Bupropion for Sexual Dysfunction

CLINICAL ACTIONS:

Bupropion for sexual dysfunction can be helpful when the patient’s concerns are arousal and orgasm. Bupropion is not indicated for sexual desire problems that do not include issues with arousal and orgasm.

• Bupropion sustained-release 150 – 400 mg per day has been studied for the treatment of Hypoactive Sexual Desire Disorder (HSDD)
  • Start at lower dose
  • Follow up at 2-4 weeks
  • Most patients do not have trouble tolerating the medication

SYNOPSIS: 

Bupropion, a norepinephrine-dopamine reuptake inhibitor, is commonly used and has been approved for depression and smoking cessation.  Following multiple studies, it is also used off-label for the treatment of HSDD. While dopamine is often associated with addiction and craving, it is also effective in aiding the access of pleasurable response. Data from studies in individuals who are not depressed indicate that the drug is useful in the setting of orgasmic dysfunction, separate from antidepressive properties it may have.

KEY POINTS:

• If after a month, the patient experiences little to limited improvement in orgasmic capability, either in ease of producing an orgasm or quality of orgasm, dose can be raised up to 400 milligrams
• Blood pressure should be monitored before prescription and after a month as bupropion can raise blood pressure
• Safety data for bupropion specifically for HSDD are not available but common side effects seen when used for depression include
  • tremor (13.5%), agitation (9.7%), dry mouth (9.2%), constipation (8.7%), excessive sweating (7.7%), dizziness (6.1%), and nausea/vomiting (4%)
  • Adverse events caused discontinuation of treatment in approximately 10% of study participants
• Contraindications include but are not limited to the following (see FDA information in ‘Learn More’ Below)
  • Seizure disorder
  • Current or previous bulimia or anorexia nervosa
  • Monoamine Oxidase Inhibitors (MAOIs)
  • Patient is already on bupropion for smoking cessation

Learn More – Primary Sources:

ISSWSH Expert Consensus Panel Review: Hypoactive Sexual Desire Disorder 

Effect of Bupropion-SR on Orgasmic Dysfunction in Nondepressed Subjects: A Pilot Study

Disorders of Orgasm in Women: A Literature Review of Etiology and Current Treatments

Cochrane Review: Strategies for managing sexual dysfunction induced by antidepressant medication

FDA: Bupropion-SR

Locate a Sexual Health Professional:

AASECT-Referral Directory 

ISSWSH-Find a Provider 

SSTAR-Find a Therapist

Your Patient’s Orgasm Has Disappeared – Next Steps

CLINICAL ACTIONS:

Secondary anorgasmia describes a situation in which a woman used to achieve orgasm and over time her response has weakened or dissipated. If you identify this concern, or a patient reports this problem

• Take the time to ascertain that the patient is indeed describing secondary anorgasmia
• Assess if the problem is secondary to medications
• In those situations where a patient is able to achieve orgasm in some way, but they are concerned because they are unable to achieve orgasm using penile/vaginal stimulation alone, psychoeducation is needed to assure them that they are perfectly normal as this is the case with 70% of women

SYNOPSIS:

Secondary anorgasmia is fundamentally much easier to treat than primary anorgasmia and can often be resolved with medication or behavioral treatment fairly effectively. Various treatment options can be offered and discussed with the patient.

KEY POINTS:

• Secondary anorgasmia can describe a situation in which one of the following scenarios is occurring:
  • It takes a woman significantly more time than it previously did to achieve orgasm
  • Orgasms are weak or almost non-discernable
  • A woman cannot reach orgasm at all
• Assess whether the secondary anorgasmia is due to side effects of medications
  • Selective serotonin re-uptake inhibitors (SSRIs) and Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) often cause secondary anorgasmia in women
  • Oral contraceptives can also affect a woman’s ability to achieve orgasm
• Treatment options include:
  • Bupropion HCl, particularly if anorgasmia is caused by antidepressants
    • 150 mg daily, increase if needed, increase to twice daily dosage up to 300 mg
    • Can take up to 2 weeks for results
  • Testosterone Treatment
    • May take 3-6 months for results
  • If secondary anorgasmia determined to be due to medication side effects, consider modification:
    • Discontinuation of oral contraceptives
    • Reduction of SSRI, if possible and under the guidance of the prescribing physician
  • Introduction of strong vibrator
  • While some authors suggest introduction of phosphodiesterase type 5 (PDE5) inhibitors, which is commonly used in men for erectile dysfunction, ACOG states that more research is required to determine efficacy before a recommendation for use in women can be made
• Education is important in those cases where, due to medication or age, more direct or higher levels of stimulation are needed so that the patient understand that this is not uncommon
• Generally, referral to a psychotherapist may not be required as this is rarely a purely psychological issue
• Referral to a sex therapist if patient interaction does not allow time for discussion, or to benefit from expertise to discuss vibrator use
• DIAGNOSIS CODES: Female Orgasmic Disorder DSM-5 302.73 (F52.31)

Learn More – Primary Sources:

Delayed Orgasm and Anorgasmia

Disorders of Orgasm in Women: A Literature Review of Etiology and Current Treatments

AAFP: Sexual Dysfunction in Women – A Practical Approach

Cochrane Review: Strategies for managing sexual dysfunction induced by antidepressant medication

NAMS Practice Pearl: Testosterone for Midlife Women: The Hormone of Desire?

Treatment Options for the Patient with Sexual Arousal Concerns

CLINICAL ACTIONS:

Arousal problems occur when women do not experience the usual sexual response to the introduction of sexual stimulation.

• Obtain a history to better understand the problem
• Ascertain that the problem is arousal, rather than desire/libido
• Clarify woman’s arousal response by asking about lubrication, mental interest, tingling or swelling normally experienced by the patient
• Consider treatment with medications, but benefit may also be gained by simultaneous referral to a sex therapist

SYNOPSIS:

Women describe problems with sexual arousal in a variety of ways: an inability to “quiet the laundry list” in their brains, or a marked absence of the swelling and tingling often felt with sexual arousal.  Absent too may be the lubrication that women have experienced in the past. Often they will describe it as “nothing happening down there.”  Once the possibility of the problem being desire rather than arousal has been excluded (see differential diagnosis desire/arousal) there are a number of treatments that can be effective.

KEY POINTS:

• Assess whether the problems with arousal is due to side effects of medications and if that is the case, consider whether those medications should be reduced or discontinued under the guidance of the prescribing physician
  • SSRIs and SNRIs can often cause arousal problems in women
  • Oral contraceptive pills can also affect a woman’s ability to become aroused. Sometimes women will describe the feeling as “being covered in a slipcover”
• Treatment options include:
  • Bupropion xl 150 mg daily, increase if needed, to twice daily up to 300 mg per day
  • Testosterone Treatment
  • Introduction of strong vibrator
  • While some advocate for the use of PDE5 (phosphodiesterase type 5) inhibitors, used for male erectile dysfunction, ACOG does not recommend use of these drugs without further study
• Education is needed in those cases where, due to medication or age, more direct or higher levels of stimulation are needed and perfectly natural
• Consider referral to a sex therapist to recommend or discuss practical solutions to increasing mental and physical stimulation
  • A sex therapist may help the patient to take more time and can suggest use of erotica, fantasy or vibrators

Learn More – Primary Sources:

Management of antidepressant-induced sexual dysfunction

Reversal of SSRI-induced female sexual dysfunction by adjunctive bupropion in menstruating women: a double-blind, placebo-controlled and randomized study

Systematic review and meta-analysis of phosphodiesterase type 5 inhibitors for the treatment of female sexual dysfunction

AAFP: Sexual Dysfunction in Women – A Practical Approach

Cochrane Review: Strategies for managing sexual dysfunction induced by antidepressant medication