Rarely does a day go by that a patient does not complain of decreased libido. I imagine that for every patient that mentions it, two or three have the complaint but do not bring it up. Sexual problems can be difficult to discuss. On the intake form in our office, decreased libido is an item that we ask all patients. This certainly helps to begin a discussion. There is no doubt that as patients experience the hormonal changes in menopause, they mention this problem more often.
This condition is now called HSDD, or hypoactive sexual desire disorder. It is the most common sexual dysfunction in women of all ages. It is defined as persistent or recurrently deficient or absence of sexual fantasies and the desire for sexual activity that causes marked distress or interpersonal problems. Other causes of HSDD including medical problems, drugs, psychiatric problems, relationship issues or conflicts, or other stresses of life would preclude this diagnosis.
To screen for this disorder, certain questions need to be asked:
Was your sexual desire at one time good, and has it decreased?
Is this causing distress, and would you like to improve it?
Understanding the history of the development of the problem, including relationship issues, medical and psychiatric problems, uses of medication, and social situation can help to understand the etiology of the problem and determine if HSDD is truly the diagnosis.
What are the treatment options?
Many physicians have used hormonal treatments for low libido. It is postulated that the increase in estrogen and testosterone at mid-cycle, during ovulation, were the cause of sexual motivation. Although attempts were made to bring testosterone to the FDA for approval for low libido, no product was ever approved. Testosterone is available as products for men, but the doses for men are too strong for women. Testosterone can be compounded for women, and this is done as off-label use. So, does it work? With few other choices, physicians do prescribe testosterone transdermal creams for decreased libido. The results are variable. Some patients respond well, others have no benefit. In a previous article on this site, it was noted that there is a window of benefit, too little or too much testosterone had no benefit. If prescribed off-label, the dose must be monitored carefully, and there is very little data about long-term risks. Short-term
risks are oily skin, facial hair growth, and aggressive or angry mood changes. These side effects will resolve after discontinuation of the drug. Patients who have been administered injectable pellets have experienced very high doses of testosterone in their bloodstream, and sometimes loss of hair.
The only drug approved for HSDD by the FDA is flibanserin. This drug is not a hormone. It works in the central nervous system by increasing dopamine and epinephrine. It was approved by the FDA for pre-menopausal women only, although studies in postmenopausal women demonstrate similar safety and efficacy. An increase is arousal, desire, orgasm and frequency of sexual activity were statistically increased, and distress was decreased. A response was noted in about 55% of women within 8 weeks, and if it did not work by then, it was unlikely to work. Side effects were dizziness, sleepiness, nausea and fatigue, each were noted in less than ten percent of study participants. Because of an interaction between the drug and alcohol causing fainting and low blood pressure, even though this side effect occurs in less than one percent of users, physicians are obligated to have patients sign that they will not use alcohol when taking this drug.
Bupropion is FDA approved for depression and smoking cessation, and is sometimes used in patients on SSRI’s and SNRI’s (some antidepressants) to treat the sexual side effects of these drugs. Benefits have been seen in some small studies, with side effects including tremor, agitation, constipation, dry mouth, sweating, dizziness and nausea.
Buspirone is FDA approved for anxiety. It has been used off-label for patients with HSDD who were taking SSRI’s. More than 50% of study participants noted increased sexual function. Side effects included dizziness, nausea, headaches, and nervousness.
Bremelanotide is being studied in men and women for decreased sexual interest. Side effects of nausea, vomiting and increased blood pressure were noted with intra-nasal and subcutaneous use. Phase 3 trials are in progress, hoping to find a beneficial dose with minimal side effects.
Clitoral stimulation: a small device that provides mild suction and vibration of the clitoris is available and intended to increase arousal. Unlike a vibrator which is intended to produce an orgasm, this device is meant to increase arousal and prepare for sexual activity.
Decisions regarding treatment of HSDD are best accomplished with your physician who can evaluate all medical issues and prescribe the best treatment for an individual situation.
Marilyn C. Jerome, MD
Supplement to OBG Management, October 2016
Hypoactive sexual desire disorder: definition and description, by Sheryl A. Kingsburg, PhD
Biologically based treatments for hypoactive sexual desire disorder, by James A. Simon, MD