Doctor Q&A: I still have a low libido after coming off antidepressants - is this permanent? Dr Renee Hoenderkamp answers all your burning questions

What can my daughter do about heavy periods besides taking the pill?  

What a lovely you mum you are, trying to find a solution to stop your daughter suffering. Well let me try and help as a fellow sufferer!

Heavy periods are debilitating, not just in practical ways but also physiologically. What does that mean. So girls and women with heavy periods, often avoid normal activity when they have their periods; so they avoid sport, miss school/university, don’t socialise and suffer a stigma from the fear of embarrassment should their period seep. On top of this, heavy periods often lead to anaemia which results in fatigue, shortness of breath and just feeling rotten. And the really frustrating part is that most often, no cause can be found.

Having said all of this, your daughter must not suffer in silence, as I did. There are things that can be done and not just the contraceptive pill!

So whilst it sounds scary, the Gold Standard treatment is a Mirena coil and for many women this will stop periods completely or reduce them to very little. I have the Mirena now and it was game changing.

After a couple of weeks of settling in and a few months of spotting, I ended up after six months with no periods at all. It is easy to insert with a little pain killing injection into the cervix. It is easier for women who have had a baby but that doesn’t rule young women out and if needed, a referral to a gynaecologist is warranted where it can be done under sedation. It can be left in place for five years, is easy to remove and fertility is restored immediately.

If the Mirena is not quite for her, there is a tablet called tranexamic acid which can reduce the flow by half and combining this with mefenamic can be synergistic and help reduce flow by a further quarter. Your GP can help with this as they are prescription medications.

After these options you are looking at either the combined contraceptive pill or progesterone only.

There are many suggestions for natural therapies and the ones which seem to come up the most are;

• Vitamin C. This vitamin may may help reduced bleeding. It might also help your body absorb iron, which can help prevent iron deficiency.
• Iron. There’s some evidence that suggests a lack of iron might contribute to heavy periods. If eating an iron-rich diet hasn’t improved your levels, supplementation may help but always do this via a doctor.
• Magnesium. Magnesium helps balance hormone levels. Foods such as seeds and nuts, green vegetables, leafy vegetables, fruits (avocados, banana), legumes, and seafood (tuna, salmon), etc. are rich in magnesium.

But please do ask her to get checked for an underlying cause. So get checked for thyroid function, PCOS, endometriosis, infection and anaemia. It is important to make sure that there isn’t a cause and/or effect that can be treated.

I hope that this helps and that she gets a solution.

I was wondering if you know why the side effects of SSRIs can be permanent after stopping? (This is called PSSD) I still have a low libido. What can I do?

Firstly for other readers, an SSRI is a selective serotonin reuptake inhibitor used commonly and widely for depression. Common names are Prozac, Citalopram, Sertraline.

Sadly this is a really interesting question to which the answer is yes. As you so rightly say, this is known as post SSRI sexual dysfunction and its very sad and not often spoken about.

Low libido is a common symptom in depression and is one of the problems SSRIs are meant to help, on the assumption that if one cures the depression, libido will return. However, SSRI’s often cause low libido/sexual dysfunction as a known side effect. I don’t think we, doctors, give enough thought to whether an SSRI will solve or exacerbate low libido. I also think doctors tend to under appreciate the important of sexual relationships and the desire and ability to have sex in terms of good mental health. So it’s a real problem and there are some interesting papers about it. This one is an interesting dissection of the problem itself and of the problem of doctors not taking it seriously.

In terms of treatment, I am sorry to say there has been nothing found currently that seems to work but in 2019, the condition was recognised and from that is hope that more research will lead to finding the cause and reversing it. There is a good paper to reference this here.

Natural remedies for low libido after SSRI are hard to assess but a 2015 review study found that Maca, Tribulus, Ginko Biloba and Gingseng might help but always discuss with your doctor first1. And overall, I would always recommend tackling all of the other areas in life that might be contributing and try and improve depression without medication if possible. There is a good summary here.

I am sorry not to have better news for you but hopefully things improve over time and that there will be some research that delivers hope.

I started taking 20mgs of Liptor about a month ago. My eyes are sore, red, gritty and very dry. I have increased my preservative free eye drops but having read widely about statins and ocular side effects, I have stopped my statins and my eyes are settling down. Is there a statin with a lower of incidence of ocular side effects? 

I am so sorry to hear this.

Lipitor, or atorvastatin, is a common statin given to people when a doctor wants to lower cholesterol levels. Whilst statins lower cholesterol, they do have side effects, having been linked to muscle pain, digestive problems and mental fuzziness in some people. Rarely, they may cause liver damage and ocular (eye) ones are well reported.

Lipids and dry, sore eyes are reported and researched and the Blue Mountains Eye Study III survey found that oral statins were associated with an increase in moderate to severe dry eye symptoms.

The mechanism is poorly understood but it is suggested that it is due to the disruption of essential cholesterol synthesis in the meibomian glands which are crucial for eye lubrication.

I struggled to find any solutions I am afraid but a prospective pilot study with 10 dry eye and blepharitis patients found that topical atorvastatin (eye drops) demonstrated improved tear film break up time, blepharitis score and redness. Clearly, larger clinical studies are required to establish the efficacy and safety of topical statin use. There is a good summary of this here.

Over and above this, we always return to lifestyle to try and lower cholesterol. So as you have stopped yours, have a look at all these other lifestyle interventions:

1. Eat non processed food

1. Exercise regularly

1. Keep a healthy body weight

1. Don’t smoke

1. Drink in moderation

1. Have a look at alternative remedies and there is a good summary here.

In the meantime it would be worthwhile testing your apolipoproteins because lipids, such as cholesterol and triglycerides, are insoluble in water and must be transported in association with proteins (lipoproteins) in the circulation.

These lipoproteins play a key role in the absorption and transport of dietary lipids by the small intestine, in the transport of lipids from the liver to peripheral tissues, and the transport of lipids from peripheral tissues to the liver and intestine (reverse cholesterol transport). So if your apolipoproteins are in range, then your raised cholesterol are not likely to be posing a risk.

Good luck!