Strattera side effects?

[phalloguy100]

Hi everyone! It's been a while!

I recently started atomaxetin (strattera) for ADHD and to relieve minor anxiety. That is in addition to low dose concerta amd Wellbutrin (depression). At first, with low doses, I noticed a sudden increase in libido but only during the first week. A month later, the doctor doubled the dose. This time the opposite happened: it decreased libido significantly, and even worse, it resulted in shrinkage!!

It's not your typical jumped-in-a-cold-water-pool shrinkage - it's almost like it thinned my penis without causing contraction in length. It made ED worse, but paradoxically, it gave me morning wood again (probably because I am sleeping better). The shrinkage and lower libido are bothersome, but it has helped bring more clarity and focus than concerta alone.

Has anyone experienced this? How did you manage it, or did you go off strattera? The discussions I found here talk about the opposite, that it causes priapism and increases libido.

From what I read strattera can decrease dopamin (which is necessary for sex drive), but Wellbutrin helps increase it a bit b,y blocking re-uptake. So in theory, they should cancel each other out! TRT+pregnyl is working (on paper at least) well with TT in mid 600s, SHBG normal and E2 normal.

 

[Nelson Vergel]

Great question, and welcome back. What you're describing is actually more nuanced than a simple "Strattera kills libido" story, and I think your own analysis is pretty sharp.

Let me work through this with you.

Atomoxetine (Strattera) is a selective norepinephrine reuptake inhibitor. It doesn't touch dopamine directly the way stimulants do. That's the key distinction. Norepinephrine is more about alertness, arousal in the neurological sense, and attention, but it also has real effects on peripheral vascular tone. That vascular piece is probably what's causing the "thinning" you're noticing. Increased norepinephrine activity causes vasoconstriction, and the smooth muscle tissue in penile vasculature is very sensitive to that. It's not the same as cold-water shrinkage (which is a cremasteric reflex and cold-induced vascular response). What you're describing sounds more like chronic mild vasoconstriction reducing the baseline tumescence and flaccid fullness. This has been reported anecdotally by some men on atomoxetine, though it's not well documented in the literature because sexual side effects in ADHD drugs are under-studied.

Your logic about Wellbutrin partially counteracting the dopamine deficit is actually reasonable. Bupropion does upregulate dopaminergic tone, which is part of why it's one of the few antidepressants that tends to preserve or even improve libido. The problem is that Wellbutrin works upstream on dopamine and norepinephrine together, while Strattera is hitting norepinephrine hard in a different way, particularly peripherally. So they don't neatly "cancel out." You can have adequate central dopamine for desire but still have peripheral vascular effects from the norepinephrine load that compromise penile blood flow and tissue fullness.

The morning wood returning is genuinely interesting and is probably explained by improved sleep architecture, as you suspected. Sleep quality has a direct and measurable effect on nocturnal penile tumescence. So that's a real benefit worth noting.

Here are some practical thoughts. First, the timing of the dose matters with atomoxetine. If you're taking it in the morning, the peak norepinephrine effect may be wearing off by evening, which could help with sexual function at night. Some men do better splitting the dose or taking it earlier. Second, a low-dose daily PDE5 inhibitor (tadalafil 2.5 to 5mg daily) could directly counteract the vasoconstrictive effect by keeping cGMP levels up in penile smooth muscle tissue. This is a reasonable conversation to have with your prescriber and it doesn't require anything exotic. Third, if the "thinning" persists and is bothersome, it's worth trying a short drug holiday from the atomoxetine to see if it reverses. That would confirm causality pretty clearly.

Given that your TRT, SHBG, and E2 are all dialed in and working, I don't think the hormonal side is the culprit here. This sounds like a norepinephrine-mediated vascular effect at the dose you're now on, plain and simple. It's a real phenomenon, it's not in your head, and it's something that can be managed without necessarily giving up the cognitive benefits you've worked to achieve.

The fact that Concerta alone wasn't enough, and that adding Strattera brought real clarity, means this is worth trying to optimize rather than just abandoning. But the dose doubling was clearly the tipping point, and your prescribing doctor should hear exactly what you've described here, including the penile changes. Don't soften that part. It's clinically relevant and it affects your quality of life.

 

[phalloguy100]

Great question, and welcome back. What you're describing is actually more nuanced than a simple "Strattera kills libido" story, and I think your own analysis is pretty sharp.

Let me work through this with you.

Atomoxetine (Strattera) is a selective norepinephrine reuptake inhibitor. It doesn't touch dopamine directly the way stimulants do. That's the key distinction. Norepinephrine is more about alertness, arousal in the neurological sense, and attention, but it also has real effects on peripheral vascular tone. That vascular piece is probably what's causing the "thinning" you're noticing. Increased norepinephrine activity causes vasoconstriction, and the smooth muscle tissue in penile vasculature is very sensitive to that. It's not the same as cold-water shrinkage (which is a cremasteric reflex and cold-induced vascular response). What you're describing sounds more like chronic mild vasoconstriction reducing the baseline tumescence and flaccid fullness. This has been reported anecdotally by some men on atomoxetine, though it's not well documented in the literature because sexual side effects in ADHD drugs are under-studied.

Your logic about Wellbutrin partially counteracting the dopamine deficit is actually reasonable. Bupropion does upregulate dopaminergic tone, which is part of why it's one of the few antidepressants that tends to preserve or even improve libido. The problem is that Wellbutrin works upstream on dopamine and norepinephrine together, while Strattera is hitting norepinephrine hard in a different way, particularly peripherally. So they don't neatly "cancel out." You can have adequate central dopamine for desire but still have peripheral vascular effects from the norepinephrine load that compromise penile blood flow and tissue fullness.

The morning wood returning is genuinely interesting and is probably explained by improved sleep architecture, as you suspected. Sleep quality has a direct and measurable effect on nocturnal penile tumescence. So that's a real benefit worth noting.

Here are some practical thoughts. First, the timing of the dose matters with atomoxetine. If you're taking it in the morning, the peak norepinephrine effect may be wearing off by evening, which could help with sexual function at night. Some men do better splitting the dose or taking it earlier. Second, a low-dose daily PDE5 inhibitor (tadalafil 2.5 to 5mg daily) could directly counteract the vasoconstrictive effect by keeping cGMP levels up in penile smooth muscle tissue. This is a reasonable conversation to have with your prescriber and it doesn't require anything exotic. Third, if the "thinning" persists and is bothersome, it's worth trying a short drug holiday from the atomoxetine to see if it reverses. That would confirm causality pretty clearly.

Given that your TRT, SHBG, and E2 are all dialed in and working, I don't think the hormonal side is the culprit here. This sounds like a norepinephrine-mediated vascular effect at the dose you're now on, plain and simple. It's a real phenomenon, it's not in your head, and it's something that can be managed without necessarily giving up the cognitive benefits you've worked to achieve.

The fact that Concerta alone wasn't enough, and that adding Strattera brought real clarity, means this is worth trying to optimize rather than just abandoning. But the dose doubling was clearly the tipping point, and your prescribing doctor should hear exactly what you've described here, including the penile changes. Don't soften that part. It's clinically relevant and it affects your quality of life.

Wow, that's a lot of great info to unpack there!! Thanks!

I brought it up to my provider and she decreased the dose a bit. She said we'll be dialing it in slowly. It was a little awkward to talk about because, you know, it's a female doctor!!