Mood swings and feelings of anxiety and sadness are common during both perimenopause and menopause, and we know that women across ages experience depression at much higher rates than men. In fact, major depressive disorder affects approximately 12 million women in the U.S. every year. Fortunately, many find relief through the use of SSRIs, or selective serotonin reuptake inhibitors. The downside is, these medications often include sexual side effects, including lower libido and sexual dysfunction, which can be especially disruptive for women in menopause who may already be experiencing sexual symptoms — a double whammy. But before you ditch the bottle, let’s take a look at what exactly is going on chemically, and what we can do about it.
Back to basics: What exactly are SSRIs?
SSRIs, or selective serotonin reuptake inhibitors, are a common form of antidepressants used to treat depression, anxiety, and panic disorder, among other mental health conditions. Some of the most common SSRIs include escitalopram, fluoxetine, paroxetine, and sertraline. The medication works by increasing levels of serotonin, a neurochemical that helps stabilize mood — also known as “the happy hormone.” Sounds great, right?
Specifically, serotonin acts as a messenger, carrying signals between the brain’s nerve cells. Following that “delivery service,” if you will, the neurotransmitter is typically reabsorbed by the nerve cells. This is where SSRIs swoop in – by preventing, or “inhibiting,” that reabsorption, so that more serotonin is active in the brain.
How are SSRIs used during menopause?
Some women may experience anxiety and depression for the first time during menopause, and for women with existing mood disorders, the severity may increase during the transition. There are so many factors at play here that are difficult to discern: socioeconomic considerations, psychological, social, health, etc. That being said, there is one major culprit we can often point to: hormone fluctuations. (Shocking, right?!) How? Well, the production of estrogen is correlated with the action of serotonin, so as estrogen levels fluctuate during menopause, serotonin pathways can be disrupted, which can affect mood.
These chemical changes, compounded with pressures like caregiving for aging parents and children and demanding work lives, can impact our mental health and overall quality of life. To date, SSRIs and SNRIs remain the first line of pharmacologic defense for anxiety and depression in peri- and menopausal women. Butttt, they aren’t always side effect-free…
How can SSRIs influence libido?
The mechanics
So, remember how we said SSRIs work by increasing the amount of available serotonin in the brain? Well, we need activation in order to get aroused, and extra serotonin actually blunts this response. The impact? In women, this can cause difficulty with arousal and low sexual desire, as well as difficulty or inability to orgasm. A cruel twist of fate, we know, especially given the fact that menopausal women may already be experiencing libido-related symptoms…
Menopause & libido
As we know, fluctuating hormones can inform a number of menopausal symptoms like hot flashes/flushes and night sweats, weight gain, osteoporosis, and decreased libido. In the case of libido, testosterone — the main hormone of desire — is a key player, and as it declines more rapidly, so too can our sex drive.
What can women experiencing low libido on SSRIs in menopause do?
Let’s just start by acknowledging that sexual symptoms are not something you just have to “deal with.” For far too long, investment in women’s sexual health as it pertains to pleasure has been poor, and if libido is something important to you, we want to make sure you have all of the tools in your toolbox. So, let’s dive into some options!
Antidepressant adjustment options
1. Consider switching to a different class of medications
If you are experiencing low libido on SSRIs, speak with your provider (or Elektra!) about trying a different medication or a medication in a slightly different class, such as SNRIs (serotonin and norepinephrine reuptake inhibitors). Unlike SSRIs, which solely affect serotonin, SNRIs also target norepinephrine, a neurotransmitter responsible for managing how we respond to stress.
2. Add an activating medication
NDRIs, or norepinephrine and dopamine reuptake inhibitors, are of a newer antidepressant generation and don’t target serotonin at all. Instead, they increase dopamine and norepinephrine activity in the brain, both of which are activating chemicals that are helpful for sexual arousal. Currently, Bupropion (which goes by brand names Wellbutrin or Aplenzin), is the only NDRI sold on the market.
3. Lower the dosage
Not ready to switch medications or add another? Not to worry – lowering your dose may be a sufficient measure to mitigate some of those unwanted sexual side effects. Try talking to your provider about adjusting your dosage.
Alternative medication options
1. Addyi
Outside of adjusting or switching antidepressants, Addyi is another option for premenopausal women. The medication, which goes by the generic name Flibanserin, is a daily pill used to treat low libido. It actually targets some of the same neurotransmitters than SSRIs do, and works by interacting with serotonin receptors, which has downstream effects on dopamine (which helps boost desire) and norepinephrine (which plays a role in sexual arousal).
And while it’s only been FDA-approved for premenopausal women, it CAN be a viable option for postmenopausal women as well (although insurance coverage may be more difficult in this case).
READ MORE: Answering Frequently Asked Questions About Addyi, A Non-Hormonal Treatment For Low Libido
2. Testosterone Replacement Therapy (TRT)
Typically considered a male hormone, we know that testosterone is also critical to the sexual functioning of women. The hormone is produced by the ovaries and adrenal glands, with peak production in our 20s – it then slowly declines to very low levels. These low testosterone levels become especially problematic after menopause, when other sex hormones such as estrogen are also decreasing.
The judicious use of the hormone restored to healthy “premenopausal” levels has recently been formally endorsed by several of the major academic communities in menopause, endocrinology and sexual health. Unfortunately (for myriad complicated reasons), there are currently no FDA-approved testosterone products for women in the United States. Therefore, practitioners who treat women through testosterone replacement therapy will often choose to prescribe an off-label transdermal gel or cream that is applied to the legs daily. Because there is currently no FDA-approved product, it is imperative that women who are interested in TRT find a practitioner who understands and respects the evidence-based guidelines menopause experts have agreed upon.
READ MORE: The Benefits of Testosterone for Menopause
Lifestyle options
In addition, or as a substitute to changing things up on the medication front, we recommend optimizing in other areas wherever possible. Now is the time to experiment and supplement, whether with fantasy, erotica, or toys — it can be helpful to focus on what you can add, rather than take away. These are a few of our favorite accessories:
- Dame: Here you’ll find a whole slew of products, including couples vibrators, suction toys, and g-spot vibrators.
- Unbound Sex Toys: This rebellious sexual wellness company makes vibrators, vaginal lubricants, and accessories — all with body-safe ingredients. We’re also big fans of founder Polly Rodriguez who, in addition to selling top-notch sex toys, has rallied her trailblazing team at Unbound to fight the MTA over sexism in NYC subway ads — and send members of Congress vibrators (!!!)
- Lelo: Ben wa balls, bullet vibrators, clitoral vibrators, g-spot vibrators, wand massagers, and more.
The bottom line:
SSRIs are an effective treatment for mood disorders — whether menopause-related or not — and can make a huge difference in quality of life. But (of course there’s a but), the sexual side effects can be disruptive and can leave us feeling like we have to choose between our mental health and sexual health. Fortunately, there is plenty we can do to improve sexual symptoms, such as switching or adding medications, adjusting dosage, and adding fun new elements to the bedroom. Because, we shouldn’t have to choose!
Interested in care? Learn more and book a visit with a board-certified, menopause-trained Elektra clinician.
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