Is Your Antidepressant Killing Your Orgasm?

For millions of women, the decision to start antidepressants can be life-changing, offering them a clear path to reclaim their mental well-being. But what many don't realize is that the same medication improving their mental health may be quietly sabotaging their sex life.

In fact, some 72 percent of those on antidepressants report problems with sexual desire, and about 42 percent on selective serotonin reuptake inhibitors (SSRIs like Prozac, Zoloft, and Lexapro), specifically, report difficulty reaching orgasm.

And yet, doctors often don’t mention these side effects to women, and women don’t always feel comfortable bringing up the topic. “What a lot of times women will say to me is, ‘I've totally lost my orgasm,’ and they won't know it's because of an SSRI,” says psychologist and sex therapist Laurie Mintz, PhD.

One small report of 112 people out of the University of British Columbia found that 96 percent of people received no counseling about potential sexual side effects before starting treatment—and said the information would have changed their decision to start treatment.

That said, the depression-sex conversation isn’t so straightforward. For example, taking SSRIs could negatively impact sexual function, yet so could leaving depression untreated. Depression is also not purely biological, and sexual dysfunction (persistent and distressing issues around libido, desire, arousal, or orgasm) isn’t solely rooted in brain chemicals and hormones—it’s also impacted by our relationships, our lifestyles, and what society at large teaches us.

Yet, while too many women on SSRIs remain in the dark about sexual side effects—a product of sexism in medicine, stigma, a lack of research, and more—experts agree that you don’t need to choose between your sex life and treating your depression.

Why do Antidepressants Affect Sex Drive?

To fully grasp what happens when you take an SSRI, you first have to understand your brain. It is a lot like a busy messaging system. Brain cells called neurons constantly pass signals to one another using chemical messengers called neurotransmitters. Serotonin—often called the brain’s “feel good” chemical—is one of them. When it’s released into the tiny gap between two neurons, it delivers its message. Then it is normally vacuumed back up into the cell that sent it. SSRIs block that reabsorption, so the serotonin lingers longer—a good thing for your mood.

For years, the simple story was: depression means low serotonin, SSRIs raise it, problem solved. Of course, it’s much more complicated than that, explains Anita Clayton, MD, chair of the department of psychiatry and neurobehavioral sciences at the University of Virginia. The ways in which depression—and an SSRI for that matter—works remains poorly understood.

Yet, we do know that serotonin functions as one of the brain's primary inhibitory neurotransmitters. That means it can put the brakes on other systems. Specifically, it exists in a constant tug-of-war with dopamine and norepinephrine, excitatory neurotransmitters—the brain's accelerators—associated with arousal.

"Serotonin is stronger than either of them," Clayton says, "and more ubiquitous in the brain."

So, when you increase serotonin activity via an SSRI? You may lift your mood, but you may also hit the brakes that govern sexual desire and arousal.

Clayton says this is a “class effect,” meaning that all SSRIs do it; no one SSRI seems to be better or worse when it comes to the sexual dysfunction side effects, she says.

Of course, not all antidepressants have this type of an impact on sexual function. While around 70 percent of women on SSRIs tend to report some sort of sexual dysfunction, that figure is closer to 45 percent for those on antidepressants called Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs). Unlike SSRIs, SNRIs have some of that “excitatory norepinephrine” which SSRIs lack, Clayton explains.

It’s also important to remember that sometimes SSRIs aren’t the problem. Sometimes they can support sexual functioning due to improved symptoms of depression. “Interestingly, if you add an SSRI, half of the people get better, and in some of those people, sexual dysfunction also improves,” Clayton says.

Why SSRIs Are So Common—and Why Women’s Sexual Side Effects Are Often Overlooked

Clayton says that despite the known side effect differences in different classes of antidepressants, SSRIs have become a go-to option for providers, especially primary care doctors, because of insurance requirements (sometimes, for example, a policy won’t cover an SNRI until an SSRI doesn’t work). Doctors also “get familiar with certain medicines, and use those over and over, even though there may be other options,” says Clayton.

She adds that, too often, “stigma and sexism” keep these conversations from happening and make good information hard to find. “The stigma around sex is greatest for women,” she says. Clayton reminds that Viagra, for one, was approved despite deaths reported among users—some involving a known dangerous interaction with heart medications—and it remained on the market. Addyi, on the other hand, which was developed for women's low sexual desireide deee EfffectseFtced by the Food and Drug Administration (FDA) twice before finally being approved in 2015.

Untangling the web of sexual dysfunction and depression looks different for everyone. Most of the time, psychosocial solutions (addressing your relationship or work stress) and medical solutions (pharmacologic interventions or seeing a therapist) work best in tandem.

How to Treat Sexual Side Effects From Antidepressants

If you’re struggling with side effects, know that there is plenty of hope. Experts suggest taking these six steps to start.

1. Find a good doctor.

Doctors don’t bring up the topic of sexual side effects related to SSRIs enough—something that, too, is tied up in sexism and stigma, says Clayton. She is firm that the onus belongs on the provider, not the patient, to start conversations about sexual side effects of SSRIs—though too often it falls the other way. Seemingly every women’s health article tends to include a line about how, as a woman, it’s important to advocate for yourself, your needs, and your health in medical appointments.

Providers need to “ask explicitly about sexual function, and do it when a patient comes back, too,” she says. “If we start someone on an SSRI, we'd better ask them about sexual functioning at the next visit.” And, if they’re not willing or able to have the conversation, it’s time to “get a new doctor,” says Clayton.

2. Ask about other prescription medications.

“What often gets lost in this conversation is that there are options that are not SSRIs that can mitigate some of those issues and either be prescribed in addition to an SSRI or separate from,” says Kristen Mark, PhD, MPH, a sex and relationships researcher, educator, and therapist at the University of Minnesota.

As mentioned, SNRIs—such as Cymbalta or Pristiq—carry meaningfully lower rates of sexual dysfunction. They're especially helpful for women in perimenopause or menopause—that’s because, as estrogen drops, the brain's norepinephrine system becomes more important for both mood and sexual function. Unlike SSRIs, SNRIs support both.

Addyi, a medication originally developed to address low sexual desire, works to counter serotonin's inhibitory effects on drive—which is why it can be a useful add-on for women already on an antidepressant, says Clayton. It's been tested for safety alongside antidepressants.

Wellbutrin is another antidepressant that not only avoids sexual side effects, but can also enhance sexual function, which is why it's sometimes added to an existing SSRI prescription.

Another thing to consider: Hormonal contraception, for some women, has been linked to sexual dysfunction—this is because, by suppressing ovulation, the pill also mitigates the testosterone your ovaries make around ovulation (which can increase desire). And, some research suggests that combining oral contraceptives with SSRIs may exacerbate the problem for certain women—though the science here is still emerging. “Sometimes we need to stop somebody's birth control pills rather than stop their SSRI. We usually start with the SSRI, but I've done it both ways,” says Clayton.

3. Try something topical.

Mintz favors a topical cream containing sildenafil, the active ingredient in Viagra, which is designed to increase genital blood flow, sensitivity, and lubrication. Often the inability to orgasm, especially when taking an SSRI, is tied to blood flow, she says.

Dare Bioscience offers a sildenafil-only cream that requires a physician's prescription, and other topicals (sometimes called “scream creams”) are available OTC and contain sildenafil plus other vasodilators, says Mintz.

4. Look at other aspects of your life.

Depression goes far beyond antidepressants and brain chemistry, and sexual dysfunction is seldom purely a biological issue.

“The interpersonal components of how satisfied you are in your relationship, how stressful work is right now, and how much sleep you're getting also have a significant and potentially more impactful role to play in our sexual function,” says Mark.

Taking stock of what’s going on in your life—and how those things could be impacting your sex life or your depression—can help you come up with an individualized plan that works for you. Professional support (more on that below), such as from a therapist, can also be helpful in sorting through factors that may be impacting your well-being and libido.

5. Be mindful.

Research by psychologist Lori Brotto at the University of British Columbia finds that simple daily practices like body scans, mindful breathing, and sensate focus exercises can meaningfully improve sexual desire and arousal long-term. “Once a woman loses her orgasm, she's going to be up in her head,” says Mintz, who just created a new course for the sexual health app MOJO about regaining your orgasm. “To orgasm requires not thinking; mindfulness teaches you to turn off your brain in that way.”

Dedicating time to sex can also be helpful for staying present. Especially for women with low desire or difficulty, doing so “clears out mental space in your brain” to focus on and prepare for intimacy, Mintz says. It can even create an anticipatory state that increases arousal.

6. Seek professional support.

If you have already tinkered with medications and need additional support with side effects, consider speaking with a therapist, sex therapist, or couples therapist.

Mark also finds that, if you’re partnered, couples therapy can be impactful. “So often when women experience sexual function issues, they blame themselves or put the pressure on themselves to fix that, when really it would be a much more effective fix if their partner was integrated in that.” Improving sexual function can come down to communication, she says, and “not allowing this elephant in the room.”