Does use of oral spironolactone affect libido?

Does spironolactone affect libido?

Spironolactone is an oral medication that is used to treat androgenetic alopecia. It is also used to treat acne and in some cases it is also used as a treatment for excessive hair growth in the face (called hirsutism).

We’ve talked about the use of spironolactone to treat androgenetic hair loss in several prior articles, along with side effects that many accompany use of this medication:

Spironolactone for Female Pattern Hair Loss
Spironolactone Side Effects: How does it Compare to Finasteride?

The Effects of Spironolactone on Sexual Health

Antiandrogens like Spironolactone can affect sexual health. That’s because androgens play a critical role in libido, arousal, genital sensitivity, and orgasm. Decreased lubrication and dyspareunia (pain with intercourse) can occur because the glands in the vaginal mucosae that produce lubricants are androgen dependent (meaning the use of antiandrogens could block their function). A number of studies have addressed sexual type side effect but clear estimates of the frequency of these issues are not available. I would estimate the following proportion of women who use spironolactone experience these side effects

a) decreased libido (sex drive) - about 10-15 % of users

b) vaginal dryness or changes in lubrication - 15-25% of users

c) reduced ability to achieve an orgasm - 1-2 %

d) vulvar (vestibular) irritation and pain - risk unclear

e) vulvar atrophy (see prior article) - risk unclear

f) dyspareunia (painful intercourse) - see prior article - risk unclear

We really do need better studies to understand these proportions better.

Side Effects often Dose Dependent

These changes is sexual health are often dose dependent. In other words, some women will notice fewer side effects on 50 mg than 100 mg and fewer on 100 mg than 200 mg. (The optimal dose for hair loss is not clear but 100-200 mg doses may be slightly better for some than 50-100 mg doses). Many issues improved with stopping.

What to do with spironolactone associated sexual dysfunction?

Sexual health has many components and I often recommend patients speak with their primary care physician or gynecologist to ensure a proper evaluation can be done.

There are several options that can be considered if spironolactone is implicated in the changes in sexual function:

1) The spironolactone dose can be reduced.

As mentioned above, many women find they have fewer side effects on lower doses. A patient on 200 mg may find improvements in various aspects of sexual health by reducing to 100 mg. There is a risk of hair loss by doing this but the risk is low and some women will choose to introduce another hair loss treatment with the hopes to compensate for the reduced spironolactone.

Changes in sexual function, such as a return to prior levels of libido can occur in 2 weeks to 4 months. It does vary from patient to patient. In some, it is quite rapid, in others it takes many months.

2) Spironolactone can be stopped for 2 weeks and reintroduced at a lower dose.

I generally recommend that medications that give side effects be stopped until side effects clear and then reintroduce if that is an option. Stopping spironolactone for 2 weeks will not be an issue for hair loss for most patients but can give time for the medication to clear from the body and side effects to resolve (or at least improve).

There is an option to stop completely until side effects are gone as well. That carries the highest risk of causing hair loss but it is an option too.

3) The medication can be stopped and alternative treatments discussed.

The option also exists to stop spironolactone and review other options for treating female pattern hair loss. These would include topical minoxidil, oral minoxidil, topical spironolactone, other topical antiandrogens, PRP, laser and hair transplantation.

4) In the case of vulvar pain and dyspareunia (painful intercourse), Spironolactone can be stopped and estradiol 0.01% /testosterone 0.1 % gel can be used twice daily.

This is the protocol reported by Mitchell and colleagues as we reviewed together last year.

Conclusions

There are many women who use spironolactone without a clear understanding of side effects including side effects on sexual health. Reduced libido does occur in a proportion of spironolactone users and not everyone is aware of the link back to the medication they are using. An improvement in libido and other aspects of sexual health (lubrication, orgasm) can occur within a few weeks to up to 3-4 months of reducing or stopping spironolactone. Patients should be sure to speak to their practitioners as reducing the dose of spironolactone does carry the risk of causing hair loss in those patients using it for treating androgenetic hair loss.