Sertraline and Insomnia, Decreased Libido

Sertraline and Insomnia, Decreased Libido

CK is a 25-year-old female who presents to your pharmacy to purchase an OTC pregnancy test. While at the counter, she expresses concern about her “female symptoms,” which include decreased libido and a recently missed period, and wonders if there could be any other cause if the pregnancy is negative. She admits she doesn’t think she is pregnant due to the decreased frequency of sexual activity with her lack of desire lately. She describes first experiencing decreased libido a few weeks after starting sertraline (Zoloft), which prompted her prescribing physician to discontinue the antidepressant entirely in the hope that her symptoms would improve. CK describes increased anxiety and worsening of both her insomnia and her female symptoms since the discontinuation of sertraline 2 weeks prior (after using it for 2 months). She is  disappointed by the side effects because she felt the Zoloft had really started to improve her mood. She also inquires about the Gardasil vaccination because her girlfriend just received it and suggested she get it too. CK thinks she read that the vaccine isn’t effective after a woman becomes sexually active.

SH: Monogamous relationship with boyfriend for 5 years (is sexually active)
Does not consume alcohol and does not smoke
No recreational drug use reported

Objective data available:

PMH: Depression
Labs: No current labs available for assessment at this visit

Weight: WNL

Current medication list:

Ramelteon (Rozerem) 8 mg nightly for insomnia (started 1 week after initiating sertraline), reports self-initiated increase in dose to two tablets (16 mg) since the discontinuation of sertraline
Naproxen 250 mg bid prn for menstrual pain
Valacyclovir 2 g for cold sore lesions (last used 6 months ago)

Recently used but no longer on:
Zoloft 100 mg qd for depression and anxiety (took for 8 weeks, then stopped 2 weeks ago)

Confirmed: No OTC or herbal agents used currently

What recommendations would you have for CK and her medication management?

Sertraline and Insomnia, Decreased Libido


The prioritization of care for this patient includes:

1. Assessment of the patient’s chief complaint of female symptoms (decreased libido and missed period this past month):

The prescriber’s early identification of the sertraline’s (Zoloft) likely contribution to the emergence of sexual side effects was appropriate; however, the abrupt discontinuation was problematic and increased CK's anxiety. In this case, because CK’s sexual symptoms worsened with the discontinuation of Zoloft, other causes should be investigated.

This further investigation should lead the prescriber and pharmacist to consider the impact of ramelteon (Rozerem) due to its association with increased prolactin and decreased testosterone concentrations in patients using this medication. Significant hyperprolactinemia has been reported in women receiving ramelteon at a dosage of 16 mg PO once daily. Increased prolactin can cause unexplained amenorrhea and decreased libido, and this is likely the clinical cause of this patient’s chief complaint.

Pursue pregnancy test to rule out and counsel patient on the continued risk of pregnancy, even with decreased frequency of activity.

Once CK is on an effective and well-tolerated depression regimen, her anxiety and insomnia should resolve and she may no longer need an additional agent to address that issue.

2. Assessment the patient’s current anxiety and insomnia:

Considering the patient’s report of improved mood with sertraline (Zoloft), the prescriber could consider another SSRI, such as escitalopram (Lexapro), which may be associated with a lesser degree of sexual side effects compared within the SSRI class. Bupropion (Wellbutrin) could be an acceptable alternative for people who are adversely affected by SSRI-induced sexual side effects. If CK is not pregnant, the prescriber could consider a short-term, low dose of zolpidem (Ambien) or other nonbenzodiazepine receptor agonist (Z-hypnotic) if CK's insomnia continues to be problematic with the initiation of the new antidepressant agent. Benzodiazepines are contraindicated during pregnancy and would therefore not be the best option for this patient’s anxious symptoms due to CK's uncertain pregnancy status and childbearing potential.

3. Assessment of patient’s request for Gardasil:

Patient would be a candidate for the immunization, as administration schedule and clinical appropriateness are based on age of less than 26 years and not on previous sexual activity and exposure. Patient’s current pregnancy status should be confirmed, and the three-dose vaccination can be initiated if she is not pregnant. Educate patient on risk of pregnancy if engaging in unprotected sex, despite low frequency of interactions.