Post-SSRI Sexual Dysfunction (PSSD)

Post-SSRI Sexual Dysfunction (PSSD) is a medical condition which as its name suggests is a sexual dysfunction which occurs after taking SSRI (selective serotonin uptake inhibitor) or SNRI (serotonin-norepinephrine reuptake inhibitor) drugs.

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SSRIs (and SNRIs) are a widely used class of drug used to treat depression, obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety, social anxiety, pre- and postmenopausal syndromes, hot flashes, chronic pain, chronic fatigue syndrome, and sometimes even paraphilias and premature ejaculation.

Basically, patients suffering from PSSD continue to experience the sexual side effects associated with the drug they took, even after discontinuation of the drug.

This SSRI-associated persistent sexual dysfunction can affect people of all ages, both male and female, and from all ethnic groups.

The condition was first reported in 1991, but only in 2006 was this condition formally defined as a syndrome.

The reason it is called Post-SSRI Sexual Dysfunction rather than the perhaps more appropriate SSRI-Induced Sexual Dysfunction is that this syndrome occurs after discontinuing SSRIs (hence, “post”).

This syndrome is “under recognized,” which is excellent for drug companies selling these drugs, but no so great for the people affected by this condition, which can be not only physically debilitating but also psychologically.

Drugs Known to Cause PSSD

Almost everyone who uses SSRIs will develop some type of sexual side effect.

The SSRIs which have been reported to induce PSSD include:

  • fluoxetine (Prozac Weekly, Sarafem, and Prozac)
  • paroxetine (Pexeva, Paxil CR, Paxil)
  • venlafaxine (Effexor XR)
  • escitalopram (Lexapro)
  • sertraline (e.g., Zoloft)
  • citalopram (Celexa)
  • fluvoxamine

Other drugs which increase serotonin levels have been associated with similar sexual side effects, including tricyclic antidepressants such as

  • doxepin (Silenor, Prudoxin, and Zonalon)
  • clomipramine (Anafranil)
  • imipramine (Tofranil)
  • amitriptyline

Symptoms of PSSD

The symptoms of PSSD can start as soon as days once SSRIs are ingested and can persist after discontinuing the drugs, which is when they become POST-SSRI Syndrome.

Even a single dose of an antidepressant can be enough to induce PSSD. Indeed, genital anesthesia has been reported to occur within 30 minutes of a first dose (!)

What is the Post SSRI syndrome?

  • genital numbness/anesthesia (decrease in sensation in the genital area)
  • decreased sex drive (libido)
  • erectile dysfunction in men

Additional possible symptoms of Post-SSRI Sexual Dysfunction may include:

  • vaginal lubrication issues, irregular menstruation, and nipple insensitivity in women
  • failure to become aroused or reach an orgasm (anorgasmia)
  • pleasure-less or weak orgasm
  • premature/delayed ejaculation
  • decreased penile size
  • smaller seminal volume
  • testicular atrophy and pain
  • a general dampening of reactivity (emotional numbing)
  • restless genital syndrome – excessive and persistent sensations of genital and clitoral arousal with the absence of conscious feeling of sexual desire
  • persistent genital arousal disorder – a disorder in which genital arousal persists for hours or days after the cessation of the sexual stimulation, despite the experience of at least one orgasm

Going over this list of symptoms, it becomes clear why this condition causes so much distress and has such a serious negative effect on people’s emotional wellbeing.

PSSD has been classified into two categories based on symptom onset:

  1. Early onset – the sexual dysfunction began during SSRI use and persisted after it was discontinued.
  2. PSSD occurring only after discontinuation of the drug.

How Does PSSD Happen?

PSSD is an iatrogenic condition, in other words, it is caused by doctors!

The problem with modern medicine is that while it’s great for treating acute conditions, such as broken bones, infections, and heart attacks, for chronic diseases, such as depression, they may sometimes do more harm than good.

Which is exactly the problem with antidepressant medications, such as SSRIs.

In fact, antidepressant medications are so ineffective that they take at least 2 weeks of ingesting daily in order to exert any effects, which means they are absolutely useless for an acute attack of severe depression and suicidality for instance.

In addition, they may induce a wide array of side effects, including sexual dysfunction, which may become permanent or last for a very long time if left untreated.

PSSD usually begins after a few doses of antidepressant drugs, but may sometimes become apparent only after years of exposure, persisting for decades afterwards.

Why Does PSSD Happen?

Scientists do not yet understand this condition, however they believe that genital numbing may related to the action of antidepressant drugs on sodium channels in the membranes of our cells.

While this action is useful for treating neuropathic pain, it is less helpful for our sex drive.

Other theories which attempt to explain why PSSD happens include:

  • downregulation of the serotonin 1A receptor (5-HT1A receptor)
  • proopiomelanocortin and melanocortin effects
  • hormonal changes in the nervous system
  • epigenetic gene expression theory
  • dopamine-serotonin interactions
  • serotonin neurotoxicity
  • cytochrome actions

For example, according to the Epigenetic Change and Receptor Downregulation Theory, the drugs can change our genes, reducing the number of a specific serotonin receptor, thereby suppressing cellular response to serotonin. Basically, your serotonin receptors become less responsive to the neurotransmitter.

Hormonal theories on the other hand blame different hormones which may cause various neurochemical changes, including persistent sexual dysfunction.

Do SSRIs cause permanent changes or does PSSD go away?

You might be wondering how long after stopping antidepressants before you will feel normal again.

No one knows, but PSSD is NOT always permanent. Each person is different. Different people may return to baseline after a few days, weeks, months, years, or never.

However, because some people do report spontaneously recovering from the condition with time while others experience brief remissions which can last days, it is generally believed that PSSD does NOT result from permanent damage.

Treating PSSD – How do you treat post SSRI sexual dysfunction?

PSSD Diagnosis

Firstly, there’s the challange of diagnosing the condition, which is done based on the symptoms; there’s no blood test or a clear and reproductive diagnostic criteria.

This is a Dream...

Each person impacted by the condition may have different symptoms in severity and duration.

The challange is especially great since the lack of sexual drive/desire and low libido could be a symptom of mental illness for which the drug was initially prescribed. Indeed, decreased sexual arousal is reported by up to 50% of depressive patients.

Also, many doctors are unaware of this condition. There’s not even a Healthline / WebMD article about it (!) They do however have pages about sexual dysfunction WHILE taking SSRIs.

Basically, your doctor will need to exclude all other possible causes of sexual dysfunction, such as urological infections or cancer, diabetes, cardiovascular disease, high blood pressure, high cholesterol, hormonal imbalances, etc.

A proper PSSD diagnosis should involve a review of drug history, onset of symptoms, and the patient’s sexual condition before starting such a medication.

It is also important not to confuse the condition with a related syndrome known as post-finasteride syndrome. It occurs in men taking urinary retention medications (5-α reductase inhibitor drugs), such as finasteride (Propecia, Propecia Pro-Pak, Proscar) and dutasteride (Avodart) and is also characterized by sexual dysfunction.

Isotretinoin (Absorica, Zenatane, Myorisan, Claravis, and Amnesteem), used to treat severe acne, is another drug which can cause anejaculation and decreased fertility.

PSSD Treatment

Even if the condition is diagnosed, there are unfortunately no effective treatments for it at the time of writing this article.

Low-power laser irradiation and phototherapy (directed toward the scrotal skin and the shaft of the penis) have shown some promising results (improved penile sensitivity with no relief of anejaculation and erectile dysfunction), but there’s still no definitive treatment for PSSD.

Drugs which have been tested for PSSD include:

  • 5HT1 agonists (buspirone)
  • a 5HT1A antagonist – 70% improvement in penile erection that had been impaired by fluoxetine use (study on rats)
  • 5HT2 and 5HT3 antagonists (trazodone and mirtazapine) – can induce a prolonged erection of the penis and increase libido in normal people, but has little to no effect in patients with PSSD.
  • dopamine agonists (pramipexole and cabergoline) – little benefit reported
  • a dopaminergic antidepressant (amineptine) – only 4% of patients who had switched to amineptine suffered from sexual dysfunction after 6 months compared to more than 50% of those who remained with SSRIs
  • sildenafil, vardenafil, and other phosphodiesterase type 5 inhibitors and testosterone – no improvement
  • donepezil (Aricept)
  • ketamine
  • metformin (Glucophage, Riomet, Glumetza)

Cognitive-behavioral therapy, often involving the patients’ partners, also has been used for PSSD. It is especially beneficial for dealing with negative thoughts (e.g., sexual inadequacy and low self-esteem) which often develop in PSSD sufferers, providing emotional and psychological support for patients and their partners.

Are there any natural remedies to try for PSSD?

Saffron was anecdotally reported to improve the sexual side effects of SSRIs (including improving sexual arousal and lubrication).

I would also suggest looking into yohimbine, which seems to work for some people.

There are additional herbal remedies (e.g., Turnera diffusa, Ginkgo biloba, and Panax ginseng), but I would need more information regarding your personal circumstances to be able to recommend them.

To recommend a herbal formula for PSSD, I would have to take into consideration the idiosyncratic symptoms of each patient.

A couple of additional tips:

  1. If you are in a country that allows it, cannabis (THC) is one of the most potent aphrodisiacs.
  2. If you are overweight, this could be aggravating your problem. Make sure to reach a normal weight.

Prevention of PSSD

Reducing the dose of SSRIs is not known to prevent PSSD.

Switching to bupropion (Wellbutrin XL, Wellbutrin SR, Forfivo XL) or nefazodone may prevent PSSD. These are antidepressants that are not known to cause any sexual adverse effects.

Even adding bupropion as an adjunct therapy may be beneficial in treating SSRI-related sexual dysfunction, improving desire and frequency of sexual activity.

A side note: My intuition tells me that any damage serotonergic drugs do, may be reversed with the serotonin balancer of nature: Psilocybin mushrooms. And microdosing magic mushrooms for depression instead of taking pharmaceuticals may prevent this disorder. Unfortunately, they are illegal in most of the US and the world so it would be quite difficult to get some of this medicine without traveling to special resorts or to cities in the US where they are decriminalized.

Conclusion

PSSD is a persistent sexual dysfunction that occurs after discontinuation of SSRI use.

While there is no definitive treatment for PSSD, there are some proposed management options, including

  • lowering SSRI dosage or replacing it with a better alternative
  • adjunct therapy (e.g., adding bupropion)
  • cognitive-behavioral therapy

It’s vital to ensure that you are not harboring any beliefs regarding the permanency of the condition.  Such a belief may make you resign to your faith and prevent you from truly trying to fix the problem. Also, the mind has power over the body. If you believe it is permanent, that belief may be the reason you’re not recovering.

I offer free as well as full consultations, which can allow me to recommend a herbal formula specifically for you in addition to other interventions that may help your condition in a manner that will not cause additional problems (e.g., not with medications since there is no medication known to help and most drugs have side effects).

It is my belief that if you give the body-mind ideal conditions (nutrition, exercise etc.) instead of adding more and more drugs, and it will heal itself.

Do you have any questions? I invite you for a free consultation with me where I will answer any questions you may have. 

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