Medication and sex: antidepressants, contraception and blood pressure

“For the first time in ages I wake up in the morning and I don’t feel awful. It’s just … something has gone. As if someone had switched off part of my body. I’m thinking of just stopping the tablets.”

People often say sentences like this quietly, as if they were admitting to something ungrateful. The medication has helped them, perhaps even given them back a year or two of their life — and now they are complaining about something that feels almost inappropriate to mention. They do not tell their doctor, because they are embarrassed or because they think it is simply the price to pay. They do not explain to their partner what is going on, because they are not sure themselves. And then one evening they decide to simply stop taking the medication.

This post is about the three groups of medicines people most often link with changes in their sex life: antidepressants, hormonal contraception and blood pressure medication. But before I begin, here is the thing that matters more than anything else in this post.

First: do not stop your medication on your own

If you notice that a medicine may have affected your sex life, do not stop it or change the dose on your own. Talk to the doctor who prescribed it.

This is not a formality. Stopping an antidepressant suddenly can cause withdrawal symptoms — dizziness, irritability, insomnia, sensations like electric shocks — and, often even more importantly, a return of the depression or anxiety you started taking it for in the first place. Stopping blood pressure medication can mean a dangerous rise in blood pressure. Stopping contraception without other protection means a risk of unplanned pregnancy.

When it comes to sexual side effects, doctors often have more options than people imagine. But they can only get to them once they know there is a problem. I am not a doctor and I will not give medical advice here. My role is different: to help you understand what is happening inside you and in your relationship, and to encourage you to speak to the people who can actually change something about the medication.

Antidepressants: a common but often unspoken side effect

The best-researched sexual side effects are those of antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) and related medicines. People describe less desire, difficulty becoming aroused, delayed or absent orgasm, and sometimes a sense that the body has somehow gone “numb”.

How common is it? The Spanish psychiatrist Angel Montejo and colleagues ran a large prospective study following 1,022 outpatients taking antidepressants. When they were asked about sex directly, more than half reported changes. The key word was directly: many people would not have mentioned it of their own accord. A later meta-analysis by Alessandro Serretti and Alberto Chiesa confirmed that the frequency varies between individual medicines — with some, sexual difficulties are considerably more common than with others.

This is not meant to scare you away from antidepressants. I wrote about how medication and psychotherapy can work together in Antidepressants and therapy are not rivals: what the research says about combining them. It is meant so that you know: if this is happening to you, you are not an exception and you are not ungrateful. It is a known, common and well-described effect, and you have every right to talk about it.

Rarely, sexual difficulties persist even after the medication has been stopped. This is described in the professional literature, but it is less common and not yet well researched. If you think this may be your experience, that too is a matter for your doctor, not for guesswork on online forums.

What is the medicine and what is the illness

This is where the story gets complicated. Depression itself often lowers sexual desire. When a person loses pleasure in the things that used to bring them joy, that often happens with sex too — I wrote about this in Anhedonia: when nothing brings joy any more. Sidney Kennedy and colleagues found that among people with major depression who had not yet started antidepressants, many already reported reduced desire and other sexual difficulties before treatment.

This means it is not always easy to tell what comes from the medicine and what comes from the illness. It helps to remember how things were before: whether desire was already lower during the depression, whether it changed only after treatment began, whether anything else changed as your mood improved. These details are valuable to a doctor.

And then there is a third layer: the relationship itself. Years of depression leave their mark on a partnership too — withdrawal, misunderstanding, exhaustion on both sides. I wrote about this in Depression in a relationship: what happens to the couple, and what you can do. Sex often does not come back automatically once mood improves, because something has changed between the partners in the meantime.

What can be done together with your doctor

What the options are is a decision for the doctor who knows your history, your doses and your other medicines. In general, though, there are several paths, and none of them is “stop the medicine and hope for the best”. Your doctor can judge whether it makes sense to wait, because some side effects ease over time, or to adjust the dose, switch medicines or look for a different solution. Only they can tell you which of these is right for you.

Many people do not raise this with their doctor because they feel awkward, or because they sense there is not enough time in the appointment. That is why it helps to prepare in advance. In the knowledge base there is a tool called Preparing for a psychiatric appointment, which you can also use for a conversation with your GP. If you are not sure who is the right person for which question, the post Who may diagnose, who may prescribe, and who leads the process may help.

Remember: doctors have heard about sexual side effects many times before. For you this may be the first and hardest conversation on the subject; for them it is part of everyday work.

Hormonal contraception: the research is mixed

With hormonal contraception the picture is less clear than with antidepressants. Many women feel they lost some of their desire after starting the pill, others notice nothing at all, and some even report an improvement — perhaps because they are no longer afraid of pregnancy, or because their period problems have eased.

Reviews of the research bear this out. In a systematic review of studies on combined oral contraceptives, Zuzana Pastor and colleagues found that most women reported no change in desire, a smaller group reported a decrease and a smaller group an increase. A review by Lara Burrows and colleagues reached a similar conclusion: the effect of hormonal contraception on sexuality varies greatly between individual women and cannot be predicted in advance.

This means two things. First, if you notice a change, you are not imagining it — for some women it is real. Second, contraception is not necessarily the cause. Desire also changes with stress, tiredness, the stage of a relationship, unresolved tension between partners and other circumstances.

The right person to talk to is a gynaecologist. There are several types of contraception with different hormones and doses, as well as non-hormonal options you can discuss. And once more: do not stop contraception without agreeing on other protection, or one worry can quickly replace another.

Blood pressure medication: the illness and the medicine intertwine

With blood pressure medication, people most often wonder about the effect on erections. Here it is important to know that high blood pressure itself damages blood vessels over time, including those that matter for sexual response. Erection difficulties are therefore more common in people with raised blood pressure regardless of medication. Review articles, such as the one by Athanasios Manolis and Michael Doumas, describe how sexual difficulties appear more often with some groups of medicines than with others, and rarely with some.

One of the most interesting studies in this area, however, is about something else. Italian researchers led by Antonello Silvestri prescribed men a beta-blocker and divided them into groups according to how much they were told about the medicine. Those who knew about the possible sexual side effects reported erection difficulties considerably more often than those who did not. This is the nocebo effect — expecting a side effect can itself contribute to it appearing.

This does not mean side effects are “all in your head”. It does mean that body and expectation are closely linked — and that with sex, the fear of failing is often part of the problem. That is why it helps to talk to your GP, a cardiologist or a urologist, who can assess what is more likely to be at the forefront. And here too: do not stop blood pressure medication on your own.

Other medicines too

Antidepressants, contraception and blood pressure medication are not the only medicines that can affect sexuality. Sexual side effects are listed in the patient information leaflets of quite a number of medicines used for very different conditions. If you take several medicines at once, it can be even harder to say what is contributing to what.

That is exactly why it is a good idea to take a list of all the medicines you take to your appointment, including over-the-counter ones and supplements. The leaflet can tell you whether a sexual side effect has been described, but it cannot tell you whether it is actually the cause in your case. Only a doctor can judge that.

What happens in the couple meanwhile

The sexual side effects of medication are not just one person’s business. When desire changes, the partner often does not understand — especially if nobody says what is going on. They may think they are no longer attractive, that something is wrong with the relationship, that there is someone else. The person taking the medicine, meanwhile, feels guilty, under pressure, or withdraws to avoid the conversation.

This is how it can sound when a couple talks about it for the first time (composed, not a real person):

“For a few months now it’s felt like you’re avoiding me.”
“I’m not avoiding you. It’s just … since I started the tablets, I don’t feel anything. As if everything were behind glass.”
“Why didn’t you tell me?”
“Because I was ashamed. And because I was afraid you’d tell me to stop taking them.”
“I wouldn’t have said that. I’m glad you’re better. I just miss you.”
“I miss myself too.”

When the explanation shifts from “he doesn’t want me” to “something is happening with his body that he didn’t know how to tell me about”, the tension often eases too. The couple can start looking for closeness in different ways that do not require everything to go back to how it was straight away. And the partner can become an ally in the conversation with the doctor, rather than an opponent waiting for everything to be “fixed”.

How to talk about sex without blame will be the subject of the post How to talk to your partner about sex without blame. If you find yourselves in a situation where one of you has considerably more desire than the other, you may also want to read the entry on differences in sexual desire.

Exercise: notes before talking to your doctor

This exercise helps you arrive at your appointment not with a vague sense that “something isn’t right”, but with clear observations. It takes fifteen minutes and you can do it today.

1. Write down all the medicines you take, with the doses and when you started taking them — including over-the-counter medicines and supplements.
2. Write down what has changed and when. Is there less desire, harder arousal, has orgasm changed? Did it start before treatment began or after?
3. Write down what else was happening in your life at the same time. A move, a new job, a birth, a loss, tension in the relationship. This is not about finding excuses, but about giving your doctor the whole picture.
4. Rate how important this is to you — on a scale from 0 to 10. For some it is a minor nuisance, for others a big loss. Both are fine, and both need to be said.
5. Write down one question you want to ask, for example: “Could this be linked to the medicine, and what options do I have?” Make it clear at the same time that you do not want to stop the medicine without their advice.

If the conversation feels uncomfortable, you can simply hand your notes to the doctor. Some people find it easier not to have to say everything out loud.

Where this explanation falls short

I want to be honest here, because the opposite can happen too — we put everything down to medication when the reason lies elsewhere.

Not every change is a side effect. Desire changes with age, with the length of a relationship, with stress and with tiredness. If sex in the relationship was already strained before, the medication may simply give it a name that is easier to say than “things aren’t good between us”.

When there is a physical problem unrelated to the medicine. Erection difficulties can be an early sign of heart and blood vessel disease, pain or dryness can have gynaecological causes, and changes in desire can be linked to hormones. That is another reason why the right first step is a doctor, not just a change of medication.

When the sexual difficulty itself is at the forefront. I am not a sexologist or a sex therapist. In couples therapy intimacy can be one of the themes we talk about, but for sexual dysfunctions the right place to go is a doctor or a specialist in sexual medicine. The post When to see a doctor, when a sex therapist, and when couples therapy is enough describes the difference.

When dark thoughts appear as you consider stopping. If you are thinking about stopping an antidepressant and thoughts of hopelessness or suicide are coming back, do not wait for your next routine appointment. Contact your doctor straight away or, in Slovenia, call the crisis line Klic v duševni stiski on 01 520 99 00 (every day from 7 pm to 7 am) or the Samaritans helpline on 116 123 (24 hours a day). In an emergency in Slovenia, call 112. I wrote about why a relapse is not a failure in When depression comes back: why a recurrence is not a failure.

Where therapy can help

Psychotherapy does not replace a doctor and does not make decisions about medication. It can, however, help with what happens around the medication: the shame that prevents a conversation with the doctor, misunderstandings in the couple, sadness about a lost part of yourself, and finding closeness that does not depend on sexual response alone. I also work with English-speaking clients in person in Ljubljana.

In couples therapy it often turns out that the biggest problem is silence, not the medicine itself. When both partners understand what is happening, they can get through the period while the body adjusts together — and prepare questions for the doctor together. And one last time, because it matters most: decisions about medication are made together with your doctor, never alone.

What to remember

• The sexual side effects of antidepressants are common and well described — you have every right to talk about them.
• With hormonal contraception the research is mixed: most women notice no change, some have less desire, some more.
• With blood pressure medication the illness and the medicine intertwine, and expectation plays a part too (the nocebo effect).
• It is often hard to separate what comes from the medicine, the illness and the relationship — which is why notes for your doctor help.
• Never stop a medicine or change the dose on your own — always talk to your doctor first.