that time, Ms. S says, her depressive symptoms (reduced interest and energy, insomnia, loss of appetite with weight loss, and inability to concentrate) have resurfaced. She says she sometimes wishes she were dead but denies intent to harm herself. We restart paroxetine at 20 mg/d and increase the dosage over 2 weeks to 40 mg/d.

Five weeks after reaching the target dosage, Ms. S reports delayed orgasms and reduced libido, which she attributes to paroxetine. She insists that we switch her to bupropion because it is less likely than other antidepressants to reduce sexual function.Sexual dysfunction: What’s love got to do with it?”). Women who have been sexually, physically, or emotionally abused tend to avoid sexual relationships. Some women become less sexually active with age, as fewer potential sexual partners become available. Others may have lost a sexual partner because of divorce, infidelity, disability, or death.

Is there a psychiatric cause?

Obtain a detailed psychiatric history, which should include:

Relationship status. Does the patient have a steady partner? If so, are she and her partner equally interested in sex? Are she and her partner fighting? If she is married, has she or her husband had an extramarital affair?6

If the patient does not have a steady partner, does she have sex? If yes, how often? Is she pleased with the experience?

Relationship history. Has the patient been in an abusive relationship?

Substance use. Does the patient use drugs or alcohol, which can impair sexual function? If yes, how often and how much?

Psychosocial history. Find out whether cultural or religious values have influenced the patient’s attitude toward sex.8 Cultural restrictions against openly discussing sex can inhibit a person’s view of sex or foster a belief that sex is not permissible.

Sexual orientation. Be nonjudgmental, but watch for signs of gender identity disorder, which requires more-focused interventions.

Past and current psychiatric disorders. Women with depression are more likely than nondepressed women to lose sexual desire and complain of anorgasmia.8

Sexual dysfunction can also accompany symptoms of posttraumatic stress disorder or anxiety, particularly if past sexual trauma caused these symptoms.

Case Continued: A turn for the worse

Several months later, Ms. S’ depressive symptoms have worsened, and she develops psychosis (primarily persecutory delusions). We hospitalize her and diagnose major depressive disorder with psychotic features. We increase paroxetine to 60 mg/d over 3 days. We also add risperidone, 1 mg nightly, and titrate over 1 week to 2 mg nightly.

After 2 weeks, we discharge Ms. S when she reports improved mood with no suicidal thoughts or psychotic symptoms. She says her marriage is stable, but her sexual interest is again diminished. Continued psychotherapy has not alleviated her sexual symptoms, nor has reducing paroxetine to 40 mg/d. Risperidone dosage is the same.

Six weeks after discharge, Ms. S reports irregular menses and galactorrhea that have been present for 1 month. She fears she is entering menopause.

Discussion. Ms. S’ case shows how convergent psychological, medical, and pharmacologic risk factors for sexual dysfunction can confound diagnosis in women with depression.

Paroxetine—like other selective serotonin reuptake inhibitors—can reduce sexual desire,9 but Ms. S’ sexual symptoms persisted after we reduced the dosage or stopped the medication. Psychodynamic psychotherapy saved her marriage but did not improve her sexual function.

  • Is Ms. S starting menopause?
  • Is risperidone—which also can decrease libido3—a contributing factor?
  • Do galactorrhea and irregular menses signal a serious medical problem?
Menopause can create a “cycle” of sexual dysfunction for older women. At age 42, Ms. S is probably not reaching menopause unless recent gynecologic surgery has triggered early onset.

Is there a medical problem?

Because so many medical conditions can contribute to one or more sexual dysfunction disorders, the presenting symptoms should guide the medical history (Table 3). Ask about:

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