How to manage the side effects of Zoloft in women

Zoloft (sertraline) is a commonly prescribed antidepressant that works by increasing serotonin levels (a feel-good hormone) in the central nervous system. As of 2020, about 38 million prescriptions were filled for sertraline—with women even more likely to be taking an antidepressant than men. In this article, two psychiatrists and a pharmacist explain the potential side effects of Zoloft that are specific to women—such as weight gain or loss, decrease in sex drive, nipple discharge, vaginal bleeding, and changes in menstrual cycle. 

Common side effects of Zoloft in women

“The majority of side effects that may come along with taking Zoloft, such as nausea, insomnia, and changes in sexual desire, are not gender specific,” says Alexa Hall, MD, psychiatrist, and medical director of Neuro Wellness Spa. “However, there are some possible side effects that only affect women or affect women more so than men.” These include:

1. Sexual side effects: “Women may experience more significant sexual side effects and sexual dysfunction such as difficulty reaching orgasm and decreased libido,” Dr. Hall says.
2. Weight changes: Women may express more concern over weight gain or loss in comparison to men, says Dr. Hall.
3. Menstrual cycle changes: It is not uncommon for women to observe changes in the regularity of periods or differences in the intensity of menstrual flow,” says Dr. Hall. Zoloft may cause changes in your periods, such as heavy bleeding, spotting, or vaginal bleeding between periods.
4. Nipple discharge: Women may also experience unusual milk secretion from the nipples.
5. Bone loss: “There are some studies that show antidepressants like sertraline can result in increased bone loss in older women,” says Alex Dimitriu, MD, founder of Menlo Park Psychiatry & Sleep Medicine in Menlo Park, California.

“The benefits [of taking Zoloft] should be closely weighed against the risks and discussed with your physician,” Dr. Dimitriu says. “In my practice, the benefits have often outweighed the risks.”

Other common side effects to expect with Zoloft—which are not specific to gender—include:

• Headache
• Nausea
• Diarrhea 
• Constipation
• Dry mouth
• Fatigue
• Drowsiness
• Trouble sleeping
• Increased anxiety

Rare and serious side effects may include:

• Low sodium levels
• Teeth grinding
• Angle-closure glaucoma (a medical emergency that occurs when fluid cannot drain from the eyes, causing increased pressure)
• Increased risk of bleeding (nose bleeds, gum bleeds, intestinal bleeding) 
• Aggressiveness
• Mood changes
• Increased excitement
• Increased sweating
• Nervousness or restlessness
• Racing heartbeat

How soon do Zoloft side effects start?

The time it takes for individuals to experience side effects while taking Zoloft varies from person to person. 

“In general, many people may notice some side effects within the first few days to weeks upon taking the medication,” Dr. Hall says. “Within the first few days, it is not uncommon to experience mild side effects such as nausea, headaches, or changes in sleep patterns. Oftentimes, these side effects are considered to be part of the body’s adjustment to the medication and may subside once fully adapted.”

Long-term side effects of Zoloft in women

Long-term adverse effects that are common with selective serotonin reuptake inhibitor (SSRI) use in women include sexual dysfunction, weight gain, and sleep problems. Zoloft belongs to this drug class. 

“Zoloft tends to be well tolerated for most individuals,” Dr. Hall says. “For those who experience sexual side effects, these may last long-term and could persist after stopping the medication. Weight gain can also be a long-term effect. Some studies have shown an increase in bone fractures with SSRIs and seizures with large doses. Other than these possible effects (which are rare), there do not seem to be lasting harmful effects from taking sertraline for long periods.”

Zoloft warnings for women

Certain medical conditions or other health factors may raise the risk of interactions with Zoloft. Before using Zoloft, talk with your healthcare provider about your health history. They’ll determine if Zoloft is right for you and your specific medical conditions—and if so, at what dosage. If you have any of the following conditions, consult your healthcare provider:

• Glaucoma: It’s important to inform your medical provider if you have glaucoma, as Zoloft has been associated with maculopathy (damage to the back of the retina) and narrow-angle glaucoma (also known as angle closure glaucoma). 

• Hypercholesterolemia: Inform your healthcare provider if you have high lipid or cholesterol levels, as Zoloft may worsen this condition. Sertraline may increase lipid levels, particularly triglycerides. 

• Bleeding disorders: SSRIs such as Zoloft have been associated with bleeding problems because the medication disrupts the clotting function of platelets. This has been associated with gastrointestinal bleeding—most common when SSRIs are combined with nonsteroidal inflammatory drugs (NSAIDs), such as ibuprofen. Other bleeding problems such as vaginal bleeding, gum bleeding, and nose bleeds are some rare side effects that have been associated with Zoloft. Let your healthcare provider know if you are taking any medications that affect bleeding risk, including prescription or over-the-counter NSAIDs or blood thinners like warfarin.

• Liver disease: Women who have liver disease should discuss the risks with their healthcare provider before using Zoloft. You may need to take a lower dose to reduce the risk of worsening the underlying liver impairment.

• Pregnancy: “[Pregnant]  women should carefully discuss with their provider if the benefit outweighs the risk,” says Whitney Prude, Pharm.D., a board-certified pharmacotherapy specialist in Rochester, Minnesota. “Sertraline does cross the human placenta, and the fetus will be exposed to the medication.” However, in some cases, the benefit of keeping the mother on the medication may outweigh the risks to the fetus, but this should be evaluated carefully with a healthcare professional as exposure in the third trimester can cause complications.
• Breastfeeding: Zoloft can be secreted in breast milk, and though it is considered safe, it is always important to seek medical advice from your healthcare provider if you are planning to breastfeed while on this medication. “Adverse events to the infant following exposure to sertraline via breast milk are limited in comparison to other SSRIs,” Dr. Prude says.

• Hyponatremia: Zoloft has been associated with low sodium in your blood, also known as hyponatremia. Older adults, people taking diuretic drugs for high blood pressure, or who have chronic diarrhea and vomiting are at increased risk of developing this condition.
• Bipolar disorder: Bipolar disorder is a chronic mental health condition characterized by intense mood swings. “The greatest risk with any medication like sertraline is in people who have bipolar disorder—in which case these medicines can intensify moods and anxiety and lead to bipolar cycling,” Dr.  Dimitriu says. 

Be sure to let your healthcare provider know if you have these health conditions or any other chronic health problems when discussing antidepressants. 

Managing Zoloft side effects in women

To reduce the potential risks of taking Zoloft, follow the prescribing information carefully and ask your pharmacist for help if anything is confusing or concerning. Additionally, here are some tips for managing Zoloft-induced side effects in women:

• If Zoloft is making you gain weight, talk to your healthcare provider about steps you can take to manage your weight, such as strength training, adding 30 minutes of brisk walking to your daily routine, and/or adjusting your diet.
• If Zoloft is affecting your sex life, talk to your healthcare provider about adjusting your dose (or changing your medication) to reduce side effects. Or, consider working with a sex therapist to find strategies to reinvigorate your sex drive.
• If Zoloft is affecting your menstrual cycle, you should talk to the prescribing healthcare provider about changing dosages or trying alternative medication options.
• If you have high triglyceride levels, you should discuss this with your healthcare provider before starting Zoloft. They will adjust your treatment plan to reduce the risk of possible metabolic changes and also follow up with regular triglyceride monitoring.
• Do not take Zoloft with medications such as serotonin and norepinephrine reuptake inhibitors (SNRIs), other SSRIs like fluoxetine or paroxetine, monoamine oxidase inhibitors (MAOIs), methylene blue injection, tryptophan, St. John’s wort,  or opioid medications such as fentanyl, meperidine, or tramadol. These medications can have drug interactions with Zoloft and may cause a rare but serious condition known as serotonin syndrome, which can be life-threatening. Be sure your healthcare provider knows about all the medications you take, including prescription and over-the-counter drugs, vitamins, and supplements—so they can screen for interactions.

Zoloft may increase suicidal thoughts in children, adolescents, and young adults, but people of any age should be alert to changes in mood and behavior. Seek emergency medical help if you are having thoughts of harming yourself or if you notice unusual symptoms such as worsening depression, agitation, recklessness, and irritability. 

Do not stop taking the medication without contacting your healthcare provider, as this may cause additional side effects or withdrawal symptoms. Instead, work with them to discontinue Zoloft in a way that’s best and safest for you.