What Happened to My Sex Life? (cont.)

A very short chemistry lesson on how SSRIs work and why they can massacre your sex drive: Higher levels of serotonin in the brain generally lead to enhanced moods. Prozac and its family of drugs increase the level of serotonin by preventing its uptake in receptor nerve cells, thereby assisting brain cells to communicate better with one another. For reasons not completely understood, the rush of serotonin causes in many people an effect that restores confidence, eases anxiety, and improves self-esteem. The downside is that while the serotonin is doing all this great stuff, another chemical in the brain, dopamine -- known to increase sexual desire -- is suppressed.

Alas, the proposition was too good to be true. There is no free lunch. No rights to sexy morning reveries or sweet-dream dalliances that provide a (legally) drug-induced feeling that makes you happy. If you want to be chemically induced confident and serene (or, at least, no longer depressed), you may have to kiss off such sexual luxuries once thought to be absolute generational rights.

As far as physicians can determine, there are four kinds of sexual dysfunction when it comes to SSRIs: loss of sexual desire, difficulty getting aroused (in men, erectile flaccidity; in women, lack of lubrication and similar lack of engorgement), duration of time from arousal to orgasm, and intensity and length of orgasm. Both women and men report about the same incidence of dysfunction when they take SSRIs.

But the incidence of dysfunction while on SSRIs probably is even greater than reported. The underlying problem is that physicians and patients often don't talk about the sexual side effects of antidepressants. Some patients are too embarrassed to 'fess up. Many are so happy that they're not depressed any longer that the dip in their sex lives becomes secondary to their spectacularly upturned mood. It's a price, but one that most SSRI-users happily pay.

Why SSRIs dampen sexual ardor is still under research. Three physicians at the University of G?teborg in Sweden (J. Matuszcyk Vega, K. Larsson, and E. Eriksson) injected a male rat with fluoxetine (the chemical compound of Prozac) and found that the rodent couldn't ejaculate when he frequented a female rat nearby.

Fellows at the department of psychiatry and neurosexology concocted another pioneering study at The Hague's Leyenburg Hospital. While having sex with their partners, volunteers equipped with stopwatches timed how long it took them to ejaculate while on SSRIs. The doctors concluded that the men's ejaculations were dramatically slowed, and in some cases, stopped by the SSRIs. Off the SSRIs, the men performed fine.

For those on SSRIs, don't despair. There are a host of legal drugs and herbs that may help restore your libido and return your orgasms. But as in prescribing SSRIs, it's a hit-and-miss proposition. Some drugs and herbs work to bring back libido; others fail.

Before you mainline yet another dose of a potent herb or drug (which, too, may carry side effects), most psychiatrists suggest one of the following strategies to help stoke your libido. Don't try the following at home until you discuss it with your physician.

  • Talk to your doctor about a drug-free holiday. For example, go off your SSRI Thursday through Sunday and then attempt sex (even wild sex!) on Sunday night. This may work with Paxil, Zoloft, Celexa, or Effexor, but it won't if you're taking Prozac, which stays in your system for a longer time than the other drugs. Drug half-life is the time it takes for the pharmaceutical to decrease by half of its original dose in your blood stream. Prozac's half-life is about a week; Paxil and Zoloft take about a day. The drug-free holiday strategy is a gamble. Many users don't want to risk being off their SSRI, even for a day.

  • Ask your doctor about lowering your dosage. The standard daily dose of Prozac, for instance, is 20 milligrams. Reduce it to 10 milligrams, by either getting a new prescription or (the less expensive way) by taking a 20-milligram capsule once every other day. This works especially well with Prozac, precisely because its half-life is so long; results with other SSRIs may be mixed.

  • Switch antidepressants. Wellbutrin, Remeron, Effexor, Luvox, Celexa, Serzone, and Desyrel may be less likely to destroy libido but, for many, aren't as effective in combating depression as Prozac, Paxil, or Zoloft. (Interestingly, the smoking-cessation drug, Zyban, is the exact same formula as Wellbutrin in a smaller dose.)

  • Wait. Give your body time to compensate for the rush of serotonin that bathes the delicate receptor tissues of the brain. Some or most of your sex drive may eventually return. Some people, like Holly, develop tolerance to the sexual side effects and eventually bounce back.

If you are able to maintain your composure and return to your sexual equilibrium after trying the above, read no further. If not, some additional gambits: The drug yohimbine has shown to reverse the sexual side effects of SSRIs, says M.J. Gitlin, a psychiatrist at UCLA. Yohimb?, an African bark, is available over the counter; your physician will have to write a prescription for yohimbine, a pharmaceutical agent. It is a non-hormonal drug, in pill form, designed to decrease the outflow of blood from the penile tissue. Yohimb? chewing gum is available in some health food stores.

Some physicians suggest taking a half-tab to one tab (5.4 milligrams each) of the pill an hour or so before the "event." Beware, though, yohimbine can produce insomnia, already a side effect for many people on SSRIs.

The herb ginkgo biloba may also work. Alan Jay Cohen, a psychiatrist at the University of California at San Francisco, did a study on ginkgo-tree leaf extracts in which he reported that 86% of patients who took two 60- to 120-milligram capsules twice a day reported substantial improvement in their sexual function, with no side effects. Cohen says that ginkgo biloba restored the blood flow to the genitalia often blocked by the serotonin-enhancing drugs. The popular prescription drug, Viagra, does much of the same.

If all else fails, here's another idea: Three psychiatrists wrote in the Journal of Clinical Psychiatry that granisetron (a sexual stimulant in rats) works great in men and women, if taken one hour before sex. But the drug, available as Kytril (and labeled for chemotherapy-related nausea control), costs $50 a pill. That means it would have to be a very hot date.

Stephen G. Bloom teaches medical reporting at the University of Iowa.

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