Educational advancement for physicians regarding PFS and Antidepressant-induced sexual dysfunction

I thought I should share that while the medical community at large remains uninformed and even apathetic about post-finasteride syndrome and persistent sexual dysfunction related to antidepressants and other medications, I have recently come across increased articles on the subject in medical education literature. For the first time I discovered a mainstream widely read continuing medical education (CME) course for physicians and other healthcare practitioners on “Male Sexual Dysfunction” and “Antidepressant-Associated Sexual Dysfunction” both released within the last 8 months that now include discussions not only of sexual side effects related to these medications and others but persistent sexual dysfunction. The sections discussed the significant negative impact on quality of life. There is no mention of downplaying or playing it off as psychological. Such sections will begin to be a regular part of such CME courses going forward. So I believe it can be said that this is a breakthrough of sorts for educating healthcare practitioners and researchers to take these conditions more seriously. I have for your convenience included clips from these courses here:

5α-REDUCTASE INHIBITORS

The enzyme 5α-R transforms testosterone into the potent androgen 5α-dihydrotestosterone. The 5α-R inhibitors finasteride and dutasteride were devel- oped to block 5α-R in order to produce an anti- androgenic effect. Both were U.S. Food and Drug Administration (FDA)-approved for treatment of benign prostate hyperplasia and male pattern hair loss [35]. However, 5α-R is broadly distributed in central nervous system tissue, and inhibition blocks synthesis of several key hormones and neuroactive steroids. This effect was later found to result in numerous adverse effects, including impaired or complete loss of libido, erectile, and orgasm func- tion; high Gleason grade prostate cancer; cardiac arrest and cardiovascular events; and depression [35]. In some patients, total sexual dysfunction has been irreversible, with significant emotional toll and impact on quality of life [36; 37; 38; 39; 40]. Treatment of 5α-R inhibitor-induced post- treatment enduring sexual dysfunction has focused on endocrine interventions, but no approach has been successful [41].

In 2013, the Sexual Medicine Society of North America published a comprehensive review that acknowledged a link between 5α-R inhibitors and persistent sexual dysfunction after treatment cessa- tion, but stopped short of stating a causal relation- ship had been established. They concluded more research was needed [42].

POST-TREATMENT ENDURING SEXUAL DYSFUNCTION

Post-SSRI sexual dysfunction is little known in the broader medical community and, when reported, has been partially attributed to psychologic factors [12]. However, the adverse impact from antide- pressant-induced sexual side effects and post-SSRI sexual dysfunction may be worse than the condi- tion for which treatment has been sought [41].

In the first review of post-SSRI sexual dysfunction in 2008, Bahrick and Harris challenged conven- tional wisdom that sexual side effects resolve with SSRI cessation, stating that research literature had failed to include systematic follow-up to support this assumption [42]. This emerging problem is sup- ported by a convergence of case reports, consumer reports, and robust evidence from efficacy studies of healthy men documenting SSRI-induced delayed ejaculation persisting long after SSRI cessation. Internet drug consumer sites may provide a data- base of this qualitative information not captured within research paradigms or existing post-market pharmacovigilance mechanisms [42].

In 2014, the broader category of post-treatment enduring sexual dysfunction (PTESD) was inves- tigated and 120 cases (mean age: 30.9 years) were identified. Highest rates occurred with SSRI agents (11.2% to 15.5%), venlafaxine (7.8%), isotretinoin (6.0%), and finasteride (5.2%). Women comprised 20% of SSRI cases, and all of the isotretinoin and finasteride cases occurred in men. PTESD occurred following medication exposure of 3 to 5,840 days, and a common feature was sexual side effect onset after medication was discontinued. The conse- quences of PTESD were severe, including several well-documented cases of suicide. The longest case was 18 years, from a brief exposure to fluoxetine at 18 years of age [43].

In a data report from 2017 including 300 cases of enduring sexual dysfunction, the highest rates of PTESD occurred with isotretinoin (18%), escitalo- pram (14%), citalopram (13.7%), and paroxetine (13.3%) [48]. The duration of the treatment ranged from a single dose to more than 16 years. The report also found that many cases of sexual dysfunction appeared or became worse when treatment came to an end. Subjects consistently reported difficulty maintaining romantic relationships and 30% reported that their work had been affected [48].

PTESD symptoms can include the entire spectrum of male and female sexual dysfunction, but the triad of penile or clitoral anesthesia, loss of libido, and loss of function is the core characteristic of PTESD, across all identified drug classes and agents [43; 44; 48]. Pleasureless orgasm has also been reported [45; 48].

Efforts to manage PTESD have involved serotonin and dopamine system modulation with the 5HT-1 agonist buspirone, the 5HT-2 and 5HT-3 antago- nists trazodone and mirtazapine, and dopamine agonists (e.g., pramipexole, cabergoline, bupropion, dexamphetamine). Phosphodiesterase type 5 inhibitors, testosterone, ketamine, donepezil, and metformin have all been tried for PTESD. How- ever, none of these have helped. This treatment- refractory characteristic may reflect epigenetic changes in PTESD [43]. Additional research into the underlying etiology of persistent sexual dys- function following antidepressant cessation will hopefully give insight into an effective treatment.

5 Likes

It’s truly a crying shame that we as victims sit and watch what we’ve known all along slowly but surely become mainstream and real medical issue. At a certain point these drugs will either become outright illegal or maybe even there will be extensive genetic testing done prior to prescribing, but that is all preventative measures. What about the guys who weren’t warned, who were deceived by uninformed, greedy and naive doctors? I guess watch history unfold and hope that by the time a cure rolls around there is still some salvageable time life in your lifetime. As satisfying as finally be to tell our doctors “we told you so,” I think everyone here just wants to get their life back on track as quick as humanly possible.

Having said that, I’m incredibly glad that it seems to finally be gaining traction. Though it is truly shameful that something like this could even happen to otherwise healthy and happy people.

6 Likes

You can be sure that theses drugs will never become illegal , billions of dollars per year are in play , they won’t care about a luckless minority like ourselves

This is fantastic progress but honestly medical institutions should get no props for recognising how harmful these medications can be decades after approval. Seemingly 1000s of stories blatantly reflecting how dangerous these drugs are have been known for years, usually following the lines of ‘I was 100% normal took this drug and now I’m completely impotent’. ‘Well maybe its in your head?? The sacred safety data says it’s not possible’.

Post approval surveillance of drugs clearly needs a massive overhaul especially when pharmaceutical companies can skew safety data. Hell maybe Merck killing over 50000 thousand people with Vioxx may have been a red flag??? No props for picking up or showing any interest in iatrogenic damage to patients after thousands of lives have been drastically changed for the worse. Where is the accountability?? What happened to do no harm??

My prescription was in 2015 or 2016 so i was never warned of permanent sides but had heard of them on the web. Does everyone get warned about them now? I’ll admit that for me personally its partially my fault, i have a scientific background i should have known better and done more research. This is not the case for everyone however. Makes me so mad.

Drugs that lead to higher mortality rates of course get more attention than ones that cause sexual dysfunction. I always tell people that there are three things that people never feel sorry about you losing: your wealth, your looks, and your sexual function. There are many precedents of lengthy post approval surveillance outcomes. When estrogen therapy was initiated to help women keep their femininity, sexual function, and beauty it was wildly popular. From the 1970’s until the 1990’s hormone replacement was the rage. Research began to trickle in that hormone therapy’s benefits were outshined by its deleterious effects, namely endometrial carcinoma and premature death. Women weren’t staying younger but dying. It was later combined with progesterone to mitigate these risks but it has fallen out of favor nonetheless. It took a couple of decades of post approval surveillance and research convergence. Drug companies will downplay such side effects for obvious reasons. Of the thousands of drugs in development, a small number achieve market success. This is after spending hundreds of millions of dollars in its development and advertisement. To this day SSRIs and SNRIs are listed by the companies as having 6% sexual side effects or less. But in reality the research says 66% to 75% in men and even more so in women. I remain suspicious with new antidepressant therapies coming out with again low numbers of sexual side effects. Doctors jump on it and say “This one has sexual side effects just like placebo”. Time will tell. Unfortunately you are correct in pointing out that when people coming forward and tell their doctors that they have lost their sexuality, the doctor will say “I have at least 300 patients on the drug and have not heard that before. It is probably something else, perhaps anxiety?” Critical mass is what moves the cause. I was totally normal before taking finasteride with a high libido and excellent erections. I was in my prime. Within 14 days of treatment I lost my libido and erections were soft and inconsistent. Eventually lost morning erections and eventually had brain-penis disconnection (where the real fun begins). This all happened in a short time. I had no medical issues otherwise after numerous testing and examinations and specialists and lots and lots of money! A common story here sadly.

1 Like

Wow that’s very interesting. Hmm becoming impotent in yours 20s or worse is allot years lost to disability don’t understand how it’s not taken seriously. Same dude my sexual function was a 10/10 before taking this drug believe it or not it was a single dose. Didn’t even care about my hair :frowning: Sounds crazy to me even now. Lost a lot of trust in medical treatment, pretty depressing for a student dr.

I think that more man have got a 20years old for me is impossible have a ed problem… Maybe I at 36 years old… Because I’m a stressed for the children for the work… But when more 20years old speack about ed problem and more more more problem… The community science are a make a interrogative… Shit world.

1 Like

When was the last time you took the drug ? since it was 1 pil your recovery will be easier , with time you’ll get back to an acceptable sexual function