The Diagnosis and Treatment of Hypoactive Sexual Desire Disorder
How comfortable are you asking patients about female hypoactive sexual desire disorder (HSDD)? If you are like the majority of clinicians, HSDD may be a topic that doesn't get discussed with patients on a regular basis. If that's the case, you could be missing one of the most common conditions your patients are dealing with, and they need your help.
A major cause of distress
Female hypoactive sexual desire disorder occurs in up to 40% of adult women in the U.S. The definition of female HSDD is a deficiency or absence of sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty.
How much distress? An online survey was conducted to better understand how low sexual desire negatively affects self-image and partner relationships.1 Four hundred and fifty pre- and postmenopausal women aged 20 to 60 years with self-described low sexual desire and related distress completed the survey. The results of the three most affected aspects found that 69% of premenopausal respondents indicated their low sexual desire impacted their body image; 51% indicated it impacted their self-confidence; and 33% indicated it impacted their self-worth.
Respondents were also asked specifically how their level of sexual desire affected relationships with their partners. Among the premenopausal respondents, 67% indicated they felt less connected to their partner; while 35% indicated less communication; and 35% indicated they worried that their partner would cheat on them. Bottom line: low sexual desire matters a lot to our patients.
Other studies support these findings. In one report, women with HSDD are 8 to 10 times more likely than women with normal desire to report feeling unhappy, disappointed, frustrated, ashamed and bitter. And yet another study found that loss of sexual desire has similar quality of life burdens on general health as other chronic conditions such as diabetes and back pain and these problems span all age groups, from millennials to octogenarians.2
This is really not surprising considering the pivotal role sex plays in relationships. When sex is good, it adds 15-20% additional value to a relationship. But when sex is bad or non-existent, it drains the relationship of 50-70% of its positive value.3
So if HSDD affects 40% of our patients and creates a strong negative quality of life burden on general health and on relationships, why isn't there more universal discussion about it when patients come into our offices? At the very least, asking about them would legitimize the problem.
The answer likely lies in our habits and our beliefs. First of all, let's discuss our habits. Think back to your medical training. You spent untold hours taking a history for belly pain, when labor begins, and diagnosing abnormal uterine bleeding. How much time did you spend taking a sexual history with your patients during medical school, internship and residency?
The truth is, most medical training programs provide limited opportunity to either observe sexual medicine in practice or to practice it ourselves. That can lead to inadequate knowledge or skill on the topic. It’s not very comfortable to do a deep dive with a patient about a topic that feels unfamiliar.
Then there are our beliefs. Sexual health is a sensitive topic and often summons a belief that we'll either feel unprepared or awkward. Equally unmotivating is the belief or fear that taking a sexual history will embarrass our patients. Remember those first vaginal and pelvic exams you did? A sexual history can feel like the verbal equivalent to that. The fact is, our patients are hopeful you will ask about this problem. Remember, there is a 40% chance they are struggling with some degree of HSDD.4
Diagnosing HSDD: it starts with a discussion with your patient
A common first question is, "If I want to do a sexual history, when is the best time to take it?" That's an easy one. The best time to take a sexual history is any time you are talking with a patient. It can be during a written patient intake, though talking with the patient is more effective. It can be during an exam, before or after a consultation, during either routine or specific office visits, or at major life events such as postpartum and or menopause.
Another common question is, "How do I take a sexual history?" That's easy too. Though you may already be thinking, "I really don't want to open up a can of worms with a waiting room full of patients."
The fact is, a sexual history can be done in literally a matter of minutes. Begin with a simple question, "Are you currently involved in a relationship? Is it sexual?", then follow with an open-ended ubiquity-style question. For example, "Many of my female patients develop sexual concerns, what concerns do you have?" The open-ended nature of the question normalizes and validates the condition as part of a usual history and physical and typically provides a higher yield of both information and patient satisfaction.
The next question might be, "Have your partners included men, women or both?" And regardless of the age of the patient or gender of the partner(s), ask about safe sex practices.
Finally, ask about any medications (including OTC and herbals) or medical conditions that might be interfering with sexual functioning. If a person has physical pain, limited motion, incontinence, or takes a medication such as an SSRI that can affect libido, it can be a major contributor to HSDD.
That's it! Done! After a few times, it becomes just another part of the history. And if you identify a problem and you're not comfortable treating it, you don't have to banish the patient. Just make a referral as a collaborative consultation, the same as if she had a torn meniscus in her knee or an unusual looking mole on her back.
To help you confirm your suspicions or make a more accurate diagnosis, there are a number of useful, validated screening tools on the Internet that you can easily download.
- The Decreased Sexual Desire Screener (DSDS) is a short, validated, diagnostic instrument that specifically identifies generalized acquired HSDD in pre-, peri-, and postmenopausal women.5 It consists of four yes/no questions followed by a fifth question that contains seven items to check as either yes or no. Because it is short, it's easy to incorporate while patients wait for an exam or for you to enter a consultation office.
- The Female Sexual Function Index or FSFI consists of multiple-choice questions that determine if a patient has issues with desire, arousal, orgasm and/or pain. It is a validated instrument that assesses key dimensions of sexual function in adult women and identifies women at risk for female sexual distress (FSD).6,7
- The Female Sexual Distress Scale – Revised (FSDS-R) is a validated tool that distinguishes between women with and without FSD and effectively measures sexually related personal distress.8
Treatment of HSDD and sexual dysfunction often involves more intensive therapeutic interventions than most generalists are either trained to do or have the time to do in a busy general practice. Some will require psychotherapy that encompasses sex therapy or couples counseling. Cognitive Behavioral Psychotherapy is also a very useful tool for treatment of HSDD. It's very helpful in identifying, challenging and replacing irrational thoughts that are prevalent among women with sexual dysfunction.
Physical therapy may be required for dyspareunia and vaginismus. In those instances the therapist will teach the woman deep muscle relaxation and then how to gradually insert dilators of increasing diameter into the vagina. Vaginal estrogen and a newly approved prescription dehydroepiandrosterone (DHEA) can be effectively prescribed for vaginal dryness.9
In the area of HSDD medication, there has been little available other than off-label prescription of either sildenafil or testosterone. Results with these medications have been spotty at best. No FDA approved medication existed until recently.
In August 2015, flibanserin (Addyi) became the first and, as of this writing, only FDA approved treatment for HSDD. The largest sex organ is the brain, and flibanserin works on the brain in a rather complicated and not entirely understood way. We know that it is both a 5HT1A agonist and a 5HT2A antagonist and these could be the reason for the pro-sexual effects. It also has activity at dopamine D4 receptors as well as moderate affinity for 5HT2B and 5HT2C receptors. Other yet to be discovered mechanisms may be involved.
Flibanserin is available as a 100mg pill taken at bedtime. Its effectiveness was proven in three separate 24-week, randomized, double-blind, placebo-controlled trials involving more than 2,300 women and labeled as the VIOLET, DAISY, and BEGONIA studies.10-12
The main objective of these three 24-week trials was to determine whether or not flibanserin increased the number of satisfying sexual experiences, defined as sexual intercourse, oral sex, masturbation, or genital stimulation by the partner. Orgasm was not required. Flibanserin consistently improved both the level and frequency of sexual desire versus placebo in all three studies using the validated FSFI–D instrument. It also found a decrease in distress versus placebo across all three studies. Most of the women who responded favorably to the medication did so within the first eight weeks of treatment.
The most common side effects, which typically began within the first 14 days of treatment, were dizziness (11.4%), somnolence (11.2%), nausea (10.4%), and fatigue (9.2%), compared to approximately 3% for the placebo group.
Initially, a more worrisome side effect was a reported increased risk of hypotension and syncope if flibanserin was used in combination with alcohol intake. A more careful look at the design of the alcohol challenge study (Data on File. Valeant Pharmaceuticals North America LLC) revealed that study participants, many of whom were men, were asked to drink the alcohol equivalent of two or four alcoholic beverages in orange juice within a 10 minute window of time after 10 hours of overnight fasting and following a light breakfast. Not surprisingly, several of the participants become light headed or fainted. Based on these results, the medication comes with a warning to avoid alcohol while taking the medication, which must be taken daily.
To ensure patient safety, flibanserin is only available through a restricted program called the ADDYI REMS (Risk Evaluation and Mitigation Strategy) Program, which requires that prescribers are certified by enrolling in and completing training, and pharmacies are certified and will not dispense flibanserin unless it is prescribed by a certified prescriber. The 4-question test is available online at www.ADDYIREMS.com and takes about 5-10 minutes to complete.
In summary, HSDD is an extremely common symptom affecting up to 40% of women of all ages. It is commonly undertreated due to women not informing their healthcare providers about it and healthcare providers also not asking their patients about it.13 Women do have the hope that they will be asked, and when they are, their patient satisfaction of the provider increases. Screening for HSDD can be done at any time during patient contact and can be done literally in a matter of minutes. Doing so can set the stage for providing some limited information to the patient and offering a collaborative consultation with an appropriate colleague. Various validated testing is available by download to confirm the diagnosis of HSDD and psychological treatment is available by those trained in this area. In addition, there is one pharmacological treatment, flibanserin, that is FDA approved to treat HSDD.
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