Emerging Perspectives on the Science and Medicine of 

Hypoactive Sexual Desire Disorder (HSDD)

The Internal Medicine and Primary Care Perspective

 

Emerging Perspectives on the Science and Medicine of 

Hypoactive Sexual Desire Disorder (HSDD)

The Internal Medicine and Primary Care Perspective

 

A New Frontiers Program A New Frontiers Program onon Women’s HealthWomen’s Health

Program Chairman and ModeratorProgram Chairman and ModeratorAnita  H.  Clayton,  MDAnita  H.  Clayton,  MD

David C Wilson ProfessorDavid C Wilson ProfessorDepartment of Psychiatry & Neurobehavioral SciencesDepartment of Psychiatry & Neurobehavioral Sciences

Professor of Clinical Obstetrics & GynecologyProfessor of Clinical Obstetrics & GynecologyUniversity of VirginiaUniversity of VirginiaCharlottesville, VA Charlottesville, VA

Program FacultyProgram FacultyProgram FacultyProgram Faculty

    PROGRAM CHAIRPERSON PROGRAM CHAIRPERSON Anita H.  Clayton,  MDAnita H.  Clayton,  MDDavid C Wilson ProfessorDavid C Wilson ProfessorDepartment of Psychiatry & Department of Psychiatry & Neurobehavioral SciencesNeurobehavioral SciencesProfessor of Clinical Obstetrics & Professor of Clinical Obstetrics & GynecologyGynecologyUniversity of VirginiaUniversity of VirginiaCharlottesville, VACharlottesville, VA

Jennifer E. Frank, MD, Jennifer E. Frank, MD, FAAFPFAAFPAssistant ProfessorAssistant ProfessorDepartment of Family MedicineDepartment of Family MedicineUniversity of Wisconsin School of University of Wisconsin School of Medicine and Public HealthMedicine and Public HealthAppleton, WisconsinAppleton, Wisconsin

  

  Sheryl Kingsberg, PhDSheryl Kingsberg, PhDDivision Chief, Behavioral Medicine Division Chief, Behavioral Medicine ProgramProgramUniversity HospitalsUniversity HospitalsAssociate Professor of MedicineAssociate Professor of MedicineCase Western Reserve UniversityCase Western Reserve UniversityCleveland, OhioCleveland, Ohio

Lori Brotto, PhDLori Brotto, PhDAssistant ProfessorAssistant ProfessorDepartment of Obstetrics and Department of Obstetrics and GynecologyGynecologyUniversity of British ColumbiaUniversity of British ColumbiaVancouver, BCVancouver, BC

  

A New Frontiers Program A New Frontiers Program onon Women’s HealthWomen’s Health

Program Chairman and ModeratorProgram Chairman and ModeratorAnita  H.  Clayton,  MDAnita  H.  Clayton,  MD

David C Wilson ProfessorDavid C Wilson ProfessorDepartment of Psychiatry & Neurobehavioral SciencesDepartment of Psychiatry & Neurobehavioral Sciences

Professor of Clinical Obstetrics & GynecologyProfessor of Clinical Obstetrics & GynecologyUniversity of VirginiaUniversity of VirginiaCharlottesville, VACharlottesville, VA

Addressing Current Addressing Current Challenges in Female Sexual Challenges in Female Sexual

Disorders Disorders What Internal Medicine Specialists What Internal Medicine Specialists

Need to Know about HSDDNeed to Know about HSDD

► Clinical focusClinical focus

► Prevalence and pathophysiology of HSDDPrevalence and pathophysiology of HSDD

► Communication strategiesCommunication strategies

► Differential diagnosesDifferential diagnoses

► Intervention and managementIntervention and management

A New Frontiers Program A New Frontiers Program onon Women’s HealthWomen’s Health

Case ExampleCase Example

► 26-year-old MWF presents with 1 year 26-year-old MWF presents with 1 year history of decreased libido, some history of decreased libido, some problems with vaginal lubrication, and problems with vaginal lubrication, and diminished orgasmic capacity. No pain diminished orgasmic capacity. No pain with intercourse. with intercourse. Change in sexual function since Change in sexual function since

marriage 4 years ago, but relationship marriage 4 years ago, but relationship still strongstill strong

1 year post-partum with mild 1 year post-partum with mild depressive symptoms since deliverydepressive symptoms since delivery

No general health problemsNo general health problems On oral contraceptives for birth controlOn oral contraceptives for birth control

Hypoactive Sexual Desire Hypoactive Sexual Desire DisorderDisorder

Prevalence and Barriers to Recognition Prevalence and Barriers to Recognition in the Primary Care Settingin the Primary Care Setting

Sheryl A. Kingsberg, Ph.DSheryl A. Kingsberg, Ph.DChief, Division of Behavioral MedicineChief, Division of Behavioral Medicine

University Hospitals Case Medical CenterUniversity Hospitals Case Medical CenterProfessor, Department of Reproductive BiologyProfessor, Department of Reproductive Biology

Case Western Reserve University School of Case Western Reserve University School of MedicineMedicine

Cleveland OHCleveland OH

A New Frontiers Program A New Frontiers Program onon Women’s HealthWomen’s Health

““Normal” Female Sexuality Normal” Female Sexuality Defined by Cultural NormsDefined by Cultural Norms

► Historically given little attentionHistorically given little attention► Victorian era: discovery that female Victorian era: discovery that female

orgasm irrelevant to conceptionorgasm irrelevant to conception► 2008: women’s sexuality hits 2008: women’s sexuality hits

‘Primetime’ ‘Primetime’ but not quite its ‘Prime’but not quite its ‘Prime’

Human Sexual Response: Human Sexual Response: Classic ModelsClassic Models

► ExcitementExcitement► PlateauPlateau► OrgasmOrgasm► ResolutionResolution

DividedDividedDesireDesire

ArousalArousal

Linear progressionLinear progressionMasters WH, Johnson VE. Human Sexual Response. Boston, Mass: Little Brown; 1966.Kaplan HS. The New Sex Therapy. 1974.

Female Sexual Response CycleFemale Sexual Response Cycle

Adapted from Masters WH, Johnson VE. Adapted from Masters WH, Johnson VE. Human Sexual InadequacyHuman Sexual Inadequacy. Little Brown; 1970. . Little Brown; 1970.

ExcitementExcitement

PlateauPlateau

OrgasmOrgasm

Resolution

ResolutionReso

lutio

nR

eso

lutio

n

Reso

lutio

nR

eso

lutio

n

AA BBCC (C)(C) (A)(A)

(B)(B)

Orgasm

Plateau

Excitement

Basson R. Basson R. Med Aspects Hum Sex. Med Aspects Hum Sex. 2001;1:41-42.2001;1:41-42.

Emotional Emotional IntimacyIntimacy

Emotional Emotional IntimacyIntimacy

Sexual Sexual StimuliStimuli

Sexual Arousal

SpontaneousSpontaneousSexual DriveSexual DriveSpontaneousSpontaneousSexual DriveSexual Drive

Emotional andPhysical Satisfaction

Arousal andSexual Desire

PsychologicalPsychological

Seeking OutSeeking Outand Being and Being Receptive toReceptive to

BiologicBiologic

Female Sexual Response CycleFemale Sexual Response Cycle

Women’s Endorsement of Models of Women’s Endorsement of Models of Female Sexual ResponseFemale Sexual Response

► The Nurses’ Sexuality StudyThe Nurses’ Sexuality Study, N=133, N=133► Equal proportions of women endorsed the Equal proportions of women endorsed the

Masters and Johnson, Kaplan, and Basson Masters and Johnson, Kaplan, and Basson models of female sexual response as models of female sexual response as representing their own sexual experience.representing their own sexual experience.

► Women endorsing the Basson model had Women endorsing the Basson model had significantly lower FSFI domain scores significantly lower FSFI domain scores than women who endorsed either the than women who endorsed either the Masters and Johnson or Kaplan models.Masters and Johnson or Kaplan models.

Michael Sand, PhD, MPH, and William A. Fisher, PhD, JSM, 2007 4: 708-719Michael Sand, PhD, MPH, and William A. Fisher, PhD, JSM, 2007 4: 708-719

Biopsychosocial Model of Female Biopsychosocial Model of Female Sexual ResponseSexual Response

1. Rosen RC, Barsky JL. Obstet Gynecol Clin North Am. 2006;334:515-526.

(e.g., physical health,neurobiology, endocrine function)

(e.g., performance (e.g., performance anxiety, depression) anxiety, depression) PsychologyPsychology

(e.g., quality of current and past relationships,

intervals of abstinence, life stressors, finances)

(e.g., upbringing, cultural norms and expectations)

SocioculturalSociocultural InterpersonalInterpersonal

BiologyBiology

US Adult Women Are US Adult Women Are Sexually Active* Sexually Active*

*Sexually active was defined as oral (active or receptive), vaginal, or anal intercourse in the past 3 months. *Sexually active was defined as oral (active or receptive), vaginal, or anal intercourse in the past 3 months. ††Age-adjusted percentages. Age-adjusted percentages.

Patel D, et al. Patel D, et al. Sex Trans Dis.Sex Trans Dis. 2003;30(3):216-220. 2003;30(3):216-220.

66667070

6565

4646

2020

00

1010

2020

3030

4040

5050

6060

7070

100100

US

Wom

en S

exua

lly A

ctiv

e (%

)U

S W

omen

Sex

ually

Act

ive

(%)

Random Digital Dialing Survey of Women 18-94 Years Old Random Digital Dialing Survey of Women 18-94 Years Old (N=2000)(N=2000)††

18-29 18-29 30-39 30-39 40-49 40-49 50-59 50-59 60-9460-94(n=362)(n=362) (n=451)(n=451) (n=473)(n=473) (n=271)(n=271) (n=443)(n=443)

Age Ranges Age Ranges

DSM-IV-TR Classification of FSDsDSM-IV-TR Classification of FSDs

Sexual Desire DisordersSexual Desire Disorders

Hypoactive Sexual Desire Hypoactive Sexual Desire DisorderDisorder

Absence or deficiency of sexual Absence or deficiency of sexual interest and/or desireinterest and/or desire

Sexual Aversion DisorderSexual Aversion Disorder Aversion to and avoidance of genital Aversion to and avoidance of genital contact with a sexual partnercontact with a sexual partner

Sexual Arousal DisordersSexual Arousal Disorders

Female Sexual Arousal Female Sexual Arousal DisorderDisorder

Inability to attain or maintain adequate Inability to attain or maintain adequate lubrication-swelling response of sexual lubrication-swelling response of sexual excitementexcitement

Orgasmic DisordersOrgasmic Disorders

Female Orgasmic DisorderFemale Orgasmic Disorder Delay in or absence of orgasm after a Delay in or absence of orgasm after a normal sexual excitement phasenormal sexual excitement phase

Pain DisordersPain Disorders

DyspareuniaDyspareunia Genital pain associated with sexual Genital pain associated with sexual intercourseintercourse

VaginismusVaginismusInvoluntary contraction of the perineal Involuntary contraction of the perineal muscles preventing vaginal muscles preventing vaginal penetrationpenetration

DSM-IV TR Criteria for FSDDSM-IV TR Criteria for FSD

► Sexual complaint or problem in desire, arousal, Sexual complaint or problem in desire, arousal, orgasm, or sexual pain: orgasm, or sexual pain:

● Judgment of severity of sexual symptom is made by the Judgment of severity of sexual symptom is made by the clinician, talking into account factors that affect sexual clinician, talking into account factors that affect sexual functioning, such as age and the context of the person’s functioning, such as age and the context of the person’s lifelife

► The disturbance causes marked distress or The disturbance causes marked distress or interpersonal difficultyinterpersonal difficulty

► The sexual dysfunction is not: The sexual dysfunction is not: ● Better accounted for by another primary psychiatric Better accounted for by another primary psychiatric

disorder (except another Sexual Dysfunction)disorder (except another Sexual Dysfunction)● Due exclusively to the direct physiological effects of a Due exclusively to the direct physiological effects of a

substance (eg, drug of abuse, medication) or a general substance (eg, drug of abuse, medication) or a general medical conditionmedical condition

American Psychiatric Association. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Diagnostic and Statistical Manual of Mental DisordersDisorders. 4th Ed, text revision (DSM-IV-TR). Washington, DC: American Psychiatric . 4th Ed, text revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.Association; 2000.

Overlap of FSDsOverlap of FSDs

Basson R, et al. Basson R, et al. J UrolJ Urol. 2000;163:888-893.. 2000;163:888-893.

Sexual DesireSexual DesireDisordersDisorders

Sexual ArousalSexual ArousalDisorderDisorder

OrgasmicOrgasmicDisorderDisorder

VaginismusVaginismus

DyspareuniaDyspareunia

Prevalence of FSD: Prevalence of FSD: A Historical PerspectiveA Historical Perspective

► OBJECTIVESOBJECTIVES: Assess the prevalence and risk of experiencing sexual dysfunction in : Assess the prevalence and risk of experiencing sexual dysfunction in men and women men and women

► NOT ASSESSED: NOT ASSESSED: Distress or interpersonal difficultyDistress or interpersonal difficulty► POPULATION: POPULATION: 1749 women and 1410 men 18-59 years of age1749 women and 1410 men 18-59 years of age► RESULTSRESULTS: 43% of women reported sexual dysfunction : 43% of women reported sexual dysfunction

*Sexual problems were measured in this study. NHLHS data on critical symptoms do not connote a clinical *Sexual problems were measured in this study. NHLHS data on critical symptoms do not connote a clinical definition of sexual dysfunction. definition of sexual dysfunction. Laumann E, et al. Laumann E, et al. JAMA.JAMA. 1999; 281(6):537-544. 1999; 281(6):537-544.

Prevalence of Sexual Dysfunction Prevalence of Sexual Dysfunction in Women by Latent Classin Women by Latent Class

Subsets for Sexual Subsets for Sexual Dysfunctions AssessedDysfunctions Assessed

4343

2222

1414

77

00

1010

2020

3030

4040

5050

Total for SexualTotal for Sexual

DysfunctionsDysfunctions

AssessedAssessed

Low SexualLow Sexual

Desire Desire

Arousal Arousal Pain Pain

Wo

men

(%

)W

om

en (

%)

Sexual Dysfunction in the United States*Sexual Dysfunction in the United States*

100100

► OBJECTIVES: Estimate the prevalence of self-reported sexual problems (any, OBJECTIVES: Estimate the prevalence of self-reported sexual problems (any, desire, arousal, and orgasm), the prevalence of problems accompanied by desire, arousal, and orgasm), the prevalence of problems accompanied by personal distress, and describe related correlatespersonal distress, and describe related correlates

► NOT DETERMINED: Whether low desire with sexually related personal distress NOT DETERMINED: Whether low desire with sexually related personal distress was primary or secondary to another illness; pain was not assessedwas primary or secondary to another illness; pain was not assessed

► POPULATION: 31,581 US female respondents ≥18 years of age from 50,002 POPULATION: 31,581 US female respondents ≥18 years of age from 50,002 households households

► RESULTS*: Response rate was 63% (n=31,581 / 50,002)RESULTS*: Response rate was 63% (n=31,581 / 50,002)

Prevalence of FSD: PRESIDEPrevalence of FSD: PRESIDE

*All results are US population age-adjusted.

Shifren JL, et al. Obstet Gynecol. 2008;112(5):970-978.

Prevalence of Female Sexual Problems Associated With Distress Prevalence of Female Sexual Problems Associated With Distress

37.737.7

25.325.3

21.121.1

43.143.1

11.511.5

4.64.65.15.19.59.5

00

55

1010

1515

2020

2525

3030

3535

4040

4545

5050

DesireDesire ArousalArousal OrgasmOrgasm AnyAny

US

Wom

en (

%)

US

Wom

en (

%)

Sexual Problems

Distressing Sexual Problems

100100

Prevalence of Sexual Problems Prevalence of Sexual Problems Associated with Distress (PRESIDE)Associated with Distress (PRESIDE)

Age-stratifiedAge-stratifiedprevalenceprevalence

DesireDesire2868/28,4472868/28,447

ArousalArousal1556/28,4611556/28,461

OrgasmOrgasm1315/27,8541315/27,854

AnyAny3456/28,4033456/28,403

18-4418-44 8.98.9 3.33.3 3.43.4 10.810.8

45-6445-64 12.312.3 7.57.5 5.75.7 14.814.8

65 or older65 or older 7.47.4 6.06.0 5.85.8 8.98.9

Shifren J et al Obstetrics & Gynecology, 2008, 112(5).Shifren J et al Obstetrics & Gynecology, 2008, 112(5).

Prevalence of Low Sexual Desire and Prevalence of Low Sexual Desire and Hypoactive Sexual Desire Disorder Hypoactive Sexual Desire Disorder

West SL et al Archives of Internal Medicine, 2008West SL et al Archives of Internal Medicine, 2008

CategoryCategoryLow Low

DesireDesireNN

Low Low DesireDesire

%%

HSDDHSDDNN

HSDDHSDD%%

AllAll 19361936 36.236.2 19201920 8.38.3

Age 30-39Age 30-39 453453 30.830.8 453453 8.38.3

Age 40-49Age 40-49 542542 25.325.3 539539 9.09.0

Age 50-59Age 50-59 824824 37.837.8 814814 9.49.4

Age 60-70Age 60-70 117117 60.760.7 114114 5.85.8

Surgical Surgical MenopausalMenopausal 635635 39.739.7 631631 12.512.5

Natural Natural MenopausalMenopausal 551551 52.452.4 541541 6.66.6

PremenopausalPremenopausal 750750 26.726.7 748748 7.77.7

Nationally Representative Sample of US Women

Decreased Sexual Desire With Decreased Sexual Desire With Distress Negatively Impacts Women’s Distress Negatively Impacts Women’s

LivesLives► Decreased sexual desire is associated Decreased sexual desire is associated

with negative effects including:with negative effects including:1,21,2 ● Poor self-imagePoor self-image● Mood instabilityMood instability● DepressionDepression● Strained relationships with partnersStrained relationships with partners

1. Shifren JL, et al. Obstet Gynecol. 2008;112(5):970-978. 2. Leiblum SR. Menopause. 2006;13(1):46-56.

Hypoactive Sexual Desire Disorder Hypoactive Sexual Desire Disorder (HSDD)(HSDD)

► Persistent or recurrent deficiency or absence Persistent or recurrent deficiency or absence of sexual thoughts, fantasies and/or desire for, of sexual thoughts, fantasies and/or desire for, or receptivity to, sexual activityor receptivity to, sexual activity

● Causes marked personal distress or interpersonal Causes marked personal distress or interpersonal difficultiesdifficulties

● Not better accounted for by another primary Not better accounted for by another primary disorder, drug/medication, or general medical disorder, drug/medication, or general medical conditioncondition

Components of Sexual DesireComponents of Sexual Desire

► Drive: Drive: ● Sex steroids and neurotransmitters play a Sex steroids and neurotransmitters play a

role in modulating sexual desire, drive, and role in modulating sexual desire, drive, and excitementexcitement

► Expectations, beliefs, and valuesExpectations, beliefs, and values► MotivationMotivation

Hull EM, et al. Hull EM, et al. Behav Brain Res. Behav Brain Res. 1999;105:105–116.1999;105:105–116.Levine S. Sexual Life, 1994Levine S. Sexual Life, 1994

Social Psychology Theories: Understanding Social Psychology Theories: Understanding Psychosocial Aspects of Female Sexual DesirePsychosocial Aspects of Female Sexual Desire

► Self-Perception TheorySelf-Perception Theory● People make attributions about their own People make attributions about their own

attitudes by relying on observations of external attitudes by relying on observations of external behaviors (Bem, 1965)behaviors (Bem, 1965)

► Wundt's schema of sensory affect (aka Kingsberg’s Wundt's schema of sensory affect (aka Kingsberg’s Ice-Cream Analogy)Ice-Cream Analogy)● Increases of stimulus intensity above threshold Increases of stimulus intensity above threshold

are felt as increasingly pleasant up to a peak are felt as increasingly pleasant up to a peak value beyond which pleasantness falls off value beyond which pleasantness falls off through indifference to increasing through indifference to increasing unpleasantness. unpleasantness.

Prevention and Treatment of Prevention and Treatment of Sexual ProblemsSexual Problems

ASK!ASK!

You cannot treat a You cannot treat a problem if you don’t know problem if you don’t know

it existsit exists

Type of Help-Seeking (n=3239Type of Help-Seeking (n=3239))

In PRESIDE About One-Third of Women With In PRESIDE About One-Third of Women With a Distressing Sexual Problem Sought Formal Care a Distressing Sexual Problem Sought Formal Care

Shifren JL, et al. Shifren JL, et al. J Women’s Health.J Women’s Health. 2009;18(4)461-468. 2009;18(4)461-468.

Formal34.5%

Informal41.9%

9.1%Anonymous

14.5%Did notseek help

Formal=HCP; informal=anyone other than an HCP.Formal=HCP; informal=anyone other than an HCP.

Physician Questioning Increases Patient Physician Questioning Increases Patient Reporting of Sexual DysfunctionReporting of Sexual Dysfunction

Spontaneous Reporting AfterSpontaneous Reporting After Reporting Direct InquiryReporting Direct Inquiry

4040

3030

2020

1010

00

Pat

ien

ts (

%)

Pat

ien

ts (

%)

N=887.Bachmann GA, et al. Obstet Gynecol. 1989:73:425-427.

3%3%

19%19%

Physician-Based BarriersPhysician-Based Barriers

► Lack of training/Inadequate knowledge or Lack of training/Inadequate knowledge or skillsskills11

► Lack of awareness of associated comorbid Lack of awareness of associated comorbid conditionsconditions

► ““Improving quality of life” may not be Improving quality of life” may not be considered a high priorityconsidered a high priority22

► Time constraintsTime constraints33

► Underestimation of prevalenceUnderestimation of prevalence

► No FDA approved treatments for female sexual No FDA approved treatments for female sexual dysfunctiondysfunction

11Broekman CPM, et al. Broekman CPM, et al. Int J Impot Res. Int J Impot Res. 1994;6:67-72.1994;6:67-72.22Eid JF, et al. Eid JF, et al. CliniguideCliniguide®® to Erectile Dysfunction. to Erectile Dysfunction. Lawrence DellaCorte Publications, Inc; 2001.Lawrence DellaCorte Publications, Inc; 2001.33Baum N, et al. Baum N, et al. Patient Care. Patient Care. Spring 1998(suppl):17-21.Spring 1998(suppl):17-21.

Training Is Not Preparing HCPs To Be Training Is Not Preparing HCPs To Be Informed in the Area of FSDInformed in the Area of FSD

Solursh DS, et al. Solursh DS, et al. Int J Impot Res.Int J Impot Res. 2003;15(suppl 5):S41-S45. 2003;15(suppl 5):S41-S45.

Curriculum Time (Hours) Dedicated to Human Sexual Health Education Curriculum Time (Hours) Dedicated to Human Sexual Health Education (N=101)*(N=101)*

*Human sexual health education was not specifically defined in the survey but included: type of *Human sexual health education was not specifically defined in the survey but included: type of educational experiences, disciplines, subject and topics areas, clinical program, continuing educational experiences, disciplines, subject and topics areas, clinical program, continuing medical education, total number of hours, amongst others.medical education, total number of hours, amongst others.

Most HCPs Have Little or No Confidence in Most HCPs Have Little or No Confidence in Screening for or Diagnosing HSDDScreening for or Diagnosing HSDD

Harsh V, et al. Harsh V, et al. J Sex Med.J Sex Med. 2008;5(3):640-645. 2008;5(3):640-645.

5757

9090

9191

00 2020 4040 6060 8080 100100

HCPs who had little confidence inHCPs who had little confidence in

ability to manage HSDDability to manage HSDD

HCPs who felt little or no confidence inHCPs who felt little or no confidence indiagnosing HSDDdiagnosing HSDD

Respondents who had not screened orRespondents who had not screened ordiagnosed patients with HSDDdiagnosed patients with HSDD

HCPsHCPs (%) (%)

Web-Based Survey Consisting of Residents and Faculty in an Academic Primary Care Clinic (N=53; 41.5% women, 58.5% men)

Patient Barriers Identified by HCPs in the Management of Patient Barriers Identified by HCPs in the Management of Sexual Dysfunction (n=133 HCPs)Sexual Dysfunction (n=133 HCPs)

HCPs Perceive Patients as Reluctant to HCPs Perceive Patients as Reluctant to Bring Up Sexual IssuesBring Up Sexual Issues

Patients‘ reluctance/reticence/embarrassment

Patient thinks it's “normal”/lackof knowledge and awareness

Indirect presentation (hidden by other symptoms)

Difficult area to discuss

Doesn't want to waste doctors' time

73.1

15

5.4

4.3

2.2

0 20 40 60 80

Total Number of Barriers (%)*

Humphrey S, et al. Fam Pract. 2001;18(5):516-518.*Total number of patient barriers=93; most HCPs identified more than one barrier.

HCP Comfort Level Impacted byHCP Comfort Level Impacted byPatient GenderPatient Gender

Burd ID, et al. Burd ID, et al. J Sex Med.J Sex Med. 2006;3(2):194-200. 2006;3(2):194-200.

Differences in Physician Comfort Level Influenced by Gender (N=69)Differences in Physician Comfort Level Influenced by Gender (N=69)

53

40

35

19

24*

45

12*

50*

0 10 20 30 40 50 60 70

Physician perception offemale patient discomfort

Physician perception ofmale patient discomfort

Physician self-report ofdiscomfort with female patients

Physician self-report ofdiscomfort with male patients

Physicians (%)Physicians (%)

Male physicians (n=40)

Female physicians (n=29)

*P<0.05.

Open-Ended QuestionsOpen-Ended Questions

► Require narrative elaboration, not yes/no or short Require narrative elaboration, not yes/no or short responseresponse

● Directive open-ended questions focus the topic Open the Directive open-ended questions focus the topic Open the door to context, understanding, & feelingsdoor to context, understanding, & feelings

► Doctors ask ≈1 question/min; >90% are closed-endedDoctors ask ≈1 question/min; >90% are closed-ended► Physicians can increase use open-ended questions & Physicians can increase use open-ended questions &

improve improve ● Assessment of functional impairment Assessment of functional impairment ● Adherence Adherence ● Patient satisfactionPatient satisfaction

► Open-ended dialog is efficient (≈ 90 seconds for Open-ended dialog is efficient (≈ 90 seconds for impairment dialog)impairment dialog)44 & effectively reveals syndromal & effectively reveals syndromal symptomssymptoms

Lipton et al. JGIM 2008;23:1145-1151.Lipton et al. JGIM 2008;23:1145-1151.Hahn et al. Curr Med Res Opin 2008;24:1711-1718.Hahn et al. Curr Med Res Opin 2008;24:1711-1718.

• HSDD and concomitant sexual dysfunctions (both should be noted)HSDD and concomitant sexual dysfunctions (both should be noted)

● Also, additional diagnosis of HSDD Also, additional diagnosis of HSDD IS NOTIS NOT made if low sexual desire is made if low sexual desire is better accounted for by another Axis I disorder (eg, major depressive better accounted for by another Axis I disorder (eg, major depressive disorder, obsessive-compulsive disorder, posttraumatic stress disorder)disorder, obsessive-compulsive disorder, posttraumatic stress disorder)

– HSDD diagnosis may be appropriate if low desire predates the Axis I HSDD diagnosis may be appropriate if low desire predates the Axis I diagnosisdiagnosis

The Challenges of the The Challenges of the Differential DiagnosisDifferential Diagnosis

• Ensure that sexual dysfunction Ensure that sexual dysfunction IS NOTIS NOT due exclusively to thedue exclusively to the

– Physiological effects of a specified general medical condition (eg, Physiological effects of a specified general medical condition (eg, neurological, hormonal, metabolic abnormalities)*neurological, hormonal, metabolic abnormalities)*

*If it is, refer to the diagnosis: Sexual Dysfunction Due to a General Medical Condition.*If it is, refer to the diagnosis: Sexual Dysfunction Due to a General Medical Condition.††If it is, refer to the diagnosis is Substance-Induced Sexual Dysfunction.If it is, refer to the diagnosis is Substance-Induced Sexual Dysfunction.

• Ensure that sexual dysfunction Ensure that sexual dysfunction IS NOTIS NOT due exclusively to thedue exclusively to the

– Physiological effects of substance (prescribed or illicit) abusePhysiological effects of substance (prescribed or illicit) abuse††

In Order to In Order to Meet the Meet the Diagnostic Diagnostic Criteria for Criteria for HSDD: HSDD:

American Psychiatric Association. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Fourth Edition, Text Revision, Washington, DC: American Psychiatric Press; 2000.Revision, Washington, DC: American Psychiatric Press; 2000.

The Challenges of Differential DiagnosisThe Challenges of Differential Diagnosis

► Mood disordersMood disorders11

● Major depressionMajor depression● Bipolar illnessBipolar illness

► Anxiety disordersAnxiety disorders2,32,3

► Psychotic illnessPsychotic illness44

► HypertensionHypertension► Neurological disordersNeurological disorders66

► Endocrine disordersEndocrine disorders77

● Diabetes, thyroid disorders, Diabetes, thyroid disorders,

hyperprolactinemiahyperprolactinemia77

● Urological problemsUrological problems88

● Sexually transmitted infectionsSexually transmitted infections99

● GynGyneecological problemscological problems— Post-partumPost-partum1010

● Other chronic illnessOther chronic illness— Rheumatoid arthritisRheumatoid arthritis1111

— PsoriasisPsoriasis1212

— Breast cancerBreast cancer1313

1. Casper RC, et al. 1. Casper RC, et al. Arch Gen Psychiatry.Arch Gen Psychiatry. 1985;42:1098-1104. 2. van Lankveld JJ, Grotjohann Y. 1985;42:1098-1104. 2. van Lankveld JJ, Grotjohann Y. Arch Sex Behav.Arch Sex Behav. 2000;29:479-498. 3. 2000;29:479-498. 3. Shifren J, et Shifren J, et al. al. Obstet GynecolObstet Gynecol. 2008;112:970-978. . 2008;112:970-978. 4. Friedman S, Harrison G. 4. Friedman S, Harrison G. Arch Sex BehavArch Sex Behav. 1984;13:555-567. 5. Okeahialam BN, Obeka NC. . 1984;13:555-567. 5. Okeahialam BN, Obeka NC. J Natl Med J Natl Med Assoc.Assoc. 2006;98:638-640. 6. Rees PM, et al. 2006;98:638-640. 6. Rees PM, et al. LancetLancet. 2007;369(9560):512-525. 7. Bhasin S, et al. . 2007;369(9560):512-525. 7. Bhasin S, et al. LancetLancet. 2007;369(9561):597-611. 8. Aslan G, et al. . 2007;369(9561):597-611. 8. Aslan G, et al. Int J Impot Res.Int J Impot Res. 2005;17:248-251. 9. Smith EM, et al. 2005;17:248-251. 9. Smith EM, et al. Infect Dis Obstet GynecolInfect Dis Obstet Gynecol. 2002;10(4):193-202. 10. Baksu B, et al. . 2002;10(4):193-202. 10. Baksu B, et al. Int Urogynecol J.Int Urogynecol J. 2007;18:401-406. 11. Abdel-Nasser A, Ali E. 2007;18:401-406. 11. Abdel-Nasser A, Ali E. Clin Rheumatol.Clin Rheumatol. 2006;25:822-830. 12. Sampogna F, et al. 2006;25:822-830. 12. Sampogna F, et al. DermatologyDermatology. 2007;214:144-150. . 2007;214:144-150. 13. Mathias C, et al. 13. Mathias C, et al. Ann OncolAnn Oncol. 2006;17(12):1792-1796. . 2006;17(12):1792-1796.

Psychiatric Illnesses and General Health Factors May Affect Sexual Psychiatric Illnesses and General Health Factors May Affect Sexual FunctionFunction

Other drug classesOther drug classes● Chemotherapeutic agentsChemotherapeutic agents66

● Aromatase InhibitorsAromatase Inhibitors77

● Triglyceride-lowering agentsTriglyceride-lowering agents88

● Histamine receptors (H2) blockersHistamine receptors (H2) blockers99

● Weight loss agentsWeight loss agents1010

● AntiepilepticsAntiepileptics1111

● ImmunosuppresantsImmunosuppresants1212

● Central alpha-adrenergic agonistsCentral alpha-adrenergic agonists1313

● Opioid antagonistsOpioid antagonists1414

1. Liu-Seifert H, et al. 1. Liu-Seifert H, et al. Neuropsychiatr Dis TreatNeuropsychiatr Dis Treat. 2009;5:47-54. 2. Serretti A, Chiesa A. . 2009;5:47-54. 2. Serretti A, Chiesa A. J Clin PsychopharmacolJ Clin Psychopharmacol. 2009;29:259-266. 3. Lithium . 2009;29:259-266. 3. Lithium carbonate [package insert]. 2003. 4. Venlafaxine hydrochloride [package insert]. 2003. 5. Imipramine hydrochloride [package insert]. 2007. carbonate [package insert]. 2003. 4. Venlafaxine hydrochloride [package insert]. 2003. 5. Imipramine hydrochloride [package insert]. 2007. 6. Fobair P, Spiegel D. 6. Fobair P, Spiegel D. Cancer JCancer J. 2009;15(1):19-26. 7. Mok K, et al. . 2009;15(1):19-26. 7. Mok K, et al. BreastBreast. 2008;17(5):436-440. 8. Fenofibrate [package insert]. 2008. 9. . 2008;17(5):436-440. 8. Fenofibrate [package insert]. 2008. 9. Ranitidine Ranitidine hydrochloridehydrochloride [package insert]. 2009. 10. [package insert]. 2009. 10. Sibutramine hydrochloride monohydrateSibutramine hydrochloride monohydrate [package insert]. 2009. 11. Rees PM, et al. [package insert]. 2009. 11. Rees PM, et al. LancetLancet. 2007;369:512-. 2007;369:512-525. 12. Muehrer RJ, et al. 525. 12. Muehrer RJ, et al. West J Nurs Res.West J Nurs Res. 2006;28:137-150. 13. Clonidine [package insert]. 2009. 14. Naltrexone hydrochloride [package insert]. 2006;28:137-150. 13. Clonidine [package insert]. 2009. 14. Naltrexone hydrochloride [package insert]. 2003. 2003.

Psychotropic drug classes/agentsPsychotropic drug classes/agents

● AntipsychoticsAntipsychotics11

● SSRIsSSRIs22

● LithiumLithium33

● SNRIsSNRIs44

● Tricyclic antidepressantsTricyclic antidepressants55

Numerous Medications are Associated Numerous Medications are Associated with Female Sexual Problemswith Female Sexual Problems

The Challenges of Differential DiagnosisThe Challenges of Differential Diagnosis

Thank youThank you

Sheryl.kingsberg@uhhospitals.orgSheryl.kingsberg@uhhospitals.org

Pathophysiology of Decreased Pathophysiology of Decreased Desire in Premenopausal Desire in Premenopausal

Women Women Psychological, Pharmacologic, and Psychological, Pharmacologic, and

Neurobiological MechanismsNeurobiological Mechanisms

A New Frontiers Program A New Frontiers Program onon Women’s HealthWomen’s Health

Program Chairman and ModeratorProgram Chairman and ModeratorAnita  H.  Clayton,  MDAnita  H.  Clayton,  MD

David C Wilson ProfessorDavid C Wilson ProfessorDepartment of Psychiatry & Neurobehavioral SciencesDepartment of Psychiatry & Neurobehavioral Sciences

Professor of Clinical Obstetrics & GynecologyProfessor of Clinical Obstetrics & GynecologyUniversity of VirginiaUniversity of VirginiaCharlottesville, VACharlottesville, VA

ObjectivesObjectives

At the conclusion of this activity, At the conclusion of this activity, participants should be able to:participants should be able to:

► Describe the psychological, Describe the psychological, pharmacological and neurobiological pharmacological and neurobiological factors affecting desire in premenopausal factors affecting desire in premenopausal womenwomen

What’s it all about anyhow?What’s it all about anyhow?

► Psychological/social/emotionalPsychological/social/emotional

► Physiological/biological: interactions of sex Physiological/biological: interactions of sex steroids and neurotransmitterssteroids and neurotransmitters

► Cognitive: thoughts, fantasies, satisfactionCognitive: thoughts, fantasies, satisfaction

► CulturalCultural

American Psychiatric Association, DSM IV, 1994American Psychiatric Association, DSM IV, 1994

Central Effects on Sexual FunctionCentral Effects on Sexual Function

estrogenestrogen

testosteronetestosterone progesteroneprogesterone

SUBJECTIVESUBJECTIVEEXCITEMENTEXCITEMENT

ORGASMORGASM

DESIREDESIRE

prolactinprolactin

oxytocinoxytocin

++norepinephrine (NE)norepinephrine (NE)

5-HT5-HT

dopamine (DA)dopamine (DA)

--

--

++

++

++++

++

--

++Modified from Clayton AH. Modified from Clayton AH. Psych Clin Psych Clin

NANA 2003; 26:673-682 2003; 26:673-682 Cohen AJ. AD-induced SD associated Cohen AJ. AD-induced SD associated

with low serum free testosterone 2000. with low serum free testosterone 2000. http://www.mental-health-today.com/rx/tehttp://www.mental-health-today.com/rx/te

stos.htmstos.htm

5-HT --++

+/-+/-

NENE++

Peripheral Effects on Sexual FunctionPeripheral Effects on Sexual Function

5-HT5-HT2A2A

NitricNitricOxide (NO)Oxide (NO)

Cholinergic fibersCholinergic fibersProstaglandin EProstaglandin E

5-HT5-HT

--

++--

Clayton AH. Clayton AH. Psychiatric Clinics of North AmericaPsychiatric Clinics of North America 2003; 26:673-682 2003; 26:673-682

++

SENSATION

gonadsadrenals

• Estrogen• Testosterone• Progestin

maintain genitalstructure andfunction

}

VASOCONGESTION

++

5-HT5-HT--

++

Clitoral andpenile tissue

Physiology of Sexual FunctionPhysiology of Sexual Function

► Desire: Desire: ● Excitatory: dopamine, norepinephrine, Excitatory: dopamine, norepinephrine,

testosterone, estrogentestosterone, estrogen● Inhibitory: serotonin, prolactinInhibitory: serotonin, prolactin

► Arousal: Arousal: ● Excitatory: dopamine, norepinephrine, nitric Excitatory: dopamine, norepinephrine, nitric

oxide, acetylcholine, estrogen, testosteroneoxide, acetylcholine, estrogen, testosterone● Inhibitory: serotonin, prolactin Inhibitory: serotonin, prolactin

Pfaus JG. Pfaus JG. J Sex Med J Sex Med 2009;6:1506-1533.2009;6:1506-1533.

Influences on Sexual FunctioningInfluences on Sexual Functioning

► NeurobiologicalNeurobiological● Reproductive endocrinology (ie. anything that Reproductive endocrinology (ie. anything that

lowers testosterone such as lowers testosterone such as hyperprolactinemia, opiates, menopause)hyperprolactinemia, opiates, menopause)

● General health status/illness (e.g. fatigue)General health status/illness (e.g. fatigue)11 and and co-morbiditiesco-morbidities

● Medication/substance useMedication/substance use► PsychologicalPsychological

● Body image (e.g. obesity)Body image (e.g. obesity)● Psychological/relationship issues, partner Psychological/relationship issues, partner

availability/agingavailability/aging11

● Fears (e.g. pregnancy, infertility, STD, history Fears (e.g. pregnancy, infertility, STD, history of sexual abuse/trauma, cultural practices)of sexual abuse/trauma, cultural practices)

11Meston C. Meston C. Western Journal of MedicineWestern Journal of Medicine 1997;167(4):285-290 1997;167(4):285-290

DSM-IV TR Criteria for HSDDDSM-IV TR Criteria for HSDD

► Sexual complaint or problem in sexual desire and/or Sexual complaint or problem in sexual desire and/or fantasiesfantasies● The judgement of severity of the sexual symptom is The judgement of severity of the sexual symptom is

made by the clinician, taking into account factors that made by the clinician, taking into account factors that affect sexual functioning, such as age and the context affect sexual functioning, such as age and the context of the person’s lifeof the person’s life

► The disturbance causes marked distress or The disturbance causes marked distress or interpersonal difficultyinterpersonal difficulty

► The sexual dysfunction is not:The sexual dysfunction is not:● Better accounted for by another Better accounted for by another primary psychiatric primary psychiatric

disorder disorder (except another Sexual Dysfunction)(except another Sexual Dysfunction)● Due exclusively to the direct physiological effects of a Due exclusively to the direct physiological effects of a

substance (e.g., a drug of abuse, a medication) or a substance (e.g., a drug of abuse, a medication) or a general medical conditiongeneral medical conditionAmerican Psychiatric Association. DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision. American Psychiatric Association. DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision.

Washington, DC: American Psychiatric Press; 2000Washington, DC: American Psychiatric Press; 2000

FSD may be Multi-faceted FSD may be Multi-faceted

► Biological/Biological/PharmacologicalPharmacological● Medical diagnosesMedical diagnoses● Psychiatric conditionsPsychiatric conditions● Other sexual disordersOther sexual disorders● Medications/substancesMedications/substances● Hormonal changesHormonal changes

► Socio-culturalSocio-cultural● Lower educationLower education● Religious restrictionsReligious restrictions● Social taboosSocial taboos● Cultural conflictCultural conflict

► PsychologicalPsychological● Prior sexual or Prior sexual or

physical abusephysical abuse● Relational (conflict, Relational (conflict,

lack of partner, lack of partner, partner SD) partner SD)

● Body image, sexual Body image, sexual self-esteemself-esteem

● Negative emotional Negative emotional statesstates

● StressStress

Relational Problems (not HSDD)Relational Problems (not HSDD)

► Sexual dysfunction in partnerSexual dysfunction in partner► Interpersonal conflictInterpersonal conflict► Extra-marital affair by either partnerExtra-marital affair by either partner► Desire discrepancyDesire discrepancy► Cultural differencesCultural differences► Reproductive concernsReproductive concerns► History of sexual abuseHistory of sexual abuse

Prevalence of Sexual DysfunctionPrevalence of Sexual Dysfunction

SEXUAL SEXUAL COMPLAINTCOMPLAINT

SEXUAL SEXUAL PROBLEMPROBLEM

PROBLEM PLUS PROBLEM PLUS DISTRESSDISTRESS

FSD WITHOUT FSD WITHOUT DEPRESSIONDEPRESSION

Desire 38.7% 10% 6.3 – 8.8%Arousal 26.1% 5.4% 3.3 – 4.7%Orgasm 20.5% 4.7% 2.8 – 4.1%Any Dysfunction 44.2% 12% 7.6 – 10.7%

Shifren J et al. Sexual problems and distress in United States women: Prevalence and correlates. Shifren J et al. Sexual problems and distress in United States women: Prevalence and correlates. Obstet Gynecol Obstet Gynecol 2008;112:970-978; Johannes CB et al. Distressing Sexual Problems in United 2008;112:970-978; Johannes CB et al. Distressing Sexual Problems in United States Women Revisited: Prevalence after Accounting for Depression. States Women Revisited: Prevalence after Accounting for Depression. J Clin Psychiatry J Clin Psychiatry 2009;70(12):1698-1706 2009;70(12):1698-1706

N=31,581. Definition of depression: Self-reported depressive sx’s + AD use; AD use without current depressive sx’s; Depressive symptoms without AD use

Leiblum SR et al.Hypoactive sexual desire disorder in postmenopausal women: US results from the Women’s International Study of Health and Sexuality (WISHeS). Menopause. 2006;13:46-56.

NaturallyNaturallypostmenopausalpostmenopausal

Surgically Surgically postmenopausalpostmenopausal

PremenopausalPremenopausal

% o

f Pa t

ient

s

Surgically Surgically postmenopausalpostmenopausal

Proportion of Partnered Women with HSDD Proportion of Partnered Women with HSDD By Age and Menopausal By Age and Menopausal

StatusStatus

Age 20-49 years

0

5

10

15

20

25

30 P=0.002

Age 50-70 years

P=0.067

Medical Conditions that mayMedical Conditions that mayImpact Sexual FunctionImpact Sexual Function

NeurologicNeurologic Spinal cord injury, neuropathy, Spinal cord injury, neuropathy, herniated disc, MS, epilepsyherniated disc, MS, epilepsy

EndocrineEndocrineHypothyroidism, adrenal Hypothyroidism, adrenal dysfunction, hypogonadism, dysfunction, hypogonadism, diabetes mellitus, menopausediabetes mellitus, menopause

VascularVascularHypertension, arteriosclerosis, Hypertension, arteriosclerosis, stroke, venous insufficiency, sickle stroke, venous insufficiency, sickle cell disorder cell disorder

GenitourinaryGenitourinary Urinary incontinence, Urinary incontinence, vaginitis, PID, endometriosisvaginitis, PID, endometriosis

Systemic IllnessSystemic IllnessRenal, pulmonary, hepatic Renal, pulmonary, hepatic diseases, advanced diseases, advanced malignancies, infectionsmalignancies, infections

PsychiatricPsychiatric Depression, anxiety Depression, anxiety disorders, psychotic illness, disorders, psychotic illness, eating disorders, PTSDeating disorders, PTSD

Clayton & Ramamurthy in Sexual Dysfunction: The Brain-Body Connection. Ed: R Balon, Karger, Basel, Switzerland, 2008; Basson R, Schultz WW. Lancet. 2007;369:409-424; Kingsberg SA, Janata JW. Urol Clin North Am. 2007;34:497-506; Zemishlany & Weizman in Sexual Dysfunction: The Brain-Body Connection. Ed: R Balon, Karger Basel, Swithzerland 2008

Pharmacotherapies and Risk of FSDPharmacotherapies and Risk of FSD

PSYCHOTROPIC PSYCHOTROPIC MEDICATIONSMEDICATIONS

SSRIs/SNRIs/TCAs Mood stabilizers

Antipsychotics

Benzodiazepines Antiepileptic drugs

ANTIHYPERTENSIVESANTIHYPERTENSIVESBeta-blockersAlpha-blockers

Diuretics

CARDIOVASCULAR AGENTSCARDIOVASCULAR AGENTSLipid-lowering agents

Digoxin

HORMONESHORMONESOral contraceptives

EstrogensProgestins

Ant-iandrogensGnRH agonists

OTHEROTHERHistamine H2-receptor blockers

NarcoticsNSAIDs

Clayton & Ramamurthy in Clayton & Ramamurthy in Sexual Dysfunction: The Brain-Body ConnectionSexual Dysfunction: The Brain-Body Connection. Ed: R Balon, Karger, . Ed: R Balon, Karger, Basel, Switzerland, 2008; Basson R, Schultz WW. Lancet. 2007;369:409-424; Kingsberg SA, Basel, Switzerland, 2008; Basson R, Schultz WW. Lancet. 2007;369:409-424; Kingsberg SA, Janata JW. Janata JW. Urol Clin North AmUrol Clin North Am. 2007;34:497-506. 2007;34:497-506..

Correlates of Distress with HSDD: Correlates of Distress with HSDD: PRESIDEPRESIDE

►PsychologicalPsychological• Having a partner (OR 4.63)Having a partner (OR 4.63)• Demographics: Greatest age < 45 years; to lesser Demographics: Greatest age < 45 years; to lesser

degree < 65 years; degree < 65 years; white racewhite race

►NeurobiologicalNeurobiological• Untreated depression > treated depressionUntreated depression > treated depression

• Presence of anxietyPresence of anxiety

• Urinary incontinenceUrinary incontinence

• Use of hormonal contraceptives or HRTUse of hormonal contraceptives or HRT

Rosen RC, et al. Correlates of sexually related personal distress in women with low sexual desire. Rosen RC, et al. Correlates of sexually related personal distress in women with low sexual desire. J Sex Med J Sex Med 2009;6:1549-1560.2009;6:1549-1560.

Decreased Sexual Desire Screener Decreased Sexual Desire Screener (DSDS)(DSDS)

©Boehringer Ingelheim International GmbH 2005. All rights reserved.©Boehringer Ingelheim International GmbH 2005. All rights reserved.

Sensitivity 0.836, 0.946, 0.956, and specificity 0.878Sensitivity 0.836, 0.946, 0.956, and specificity 0.878Goldfischer ER et al. Goldfischer ER et al. ObstetObstet Gynecol 2008;111:109S Gynecol 2008;111:109SClayton A et al. J Sex Med 2009;6:730Clayton A et al. J Sex Med 2009;6:730–738–738Nappi R et al. J Sex Med 2009;6(suppl 2):46Nappi R et al. J Sex Med 2009;6(suppl 2):46

ConclusionsConclusions

► Multiple factors may affect sexual Multiple factors may affect sexual functioning in women across the life functioning in women across the life cyclecycle

► Appropriate assessment is important in Appropriate assessment is important in managementmanagement

Addressing Current Addressing Current Challenges in Female Sexual Challenges in Female Sexual

DisordersDisordersWhat Internal Medicine Specialists What Internal Medicine Specialists Need to Know About HSDDNeed to Know About HSDD

A New Frontiers Program A New Frontiers Program onon Women’s HealthWomen’s Health

Lori Brotto, PhDLori Brotto, PhDAssistant ProfessorAssistant Professor

Department of Obstetrics and GynecologyDepartment of Obstetrics and GynecologyUniversity of British ColumbiaUniversity of British Columbia

Vancouver, BCVancouver, BC

OutlineOutline

► Physician-patient Physician-patient communicationcommunication

► Screening strategiesScreening strategies► Differential diagnosisDifferential diagnosis► Interview techniquesInterview techniques► PLISSIT / ALLOWPLISSIT / ALLOW

Why is inquiry about Why is inquiry about sexual function difficult?sexual function difficult?

► Topic not important enoughTopic not important enough► It is a private experienceIt is a private experience► EmbarrassmentEmbarrassment► ““I don’t exactly know why I am asking”I don’t exactly know why I am asking”► Lack of trainingLack of training► Absence of normsAbsence of norms► Sexual behaviour is a topic only when it is Sexual behaviour is a topic only when it is

deviantdeviant or when others are or when others are at riskat risk► Incorrect beliefs about the benefit of askingIncorrect beliefs about the benefit of asking

Is Marriage Good for Your Health?Is Marriage Good for Your Health?

New York Times Magazine, April 12, 2010New York Times Magazine, April 12, 2010

Complicating factors: Complicating factors: Symptom or disorder?Symptom or disorder?

► Factoring in distress, Factoring in distress, rates of low desire drop rates of low desire drop by half in all studiesby half in all studies

► Note, DSM-IV-TR criteria Note, DSM-IV-TR criteria for HSDD and all sexual for HSDD and all sexual dysfunctions require dysfunctions require distressdistress

Lutfey et al., 2008, Arch Sex BehavLutfey et al., 2008, Arch Sex Behavn = 3,205; Black, Hispanic, Whiten = 3,205; Black, Hispanic, White

► Oberg et al. (2004) found a prevalence of manifest distress despite the Oberg et al. (2004) found a prevalence of manifest distress despite the absence of any sexual symptoms of 12.4%absence of any sexual symptoms of 12.4%

► Bancroft, Loftus, and Long (2003) found that 8% of women reported distress Bancroft, Loftus, and Long (2003) found that 8% of women reported distress about the relationship and 5.4% reported personal distress despite absence of about the relationship and 5.4% reported personal distress despite absence of sexual symptomssexual symptoms

► Lutfey, Link, Rosen, Wiegel, and McKinlay (2008) reported that 5.5% of women Lutfey, Link, Rosen, Wiegel, and McKinlay (2008) reported that 5.5% of women were dissatisfied or very dissatisfied despite not having any sexual symptoms.were dissatisfied or very dissatisfied despite not having any sexual symptoms.

► Cain et al. (2003) in the SWAN study found that 70% of women reported Cain et al. (2003) in the SWAN study found that 70% of women reported thinking about sex less than once/week but 86% remained sexually satisfied.thinking about sex less than once/week but 86% remained sexually satisfied.

► King et al. (2007) found that 19% of women did not have an ICD-10 diagnosed King et al. (2007) found that 19% of women did not have an ICD-10 diagnosed sexual dysfunction but still reported significant low sexual satisfaction.sexual dysfunction but still reported significant low sexual satisfaction.

► Dunn et al. (2000) found that 79% of women were very sexually satisfied but Dunn et al. (2000) found that 79% of women were very sexually satisfied but 24% had no sexual activity in the past 3 months.24% had no sexual activity in the past 3 months.

► Laumann et al. (2005) in the GSSAB found that 7.7% - 17.4% of women Laumann et al. (2005) in the GSSAB found that 7.7% - 17.4% of women reported not finding sex pleasurable/satisfying.reported not finding sex pleasurable/satisfying.

Complicating Factors: Low Desire Complicating Factors: Low Desire Does Not Always Imply Does Not Always Imply

DissatisfactionDissatisfaction

► Sexual dysfunction is commonSexual dysfunction is common

► Integral component of quality of life Integral component of quality of life and general well-beingand general well-being

Why assess sexual function?Why assess sexual function?

Lindau et al., NEJM, 2007Lindau et al., NEJM, 2007

Physician-patient Physician-patient communicationcommunication

► 53 primary care physicians (or internal 53 primary care physicians (or internal medicine residents) at UVA completed medicine residents) at UVA completed questionnaire about their experience questionnaire about their experience asking about HSDDasking about HSDD● 86.3% had not screened for HSDD86.3% had not screened for HSDD● 90% had not diagnosed HSDD90% had not diagnosed HSDD● 53% felt not confident at all, 38% little 53% felt not confident at all, 38% little

confidenceconfidence

Harsh et al., J Sex Med 2008

Are physicians asking?Are physicians asking?

Survey Participants and Patients who Survey Participants and Patients who Initiate First Discussion of FSDsInitiate First Discussion of FSDs

J Sex Med 2006;3:639-645J Sex Med 2006;3:639-645

Survey participants initiatingSurvey participants initiatingfirst discussion of FSDfirst discussion of FSD

Patients initiatingPatients initiatingfirst discussion of FSDfirst discussion of FSD

Per

cent

age

of s

urve

y pa

rtic

ipan

ts

Per

cent

age

of s

urve

y pa

rtic

ipan

ts

prov

idin

g es

timat

epr

ovid

ing

estim

ate

Who should I ask about sexuality? Who should I ask about sexuality?

► EVERYONE! EVERYONE! ► Legitimizes the patient’s concerns with and Legitimizes the patient’s concerns with and

interest in sexinterest in sex► Allows the patient to ask questions Allows the patient to ask questions ► Identifies the provider as a potential resource Identifies the provider as a potential resource

for sexual informationfor sexual information► Maximizes the chances that patients will get Maximizes the chances that patients will get

help for sexual and relationship problemshelp for sexual and relationship problems

Screening StrategiesScreening Strategies

Screening questionsScreening questions

► Are you satisfied with your sexual Are you satisfied with your sexual response (sex life)? If not, why not?response (sex life)? If not, why not?

► Are you currently active with a sexual Are you currently active with a sexual partner?partner?● Men, women or bothMen, women or both● Frequency (activity including masturbation)Frequency (activity including masturbation)

► How often do you have difficulty How often do you have difficulty _________?_________?

► What questions or problems related to sex What questions or problems related to sex would you like to discuss?would you like to discuss?

When to ask?When to ask?

1. 1. During routine inquiryDuring routine inquiry► Include it in a standard set of questions Include it in a standard set of questions

during developmental and during developmental and psychosocial periodspsychosocial periods

► Include it on self-report questionnaireInclude it on self-report questionnaire

“you were telling me about your male friendships you were telling me about your male friendships

growing up…Do you remember when you first growing up…Do you remember when you first

became aware of sexual feelings?”became aware of sexual feelings?”

2. 2. After direct presentationAfter direct presentation► Patient directly states problemPatient directly states problem► Ask permission and collect informationAsk permission and collect information

3. 3. After indirect presentationAfter indirect presentation► Patient is indirect and vague, hoping the Patient is indirect and vague, hoping the

clinician will ask about sexual clinician will ask about sexual complaintscomplaints

► e.g., medication non-compliancee.g., medication non-compliance► Know about that particular condition Know about that particular condition

and side-effect profiles of medicationsand side-effect profiles of medications

When to ask?When to ask?

1.1. Need clinical knowledge, a non-Need clinical knowledge, a non-judgmental attitude, and judgmental attitude, and fundamental interviewing skillsfundamental interviewing skills

► Observing and monitoringObserving and monitoring► Interpreting skillsInterpreting skills► Responding skillsResponding skills

How to ask?How to ask?

2. 2. Clarify the problemClarify the problemPatient: Patient: I’ve lost my natureI’ve lost my natureClinician: Clinician: Tell me what a nature is? I Tell me what a nature is? I haven’t heard that expression before.haven’t heard that expression before.

3. 3. Use personalized languageUse personalized language► Use the correct term and allow the Use the correct term and allow the

patient to pick up on itpatient to pick up on it► Sometimes may be appropriate to use Sometimes may be appropriate to use

patient’s languagepatient’s language

How to ask?How to ask?

4. 4. Use open-ended questionsUse open-ended questions► UseUse: “to what extent…what…how…”: “to what extent…what…how…”► Don’t useDon’t use: “do you…did you…are you…: “do you…did you…are you…

have you…”have you…”““What were the circumstances that led you What were the circumstances that led you

totobe sexual with him?”be sexual with him?”

5. 5. Be empathicBe empathic► Is an expression of professional Is an expression of professional

understandingunderstanding► ““that must have been really difficult for that must have been really difficult for

you…”you…”

How to ask?How to ask?

6. 6. FacilitateFacilitate► Encourage the patient to continue by Encourage the patient to continue by

nodding, leaning forward, using “yes…nodding, leaning forward, using “yes…go on.”go on.”

7. 7. Provide informationProvide information► Anticipate worries and speculateAnticipate worries and speculate► Confirm understanding of the problem Confirm understanding of the problem

before proceedingbefore proceeding

How to ask?How to ask?

Differential DiagnosisDifferential Diagnosis

Comorbidity of Comorbidity of Women’s Sexual DifficultiesWomen’s Sexual Difficulties

Desiredifficulties

Arousal difficulties

Orgasm difficulties

Pain

Vaginismic difficulties

Basson et al., 2003J Psychosom Obstet Gynaecol

• desire and lubrication – 65%• desire and orgasm - 53%• desire and vaginismus – 75%• lubrication and orgasm – 28%• lubrication and dyspareunia – 61%

Depression?

Interview TechniquesInterview Techniques

Self-report measuresSelf-report measures

Use of Validated QuestionnairesUse of Validated Questionnaires

► Decreased Sexual Desire Screener (DSDS) Decreased Sexual Desire Screener (DSDS) Clayton et al. 2009, J Sex MedClayton et al. 2009, J Sex Med

► Female Sexual Function Index (FSFI)Female Sexual Function Index (FSFI)Rosen et al. 2000, J Sex Marital TherRosen et al. 2000, J Sex Marital Ther

► Profile of Female Sexual FunctionProfile of Female Sexual FunctionMcHorney et al. 2004, MenopauseMcHorney et al. 2004, Menopause

► Female Sexual Distress Scale (FSDS)Female Sexual Distress Scale (FSDS)Derogatis et al. 2002, J Sex Marital TherDerogatis et al. 2002, J Sex Marital Ther

Decreased Sexual Desire ScreenerDecreased Sexual Desire ScreenerClayton, Goldfischer, Goldstein, DeRogatis, Lewis-D’Agostino, Clayton, Goldfischer, Goldstein, DeRogatis, Lewis-D’Agostino,

Pyke, J Sex Med 2009;6:730-738Pyke, J Sex Med 2009;6:730-738

1.1. In the past was your level of sexual desire or In the past was your level of sexual desire or interest good and satisfying to you?interest good and satisfying to you?

2.2. Has there been a decrease in your level of Has there been a decrease in your level of sexual desire or interest?sexual desire or interest?

3.3. Are you bothered by your decreased level of Are you bothered by your decreased level of sexual desire or interest?sexual desire or interest?

4.4. Would you like your level of sexual desire or Would you like your level of sexual desire or interest to increase?interest to increase?

5.5. Please check all the factors that you feel may be Please check all the factors that you feel may be contributing to you current decrease in sexual contributing to you current decrease in sexual desire or interest.desire or interest.

Use of a Validated Structured InterviewUse of a Validated Structured Interview

► Women’s Sexual Interest Women’s Sexual Interest Diagnostic Interview Diagnostic Interview DeRogatis et al. 2008, J Sex MedDeRogatis et al. 2008, J Sex Med

*39 items assessing desire, arousal, orgasm, pain and distress, partner *39 items assessing desire, arousal, orgasm, pain and distress, partner sexual dysfunction, relationship problems, depressionsexual dysfunction, relationship problems, depression

* Permission to use the WSID can be obtained by contacting Solvay * Permission to use the WSID can be obtained by contacting Solvay Pharmaceuticals, Inc. (+1-770-579- 7374, chun-yuan.guo@solvay.com)Pharmaceuticals, Inc. (+1-770-579- 7374, chun-yuan.guo@solvay.com)

► Sexual Interest and Desire Sexual Interest and Desire Inventory-Female Version Inventory-Female Version (SIDI)(SIDI)Clayton et al. 2005, J Sex Marital TherClayton et al. 2005, J Sex Marital Ther**13-item clinician administered measure of sexual interest, desire and 13-item clinician administered measure of sexual interest, desire and

arousabilityarousability

Interview TechniquesInterview Techniques

Face-to-face interviewFace-to-face interview

PLISSITPLISSIT

► PPermission ermission ● Acceptance, empathyAcceptance, empathy● ““I ask all my patients about sex. Is it OK to do so now?”I ask all my patients about sex. Is it OK to do so now?”

► LLimited imited IInformation nformation ● Basic education regarding anatomy & sexual responseBasic education regarding anatomy & sexual response

► SSpecific pecific SSuggestions uggestions ● Medical-medication, procedures to relieve discomfort Medical-medication, procedures to relieve discomfort ● Psychological-behavioral strategies, communication skillsPsychological-behavioral strategies, communication skills

► IIntensive ntensive TTherapy herapy ● Individual or couples therapy to manage sexual or Individual or couples therapy to manage sexual or

relationship issuesrelationship issues● Surgery (penile implants, vestibulectomy)Surgery (penile implants, vestibulectomy)

ALLOWALLOW

Sadovsky, 2002Sadovsky, 2002

Goals of a Comprehensive Sexual Goals of a Comprehensive Sexual HistoryHistory

► Identify the primary complaint Identify the primary complaint

► Determine patient’s perspective of their Determine patient’s perspective of their problemproblem

► Develop hypotheses about etiologyDevelop hypotheses about etiology

► Decide on an appropriate course of Decide on an appropriate course of treatment (including referral)treatment (including referral)

Elements of a ComprehensiveElements of a ComprehensiveSexual HistorySexual History

► Assess sexual Assess sexual functioningfunctioning

► Assess Assess medical/organic medical/organic contributorscontributors

► Assess relationship Assess relationship satisfaction and satisfaction and functioningfunctioning

► Assess risk Assess risk behavioursbehaviours

► Assess partner statusAssess partner status

► Ask about history of Ask about history of childhood sexual or childhood sexual or physical abusephysical abuse

► Assess moodAssess mood

Sample Assessment QuestionsSample Assessment Questions

► What is your sexual interest like? What factors What is your sexual interest like? What factors enhance and/or inhibit your desire?enhance and/or inhibit your desire?

► Many people engage in self-stimulation. Is this part Many people engage in self-stimulation. Is this part of your sexual experiences?of your sexual experiences?

► Some people avoid sexual activity for any variety of Some people avoid sexual activity for any variety of reasons? Can you relate to this?reasons? Can you relate to this?

► Many women talk about difficulties with lubrication Many women talk about difficulties with lubrication or sexual activity that is painful. What is your or sexual activity that is painful. What is your experience with this?experience with this?

► Most men experience occasional difficulties with Most men experience occasional difficulties with their erection. Has this been the case for you?their erection. Has this been the case for you?

► Do you notice any difference between your Do you notice any difference between your erections during sexual intercourse, during erections during sexual intercourse, during masturbation, and those when you wake up?masturbation, and those when you wake up?

► When you’re experiencing this difficulty, can you When you’re experiencing this difficulty, can you recall what you’re thinking or feeling at the time? recall what you’re thinking or feeling at the time? How about right before?How about right before?

► Of your last 10 sexual encounters, on how many of Of your last 10 sexual encounters, on how many of them did you experience this difficulty?them did you experience this difficulty?

► What do you do in response to this difficulty? What do you do in response to this difficulty? What does your partner do?What does your partner do?

► Can you describe the sensation of the pain? Is it Can you describe the sensation of the pain? Is it burning, throbbing, or sharp? When do you burning, throbbing, or sharp? When do you experience it?experience it?

Sample Assessment QuestionsSample Assessment Questions

Problems to Avoid During Problems to Avoid During the Sexual Interviewthe Sexual Interview

► Meddling: always rationalize your Meddling: always rationalize your questioningquestioning

► Preoccupation: focus on each responsePreoccupation: focus on each response

► Identification: consult with a colleague if Identification: consult with a colleague if you’re not able to be objectiveyou’re not able to be objective

► Sexual arousal: be aware of your own Sexual arousal: be aware of your own feelingsfeelings

Putting the Sexual HistoryPutting the Sexual Historyin Contextin Context

► What explanations does the patient have What explanations does the patient have (their theory)? (their theory)?

► What have they done to try to resolve the What have they done to try to resolve the problem?problem?

► Are there problems in multiple areas of sexual Are there problems in multiple areas of sexual functioning? What is the relationship between functioning? What is the relationship between these?these?

► What have they discussed with their partner What have they discussed with their partner and what was the reaction?and what was the reaction?

Multi-Factorial ModelMulti-Factorial Model

Predisposing Factors

MaintainingFactors

PrecipitatingFactors

EarlyDevelopment

CurrentFunctioning

Download free of charge at:Download free of charge at:http://www.kinseyinstitute.org/resources/maurice.htmlhttp://www.kinseyinstitute.org/resources/maurice.html

Jennifer Frank, MD, FAAFPJennifer Frank, MD, FAAFPAssistant ProfessorAssistant Professor

Department of Family MedicineDepartment of Family MedicineUniversity of Wisconsin School of Medicine University of Wisconsin School of Medicine

and Public Healthand Public Health

Current and Emerging Therapies for Current and Emerging Therapies for Hypoactive Sexual Desire DisorderHypoactive Sexual Desire Disorder

A New Frontiers Program A New Frontiers Program onon Women’s HealthWomen’s Health

Learning ObjectivesLearning Objectives

► Describe a multimodal treatment Describe a multimodal treatment approach to HSDDapproach to HSDD

► Identify components of Identify components of nonpharmacologic treatment of HSDDnonpharmacologic treatment of HSDD

► Describe current pharmacologic Describe current pharmacologic treatment options for HSDD in both treatment options for HSDD in both postmenopausal and premenopausal postmenopausal and premenopausal womenwomen

► Identify emerging pharmacologic Identify emerging pharmacologic treatment options for HSDDtreatment options for HSDD

HSDD Treatment Starts with HSDD Treatment Starts with Nonpharmacologic ApproachesNonpharmacologic Approaches

► Foundation of therapyFoundation of therapy► Includes treatment initiated and Includes treatment initiated and

managed by the primary care managed by the primary care physicianphysician

► May include treatment by specialist May include treatment by specialist partnerspartners● Sex therapistSex therapist● Physical therapistPhysical therapist● Cognitive behavioral therapistCognitive behavioral therapist● Marital/relationship counselorMarital/relationship counselor

Nonpharmacologic TreatmentNonpharmacologic Treatment

PCP basedPCP based Specialist basedSpecialist based► EducationEducation

● Dispelling mythsDispelling myths

► ExerciseExercise► Healthy DietHealthy Diet► Adequate RestAdequate Rest► Stress ReductionStress Reduction

► CBTCBT► Sensate-focusSensate-focus► Controlled self-Controlled self-

stimulationstimulation► Couples Couples

counselingcounseling► Physical therapyPhysical therapy

● Vaginal dilatorsVaginal dilators● BiofeedbackBiofeedbackBitzer J, Brandenburg U. Psychotherapeutic interventions for female sexual dysfunction. Maturitas Bitzer J, Brandenburg U. Psychotherapeutic interventions for female sexual dysfunction. Maturitas

2009;63:160-3.2009;63:160-3.

Sex Therapy for the PCPSex Therapy for the PCP

► EducationEducation What is normal?What is normal? Basics of anatomy and physiology?Basics of anatomy and physiology?

► LubricationLubrication Basic familiarity with 3 or 4 different productsBasic familiarity with 3 or 4 different products

► Maximize intimacy and opportunities for intimacyMaximize intimacy and opportunities for intimacy► Introduce novelty – different positions, venues, toys, Introduce novelty – different positions, venues, toys,

etc.etc.► Getting into a sexual frame of mindGetting into a sexual frame of mind

““Men are like light switches, women are like ovens.”Men are like light switches, women are like ovens.”► Patient focused readingPatient focused reading► T.L.C.T.L.C.► Redistribution of childcare and household Redistribution of childcare and household

responsibilitiesresponsibilities► Improving body imageImproving body imagePotter JE. A 60-year-old woman with sexual difficulties. JAMA 2007;297:620-33.Potter JE. A 60-year-old woman with sexual difficulties. JAMA 2007;297:620-33.UpToDate and www.sexedsolutions.comUpToDate and www.sexedsolutions.com

Barriers to Nonpharmacologic Barriers to Nonpharmacologic TreatmentTreatment

► Physician’s unfamiliarity with counseling Physician’s unfamiliarity with counseling and recommendationsand recommendations

► Physician’s discomfort with this rolePhysician’s discomfort with this role► Patient’s resistance to relationship workPatient’s resistance to relationship work► Patient’s perceived barriers to Patient’s perceived barriers to

implementing changeimplementing change► Patient’s unwillingness to changePatient’s unwillingness to change► Patient’s belief in a “little blue pill”Patient’s belief in a “little blue pill”► Lack of or paucity of hopeLack of or paucity of hope► Reward not worth the workReward not worth the work

Current Pharmacologic Treatment Current Pharmacologic Treatment Options for FSDOptions for FSD

► HormonalHormonal● EstrogenEstrogen● Testosterone*Testosterone*

► Psychotropic medicationsPsychotropic medications● Buproprion*Buproprion*

► Phosphodiesterase inhibitorsPhosphodiesterase inhibitors● Sildenafil*Sildenafil*

*Not FDA approved for this indication*Not FDA approved for this indication

Local Estrogen Therapy for Local Estrogen Therapy for Vaginal Atrophy (Level C)Vaginal Atrophy (Level C)

► Postmenopausal women without a history Postmenopausal women without a history of hormone-dependent breast cancerof hormone-dependent breast cancer

► Low dose as long as symptoms persistLow dose as long as symptoms persist

► Not indicated for HSDD but can be helpful Not indicated for HSDD but can be helpful if pain/dryness is contributing to low if pain/dryness is contributing to low desire desire

► Consider if prescribing testosteroneConsider if prescribing testosterone

Consider Testosterone for Post-Consider Testosterone for Post-Menopausal Women with HSDDMenopausal Women with HSDD

► Good evidence (Level A) to support its use Good evidence (Level A) to support its use in estrogen replete womenin estrogen replete women1-31-3

► 300 mcg patch for 24 weeks300 mcg patch for 24 weeks► Both naturallyBoth naturally44 and surgically and surgically1-31-3 menopausal menopausal

womenwomen► Improvements seen in Improvements seen in desiredesire, orgasm , orgasm

frequency and total number of sexually frequency and total number of sexually satisfying encounterssatisfying encounters

1. Braunstein et al. Safety and efficacy of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women. Arch Intern Med 2005;165:1582-9.,

2. Buster et al. Testosterone patch for low sexual desire in surgically menopausal women: a randomized trial. Obstet Gynecol 2005;105:944-52.,3. Davis et al. Efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a

randomized, placebo-controlled trial. Menopause 2006;13:387-96. 4. Shifren et al. Testosterone patch for the treatment of hypoactive sexual desire disorder in naturally menopausal women: results from the INTIMATE

NM1 study. Menopause 2006;5:770-9.,

Testosterone’s Role in Testosterone’s Role in Postmenopausal Women without Postmenopausal Women without

ERTERT► DBRCT of placebo vs. testosterone patchDBRCT of placebo vs. testosterone patch► Increase in SSEs/month at 300 mcg daily Increase in SSEs/month at 300 mcg daily

dose dose ● 2.1 (active) vs. 0.7 (placebo)2.1 (active) vs. 0.7 (placebo)

► Increase in desireIncrease in desire► Decrease in distressDecrease in distress► Treatment effect similar in naturally and Treatment effect similar in naturally and

surgically menopausal womensurgically menopausal women► 4 episodes of breast cancer in study 4 episodes of breast cancer in study

participants (n=537)participants (n=537)Davis et al. Testosterone for low libido in postmenopausal women not taking estrogen. N Davis et al. Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med 2008;359:2005-17.Engl J Med 2008;359:2005-17.

Testosterone for Premenopausal Testosterone for Premenopausal Women may Have a RoleWomen may Have a Role

DBRPCT of 261 premenopausal women DBRPCT of 261 premenopausal women Not depressedNot depressed Low serum testosteroneLow serum testosterone

Testosterone at 90 microliters/day (spray) daily x Testosterone at 90 microliters/day (spray) daily x 16 weeks 16 weeks

Increase of 0.8 SSEs/month over placeboIncrease of 0.8 SSEs/month over placebo Strong placebo effectStrong placebo effect SSE not related to testosterone levelsSSE not related to testosterone levels Levels returned to baseline at 20 weeks (4 weeks after study) Levels returned to baseline at 20 weeks (4 weeks after study)

but SSEs did notbut SSEs did not

Davis et al. Safety and efficacy of a testosterone metered-dose transdermal spray for treating Davis et al. Safety and efficacy of a testosterone metered-dose transdermal spray for treating decreased sexual satisfaction in premenopausal women. Ann Intern Med 2008;148:569-577.decreased sexual satisfaction in premenopausal women. Ann Intern Med 2008;148:569-577.

Testosterone Treatment LimitationsTestosterone Treatment Limitations

► Androgen levels not clearly associated with decreased Androgen levels not clearly associated with decreased desiredesire

Difficult to measure testosterone levels accuratelyDifficult to measure testosterone levels accurately

► Role in premenopausal women is not establishedRole in premenopausal women is not established11

► Off label indicationOff label indication

► Long term efficacy/safety not knownLong term efficacy/safety not known1-31-3

► Study population (definition of decreased desire)Study population (definition of decreased desire)11

► Relationship between arousal and desireRelationship between arousal and desire11

► Need for concomitant use of estrogen (?)Need for concomitant use of estrogen (?)11

1. Basson R. Pharmacotherapy for women’s sexual dysfunction. Expert Opin Pharmacother 1. Basson R. Pharmacotherapy for women’s sexual dysfunction. Expert Opin Pharmacother 2009;10:1631-48.2009;10:1631-48.2. NAMS. The role of testosterone therapy in postmenopausal women: position statement of the North 2. NAMS. The role of testosterone therapy in postmenopausal women: position statement of the North American Menopause Society. Menopause 2005;12:497-511.American Menopause Society. Menopause 2005;12:497-511.3. Wierman et al. Androgen therapy in women: an Endocrine Society clinical practice guideline. J Clin 3. Wierman et al. Androgen therapy in women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2006;91:3697-3710.Endocrinol Metab 2006;91:3697-3710.

Buproprion has Limited Data to Buproprion has Limited Data to Demonstrate Efficacy in HSDD (Level B/C)Demonstrate Efficacy in HSDD (Level B/C)

Buproprion (300 mg/day) x 112 days in non-depressed Buproprion (300 mg/day) x 112 days in non-depressed premenopausal women with normal serum testosteronepremenopausal women with normal serum testosterone11

Global improvement in sexual functioning and on subsets of Global improvement in sexual functioning and on subsets of arousal, orgasm completion and pleasure on one of the scales arousal, orgasm completion and pleasure on one of the scales used(Level C)used(Level C)

No statistically significant improvement in desireNo statistically significant improvement in desire 268 women ages 20-40 diagnosed with HSDD (Level B)268 women ages 20-40 diagnosed with HSDD (Level B)22

Premenopausal, not depressed, normal testosteronePremenopausal, not depressed, normal testosterone 12 weeks of buproprion SR 150 mg/day12 weeks of buproprion SR 150 mg/day Improvement in rating scale of sexual function (globally and Improvement in rating scale of sexual function (globally and

specific subsets)specific subsets) Greatest improvement in frequency of sexual activity, Greatest improvement in frequency of sexual activity,

thoughts/desire, and pleasure/orgasmthoughts/desire, and pleasure/orgasm Decrease in personal distress scoreDecrease in personal distress score Add-on or substitute therapy for SSRI induced sexual Add-on or substitute therapy for SSRI induced sexual

dysfunction(Level B)dysfunction(Level B)3,43,4

1. Segraves et al. Buproprion SR for the treatment of HSDD in premenopausal women. J Clin Psychopharm 2004;24:339-42.2. Safarinejad et al. A randomized, double-blind, placebo-controlled study of the efficacy and safety of buproprion for treating hypoactive sexual

desire disorder in ovulating women. BJU International Feb 2010 [Epub].3. Safarinejad . Reversal of SSRI-induced female sexual dysfunction by adjunctive buproprion in menstruating women: a double-blind, placebo-

controlled and randomized study. J Clin Psychopharm Jan 2010 [Epub].4. Seretti A, Chiesa A. Treatment-emergent sexual dysfunction and anti-depressants: a meta-analysis. J Clin Psychopharm. 2009;29:259-66.

Phosphodiesterase InhibitorsPhosphodiesterase Inhibitors

► No demonstrable role in the treatment No demonstrable role in the treatment of HSDDof HSDD

► Use in antidepressant associated FSDUse in antidepressant associated FSD11

● Main effect on orgasmic capacityMain effect on orgasmic capacity

► Potential use in women with Potential use in women with neurovascular mediated sexual neurovascular mediated sexual dysfunctiondysfunction22

● Primarily arousal, orgasmic dysfunctionPrimarily arousal, orgasmic dysfunction

1.1. Nurnberg et al. Sildenafil treatment of women with antidepressant-associated sexual dysfunction. Nurnberg et al. Sildenafil treatment of women with antidepressant-associated sexual dysfunction. JAMA 2008;300:395-404.JAMA 2008;300:395-404.

2.2. Brown DA et al. Assessing the clinical efficacy of sildenafil for the treatment of female sexual Brown DA et al. Assessing the clinical efficacy of sildenafil for the treatment of female sexual dysfunction. Ann Pharmacother 2009;43:1275-85.dysfunction. Ann Pharmacother 2009;43:1275-85.

Emerging Pharmacologic TherapiesEmerging Pharmacologic Therapies

► HormonalHormonal● TestosteroneTestosterone

► Centrally acting agentsCentrally acting agents● FlibanserinFlibanserin

► Phosphodiesterase InhibitorsPhosphodiesterase Inhibitors

► OthersOthers● Prostaglandin gelProstaglandin gel

Testosterone in the FutureTestosterone in the Future11

► Premenopausal womenPremenopausal women● Effects of long term use are unknownEffects of long term use are unknown

► Search for an FDA approved Search for an FDA approved preparationpreparation● LibiGelLibiGel● IntrinsaIntrinsa22

► TiboloneTibolone33 - - estrogenic, estrogenic, progestogenic, androgenic synthetic progestogenic, androgenic synthetic hormonehormone

► Combined with ERT?Combined with ERT?1.1. Krapf and Simon. The role of testosterone in the management of hypoactive sexual desire disorder in Krapf and Simon. The role of testosterone in the management of hypoactive sexual desire disorder in

postmenopausal women. Maturitas 2009;63:213-9.postmenopausal women. Maturitas 2009;63:213-9.2.2. Davis et al. Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med Davis et al. Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med

2008;359:2005-17.2008;359:2005-17.3.3. Wylie and Malik. Review of drug treatment for female sexual dysfunction. Int J STD AIDS 2009;20:671-4.Wylie and Malik. Review of drug treatment for female sexual dysfunction. Int J STD AIDS 2009;20:671-4.

Centrally Acting AgentsCentrally Acting Agents11

► BremelanotideBremelanotide33

● Melanocortin agonistMelanocortin agonist● FSADFSAD

► FlibanserinFlibanserin11

● Acts as a partial serotonin agonist/antagonistActs as a partial serotonin agonist/antagonist● Specifically being studied for HSDDSpecifically being studied for HSDD

1.1. Wylie and Malik. Review of drug treatment for female sexual dysfunction. Int J STD AIDS 2009;20:671-4.Wylie and Malik. Review of drug treatment for female sexual dysfunction. Int J STD AIDS 2009;20:671-4.2.2. Baldwin. Agomelatine in the treatment of mood and anxiety disorders. Brit J Hospital Med 2010;71:153-6.Baldwin. Agomelatine in the treatment of mood and anxiety disorders. Brit J Hospital Med 2010;71:153-6.3.3. Safarinejad. Evaluation of the safety and efficacy of bremelanotide, a melanocortin receptor agonist, in female Safarinejad. Evaluation of the safety and efficacy of bremelanotide, a melanocortin receptor agonist, in female

subjects with arousal disorder: a double-blind placebo-controlled, fixed dose, randomized study. J Sex Med subjects with arousal disorder: a double-blind placebo-controlled, fixed dose, randomized study. J Sex Med 2008;887-97.2008;887-97.

Other AgentsOther Agents

► Phosphodiesterase inhibitorsPhosphodiesterase inhibitors● Role will likely be focused to Role will likely be focused to

specific populationsspecific populations● No demonstrable effect on desireNo demonstrable effect on desire

► Alprostadil (Prostaglandin E1) Alprostadil (Prostaglandin E1) in trials for FSAD (vasodilatory in trials for FSAD (vasodilatory propertiesproperties))

ConclusionsConclusions

► The foundation of HSDD treatment is The foundation of HSDD treatment is nonpharmacologic including PCP nonpharmacologic including PCP directed and specialty directed directed and specialty directed modalities.modalities.

► Pharmacotherapeutic options are limited Pharmacotherapeutic options are limited at this time.at this time.

► Most promising treatments for HSDD Most promising treatments for HSDD include hormonal (testosterone) and include hormonal (testosterone) and centrally acting agents (buproprion and centrally acting agents (buproprion and flibanserin).flibanserin).

► Other medications may have role for Other medications may have role for different types of FSD.different types of FSD.

Case ExampleCase Example

► 26-year-old MWF presents with 1 year 26-year-old MWF presents with 1 year history of decreased libido, some history of decreased libido, some problems with vaginal lubrication, and problems with vaginal lubrication, and diminished orgasmic capacity. No pain diminished orgasmic capacity. No pain with intercourse. with intercourse. Change in sexual function since marriage 4 Change in sexual function since marriage 4

years ago, but relationship still strongyears ago, but relationship still strong 1 year post-partum with mild depressive 1 year post-partum with mild depressive

symptoms since deliverysymptoms since delivery No general health problemsNo general health problems On oral contraceptives for birth controlOn oral contraceptives for birth control

Differential DiagnosisDifferential Diagnosis

Evaluation/InterventionsEvaluation/Interventions

► Consider labs such as TSHConsider labs such as TSH

► Consider change from birth control pills Consider change from birth control pills to non-hormonal contraceptiveto non-hormonal contraceptive

► Specific suggestionsSpecific suggestions

► Consider adding bupropion to treat Consider adding bupropion to treat depression and enhance sexual depression and enhance sexual functioningfunctioning

► If no improvement, check testosterone If no improvement, check testosterone levels before supplementinglevels before supplementing