Stress and Medications Affecting Sexual Health

Chronic stress suppresses sexual function

When the body receives a signal of danger or sustained pressure, the hypothalamic-pituitary-adrenal axis is activated and secretes more cortisol. Cortisol suppresses two sex hormone axes: in men it lowers luteinizing hormone and thereby reduces testosterone; in women it suppresses estrogen and progesterone secretion. A physiology review published in Journal of Neuroendocrinology in 2014 found that repeated or chronic activation of the stress axis has a clear suppressive effect on testosterone and estrogen secretion.

This is an evolutionarily rational mechanism: when survival is threatened, the body prioritizes energy for the fight-or-flight response rather than for reproduction. The problem is that in modern life, work stress and psychological pressure are sustained continuously, with no resolution the way a real danger would have, causing this axis to be chronically activated.

Performance anxiety

Performance anxiety is worry and apprehension that occurs before or during sex, usually centered on the question "Will I be able to perform?" This creates a cycle: anxiety makes erection or arousal difficult, that failure reinforces the worry, and the next time the anxiety is greater.

A 2020 review in Sexual Medicine Reviews found that performance anxiety affects 9 to 25% of men and 6 to 16% of women, and is the cause or maintaining factor in the majority of psychogenic erectile dysfunction cases. In women, performance anxiety manifests as fear of not reaching orgasm, body image concerns, or worry about a partner's reaction.

Cognitive behavioral therapy and sensation-focused psychological approaches have been found effective for performance anxiety, though direct randomized controlled trials remain few. See the article on breathing and relaxation for some specific starting steps.

Depression and sexual function

Depression affects sexual function through multiple pathways. Low mood and widespread loss of interest extend to activities including sex. Depression is also associated with lower testosterone and changes in neurotransmitter levels needed for arousal and erectile reflexes.

In addition, many people with depression need medication for treatment, and those same medications can affect sexual function as described in the next section. Effective treatment of depression generally improves sexual function, though medication side effects need to be managed separately. Do not leave depression untreated out of concern about medication side effects.

Medication classes that may affect sexual function

Many classes of medication used for common conditions may affect sexual function in some people. This does not mean the medication is harmful or needs to be stopped. Each case requires individual evaluation by the treating doctor.

• Selective serotonin reuptake inhibitors: commonly used for depression and anxiety. A 2002 review found that an estimated 30 to 60% of people using this class experience sexual dysfunction in one or more forms, including reduced desire, difficulty reaching orgasm, and delayed ejaculation. The degree varies by specific drug and by individual.
• Serotonin and norepinephrine reuptake inhibitors: may also cause similar sexual side effects, but generally at lower rates than the above class.
• Antihypertensive medications: an analysis published in International Journal of Impotence Research in 2007 found that roughly 67 to 68% of men with high blood pressure showed some degree of erectile dysfunction. Thiazide diuretics and beta-blockers are more associated with this side effect than ACE inhibitors or calcium channel blockers.
• Prostate treatment medications: drugs that reduce or block androgens used in treating benign prostatic hyperplasia and prostate cancer may lower desire and affect erectile function.
• Other classes: certain antiepileptic drugs, antihistamines, opioids, and some psychiatric medications may also affect sexual function.

Talk to your doctor, do not stop medication on your own

When you notice sexual effects that may be related to a medication, the next step is to report it to the prescribing doctor, not to decide on your own. The doctor can consider adjusting the dose, substituting a drug within the same class that has a better side-effect profile, switching to a different class, or adding parallel treatment.

With antidepressants, there are significant differences in sexual side effects between individual drugs even within the same class. A psychiatrist is the most appropriate person to help calibrate this. See also the articles on reduced desire in women and reduced desire in men and testosterone.

When to see a doctor

See a doctor when:

• Anxiety or chronic stress is clearly affecting sexual function and has not improved after lifestyle adjustments such as adequate sleep, reduced alcohol, and exercise.
• You have signs of depression: persistent loss of interest, low mood, fatigue, difficulty concentrating, together with reduced sexual function.
• You are on long-term medication and notice a clear change in desire or sexual function after starting or changing the medication.
• Performance anxiety is significantly limiting your daily life and relationships.

Appropriate specialties: psychiatry or clinical psychology for anxiety and depression, endocrinology or a men's health doctor (andrologist or urologist) to check hormones, cardiology or internal medicine if being treated for high blood pressure.

Questions and answers

Sources

1. Toufexis D, Rivarola MA, Lara H, Viau V. Stress and the reproductive axis. J Neuroendocrinol. 2014;26(9):573-86. PubMed 25040027
2. Pyke RE. Sexual Performance Anxiety. Sex Med Rev. 2020;8(2):183-190. PubMed 31447414
3. Gregorian RS, Golden KA, Bahce A, Goodman C, Kwong WJ, Khan ZM. Antidepressant-induced sexual dysfunction. Ann Pharmacother. 2002;36(10):1577-89. PubMed 12243609
4. Kloner R. Erectile dysfunction and hypertension. Int J Impot Res. 2007;19(3):296-302. PubMed 17151696

This page is general health information compiled from international medical sources. It has not been reviewed by a physician and is not a diagnosis or a treatment instruction. The content is for readers aged 18 and over. If symptoms persist, please see a doctor.

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