Spinderella cut it up one time

Yo, I don't think we should talk about this
Come on, why not?
People might misunderstand what we're tryin' to say, you know?
No, but that's a part of life

Come on

Let's talk about sex, baby.

Or not.  Because 20-40% of all patients taking an SSRI, or Selective Serotonin Reuptake Inhibitor, experience sexual dysfunction in the form of decreased libido, difficulty with arousal, and/or changes in orgasm or even (gasp!) anorgasmia.

SSRIs cause sexual dysfunction to different extents.  Data from a wide variety of studies show varying percentiles, but have consistently shown that paroxitine (or Paxil) has been the greatest offender, fluoxetine (Prozac) with the lowest incidence, with sertraline (Zoloft) and citalopram (Celexa) being in between. 

The exact prevalence has not been established due to wide range of percentiles.  While some patients are able to tolerate the side effect in relation to their improvement in mood, it is intolerable to others and hinders the use of these medications.  As a result, there has been great interest in the management of sexual dysfunction in patients taking an SSRI.

Let's talk about you and me
Let's talk about all the good things
And the bad things that may be
Let's talk about sex
Let's talk about sex

All patients are created differently.  While decreasing the dose will often not alleviate the side effect, switching to another medication within the class can help.

There has also been interest in the use of ginkgo biloba for sexual dysfunction in patients taking SSRIs.

Ginkgo biloba is an herbal remedy that has recently been catching on in the U.S. after thousands of years of use in China.  Its potential uses include everything under the kitchen sink, including neuroprotection, anti-platelet effects, protection against airway hyperactivity, and sexual dysfunction. 

Let's talk about sex for now to the people at home or in the crowd
It keeps coming up anyhow
Don't decoy, avoid, or make void the topic
Cuz that ain't gonna stop it

Unfortunately there is not very much financial interest in the investigation of herbal products, but there have been a few small scale trials looking at ginkgo for sexual dysfunction.

While some small scale trials have showed increased libido or increased penile blood flow, most of the evidence does not support ginkgo as an effective treatment for sexual dysfunction.

The greatest problem with ginkgo and other herbal supplements is the lack of regulation in preparation and administration.  There is no standardization of dosing or manufacture.  Dosing used in trials for sexual dysfunction ranged from 60 mg daily to 300 mg three times daily, with no established efficacy for any of the doses. 

Additionally, the components of ginkgo have a wide range of effects, which does establish ginkgo as a remedy for a wide range of indications, but also means that the herb does not come without side effects.  Most concerning of which, is the risk of bleeding secondary to platelet inhibition.

Patients taking warfarin, aspirin, plavix or any other anti-coagulant should notify their physician before taking ginkgo.  Additionally, high doses of ginkgo may result in bleeding.  Doses above 240 mg daily have also been associated with skin reactions, vomiting, and diarrhea.

Now we talk about sex on the radio and video shows
Many will know anything goes
Let's tell it how it is, and how it could be
How it was, and of course, how it should be
Those who think it's dirty have a choice
Pick up the needle, press pause, or turn the radio off
Will that stop us, Pep? I doubt it
All right then, come on, Spin

So what’s left?  Ginkgo is not the only herbal supplement available for the potential alleviation of sexual dysfunction related to SSRIs.  A retrospective study by Keller Asher in 1997 examined the use of amantadine, yohimbine, and cyproheptadine in reversing SSRI induced sexual dysfunction in 596 patients.  While all three therapies were found to be safe and relatively effective, yohimbine was found to be significantly more effective. 

Yohimbine is an alpha-2 antagonist derived from the bark of an African tree.  Most of the data supporting the use of yohimbine has been in men and supporting erections, although there is sparse evidence to show that it may be useful for anorgasmia secondary to anti-depressant use in females as well.  Side effects include sweating, hypertension, and agitation; therefore it should not be recommended to patients with certain cardiac or psychiatric conditions.  Yohimbine doses range from 5.4 mg to 16.2 mg as needed 1 to 4 hours before intercourse.

Cyproheptadine is a serotonin receptor blocker, making it an effective treatment for serotonin syndrome and effective in reversing the side effects of SSRIs.  However, benefit in its ability to alleviate sexual dysfunction result from a reversal in the action of the antidepressant.  It should not be used daily for SSRI induced sexual dysfunction because it would negate the action of the SSRI on improving mood.

Both amantadine and bupropion, which increase dopaminergic activity, have also been shown to improved SSRI induced sexual dysfunction.  A survey by Dording et al in 2002 showed that the addition of bupropion was the most popular method in managing SSRI induced sexual dysfunction, followed by switching agents.

Ladies, all the ladies, louder now, help me out
Come on, all the ladies - let's talk about sex, all right

Yo, Pep, I don't think they're gonna play this on the radio
And why not? Everybody has sex
I mean, everybody should be makin' love
Come on, how many guys you know make love?

Let's talk about sex.

References:

Demyttenaere K et al.  Bupropion and SSRI-induced side effects.  Journal of Psychopharmacology 2008;22(7):792-804.

Uptodate online resource.  Clinical use of ginkgo biloba.  Last updated January 2010.  Available at www.uptodate.com.

Wheatley D.  Triple-blind, placebo-controlled trial of Ginkgo biloba in sexual dysfunction due to antidepressant drugs.  Human psychopharmacology 2004;19:545-8.

Rowland DL et al.  A review of plant-derived and herbal approaches to the treatment of sexual dysfunctions.  Journal of Sex & Marital Therapy 2003;29(3):185-205.

Keller Ashton A et al.  Serotonin reuptake inhibitor-induced sexual dysfunction and its treatment: a large-scale retrospective study of 596 psychiatric outpatients.  Journal of Sex & Marital Therapy 1997;23(3):165-75.

Mayo Clinic.  Erectile dysfunction herbs: a natural treatment for ED? 2008.  Available at http://www.mayoclinic.com/health/erectile-dysfunction-herbs/MC00064.

Kanaly KA et al.  Sexual side effects of SSRI medications: potential treatment strategies for SSRI-induced female sexual dysfunction.  Current Women’s Health Reports 2002;2:409-416.

Dording CM et al.  The pharmacologic management of SSRI-induced side effects: a survey of psychiatrists.  Annals of Clinical Psychiatry 2002;14(3):143-147.