Medications that may contribute to sexual disorders: a guide to assessment and treatment in family practice

Journal of Family Practice, Jan, 1997 by William W. Finger, Margaret Lund, Mark A. Slagel

Approximately 15% to 25% of family practice patients have concerns about sexual function and are most comfortable discussing these issues with their family physician. While many physicians have avoided this topic in the past, citing lack of knowledge and skill, the family practice setting is ideal for a preliminary evaluation of sexual dysfunction and treatment for certain etiologies. This especially is true for changes in sexual function secondary to medication effects. This article provides basic guidelines designed to assist physicians in evaluating the effects of medications and other substances on sexual function. Also included are lists of medications known or suspected to have adverse effects on sexual function. Physicians are encouraged to address the sexual concerns of their patients and to incorporate these guidelines and the medication lists into their evaluation.

KEY WORDS. Family practice; sex disorders; drugs; drugs, non-prescription; street drugs; substance abuse. (J Fam Pract 1997; 44:33-43)

It is estimated that 15% to 25% of patients seen in family practice have concerns about sexual function.[1,2] In addition, the majority of patients report feeling most comfortable discussing these issues with their family physician, and expect that their physician will provide advice or treatment.[3] Historically, many physicians have avoided discussing sexual concerns, even when a problem is suspected, citing lack of knowledge and skills as a common reason.[4] While it is true that some of the sexual disorders likely to present in family practice settings will require referral for psychological counseling or specialist treatment, others can be successfully diagnosed and treated in the family practice setting.[5] This especially is true for cases involving medication-related changes in sexual function.

Over 1.5 billion prescriptions are written every year in the United States, which amounts to about six prescriptions per person.[6] Over two thirds of physician office visits result in one or more new prescriptions being written.[6] In addition, numerous non-prescription medications, homeopathic remedies, illicit drugs, and other substances (eg, tobacco and alcohol) likely to have an impact on physiological function are commonly used by patients seen in family practice settings. As a result, most family practice physicians can assume that many of their patients will be taking or will have recently taken medications or other substances.

Several reasons exist for focusing on the effects of these substances when assessing a patient's concerns about sexual function. Primarily, many of the most commonly prescribed medications have been suspected or implicated in the development or exacerbation of sexual dysfunctions.[7,8] Second, a medication change is often the simplest intervention, and may save the patient significant time, money, and emotional distress. Third, when multiple causative factors contribute to the disorder, removing one contributing cause (ie, medication) may restore sexual function to an acceptable level. Fourth, patients who suspect that their medications are causing a sexual disorder may make medication changes on their own if their physician does not address this issue.[9] Finally, referral for psychological treatment for a sexual problem will be ineffective or only partially effective when medications are contributing to the disorder. Consequently, when evaluating sexual disorders, it is imperative to determine the history of medication and other substance use and determine the role these factors may be playing in the disorder.[10]

While some medications are well documented to cause disruption of sexual function, controlled research is sparse for the majority of medications and substances implicated in the etiology of sexual disorders.[11] Most articles present anecdotal evidence or case reports.[12] Many medications cited in articles are referenced only in medication inserts, or no reference is provided. Often, the exact type of dysfunction (eg, erectile disorder, delayed orgasm) is omitted, with terms such as "sexual dysfunction" or "sexual difficulties" substituted. While a few larger studies exist, there is some question as to the accuracy of such data. Reports of erectile disorder can vary from 10% to 26% within the same sample, depending on whether the subjects fill out a self-report or are questioned directly.[13] Even direct questioning may not elicit accurate reporting. Patients completing confidential questionnaires at home are almost twice as likely to report difficulty obtaining erections as patients questioned directly in their physician's office.[14] Such data suggest that the social stigma attached to sexual disorders creates significant underreporting, and may make results from even well-controlled studies questionable. In spite of these limitations, physicians need a starting point for directing assessment and treatment.

In an effort to provide this starting point, the following is a discussion of prescription medications and other substances that have been cited as possibly having side effects that adversely affect sexual function. The accompanying tables also list the most commonly cited side effects, as well as the relative likelihood that the side effect will occur. In light of the factors discussed above, it is impossible to provide exact figures in many cases. Instead, an effort has been made to approximate the likelihood of disorders occurring with different medications. Given the number of articles used in the compilation of the tables, the references for each medication have been omitted.(*)