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Sexuality and Reproductive Issues (PDQ®): Supportive care - Health Professional Information [NCI] - Pharmacological Effects of Supportive Care Medications on Sexual Function

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The long-term effects of reduced testosterone and amenorrhea are not well known. Sexuality is an important component of one's quality of life, especially for cancer survivors, but also for some people with advanced disease. Patients may report a history of changes in libido and sexual dysfunction. If these changes are distressing to the patient, serum total- and free-testosterone levels and prolactin levels may be obtained.[14] Should the patient seek improvement in libido and performance, treatment is often empirical, keeping in mind that there are many potential causes of changes in sexual function. Treatment options may include using nonopioids for pain, adding adjuvant analgesics in the hope that the opioid dose may be reduced, or replacing testosterone through injections, a patch, or gel if not contraindicated.[15] More research is needed to understand the relationship between opioids and sexual function, as well as the most effective treatment strategies.

Selective Serotonin Reuptake Inhibitors

Decreased sexual desire is a frequent symptom of depression, and sexual impairment in depressed patients has been consistently confirmed in controlled studies.[16,17][Level of evidence: II] Continued recognition of the difficulty in discerning the subjective complaints that are a part of the depressive syndrome, the consequences of treatment, a pre-existing sexual dysfunction, or a combination of these factors is needed. Approximately one-third of depressed patients without medication treatment report reduced sexual desire, anorgasmia, delayed ejaculation, or erectile dysfunction.[18] Selective serotonin reuptake inhibitors (SSRIs), tricyclics, monoamine oxidase inhibitors, and lithium have all been associated with sexual dysfunction.[19,20]

Sexual desire is mediated through the central nervous system by the reception of sensory stimuli and the subsequent interpretation through the limbic system and prefrontal cortex.[21] Additionally, the hypothalamic and preoptic nuclei contribute to the mediation of this process. Serotonin inhibits hypothalamic arousal postsynaptic receptors resulting in the release of excitatory neurotransmitters. These neurotransmitters are responsible for the activation of the erectile centers of the spinal column. Upon activation of the erectile centers, subsequent erection, orgasm, and detumescence occur in males, whereas genital vasocongestion, vaginal lubrication, and clitoral enlargement occur in females.[22] Physiologically, serotonin is stored in synaptosomal vesicles awaiting another impulse for release. SSRIs inhibit this uptake mechanism, which results in the pooling of serotonin in the synaptic space.[21,23] The excess serotonin causes the postsynaptic receptors to down-regulate, resulting in decreased stimulation of the lower erectile centers. It is this action that is thought to be the principal mechanism for SSRI-induced sexual dysfunction.

There are no well-controlled studies that evaluate the effects of SSRIs on sexual function within the oncology patient population. There are several studies, however, that have examined the effects of fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft) on sexual function in patients being treated for depression or obsessive-compulsive disorder. There are few data regarding the prevalence of sexual dysfunction with the use of citalopram (Celexa) in the treatment of depression. Sexual dysfunction from SSRIs has generally been reported to affect approximately 1% to 15% of patients in clinical trials of these medications in physically healthy depressed patients. Other studies, however, report significantly higher rates of sexual dysfunction that may more accurately reflect the incidence typical of clinical practice. A large-scale retrospective nonrandomized comparison trial of 596 psychiatric outpatients (167 men, 429 women) treated for at least 6 months with sertraline (n = 170), fluoxetine (n = 298), venlafaxine (n = 36), or paroxetine (n = 265) found that symptoms of sexual dysfunction were spontaneously reported by approximately 20% of patients overall and were more common in men (23.4%) and married individuals of both genders. The rates of sexual dysfunction associated with each of the SSRIs were the following: sertraline (16%), fluoxetine (20%), paroxetine (22%), and venlafaxine (38%). For this sample, the most common sexual symptoms reported were orgasmic delay or anorgasmia, followed by decreased desire and arousal difficulties.[24][Level of evidence: III] A prospective multicenter study of 344 patients (152 men, 192 women) with mixed psychiatric disorders treated with SSRIs and systematic inquiry of sexual dysfunction by the physician found the frequency of sexual side effects was highest for paroxetine (65%), followed by fluvoxamine (59%), sertraline (56%), and fluoxetine (54%).[25][Level of evidence: II] Paroxetine produced significantly greater delay of orgasm or ejaculation (48%) and more frequent erectile dysfunction and vaginal lubrication difficulties than sertraline (37% and 16%), fluvoxamine (31% and 10%), or fluoxetine (34% and 16%). Loss of libido and anorgasmia were more severe in women, though men reported a greater frequency of sexual dysfunction. The effects of SSRIs are dose related and may vary among the group. The incidence of sexual dysfunction obtained by patient self-report does not appear to reflect the true incidence of sexual dysfunction associated with antidepressant therapy, and systematic inquiry by providers is needed as sexual dysfunction may be an unrecognized cause of noncompliance.[26] Two critical reviews of the effects of SSRIs on sexual function are available.[26,27][Level of evidence: IV]

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WebMD Public Information from the National Cancer Institute

Last Updated: February 25, 2014
This information is not intended to replace the advice of a doctor. Healthwise disclaims any liability for the decisions you make based on this information.
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