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Sexual Health & Intimacy

Hypoactive Sexual Desire

Susan Kellogg-Spadt, PhD, CRNP Jennifer Giordano, EdD, NCC

"I have several premenopausal patients in their 30s and a 40s who relate to me a complete disinterest in physical intimacy. They have no apparent physical problems, menstruate regularly, and show no signs of depression, arousal, or orgasm problems. They confirm their relationships with their husbands are satisfactory, but they simply lack desire. Many have read about topical testosterone cream in the lay press and are asking that I prescribe it. Could you comment on this?"

Of the 43% of American women with sexual dysfunction, lack of desire for physical intimacy is the most common sexual complaint and can be the most difficult to assess and treat.¹

CLASSIFICATIONS
Desire disorders are classified as a form of female sexual dysfunction and are divided into two major categories:

1. Hypoactive sexual desire disorder (HSDD), which is a persistent or recurring deficiency or absence of sexual fantasies, thoughts, and/or receptivity to sexual activity, which causes personal distress; or
2. Sexual aversion disorder (SAD), which is a persistent or recurring phobic aversion to and avoidance of sexual contact with a partner, which causes personal distress.¹

There are several situational phenomena that can contribute to HSDD, including physiologic, psychosexual, and/or cultural factors. The more dramatic aversion responses are often emotionally based and may result from trauma or abuse.² A final desire issue many women describe is "desire discrepancy." In this circumstance, women verify that they experience fantasy thoughts and are interested in sexual activity, but at a far less frequent interval than their partners. When this creates personal and interpersonal distress, intervention may be warranted.³

ASSESSMENT
An initial step in assessing complaints of lack of interest is to identify a woman's "baseline or normal" pattern of initiation and receptivity to sexual activity, contrast it with her current patterns of initiation and receptivity to sexual activity, and identify if, how, and when patterns changed. Assessment of nonpartner-oriented sexual expression such as desire for and enactment of self-stimulation, incidence of erotic nighttime dreams, and spontaneous sexual thoughts during the day are also factors that identify the extent of the disorder. Asking about partner response to HSDD, his/her support of seeking treatment, and about relationship conflict issues are key.²

A referral to a qualified intimacy or marital therapist helps address psychosexual and interpersonal concerns that can underlie HSDD. It can also assist in the assessment of the woman and her partner and can be a valuable adjunct to medical management.³ Counseling sessions with a therapist can be particularly helpful with couples who have desire discrepancies, where negotiation of acceptable "middle ground" is critical for resolution.

It is important to check medication profiles for drugs known to adversely affect desire including SSRIs, tricyclic antidepressants, anticonvulsants, antihypertensives, and tranquilizers. Altering medications or adding drugs with prosexual effects such as bupropion to current regimens may reawaken desire.¹

HORMONE LEVELS
Hypoactive desire for a woman at perimenopause may be related to falling serum estradiol levels as well as low free serum testosterone. These levels are best measured at midcycle and off any form of prescription or nonprescription hormone supplementation. Inhibited desire is often associated with:

1. free testosterone levels below or in the lowest quartile of the "normal range" for women; and/or
2. serum estradiol levels less than or equal to 50 pg/mL. Other lab values that are helpful at initial assessment are DHEA-S, androsteindione, TSH, lipid, and liver function panels.^4-6

MANAGEMENT
Before giving any woman a prescription for libidinal-enhancing compounds, sexual medicine providers generally require a behavioral commitment. This involves "directed resexualization activities" and may include: reading of erotic literature, regular exercise that increases blood flow to the lower extremities and genitals (brisk walking, cycling, yoga), and manual or vibrator self-stimulation of the genitals. Women can be reminded that feeling "sexual" usually requires more than cream, and that thinking sexual thoughts and feeling the effects of arousal and exercise are part of increasing libido.^2,3

For women on oral contraceptives, a beneficial effect on libido is often achieved by changing a woman's pill to one with a stronger androgenic or a stronger estrogenic effect. Other times, a trial of 2 months off oral contraceptives restores libido.¹

Some women benefit from transdermal supplementation with testosterone cream. When prescribing this, it is important that a woman be off birth control pills or other hormone regimens. After baseline levels are assessed, the goal is to raise levels into the upper quartile of the normal range for free testosterone for women. Testosterone cream is usually made for the patient by a compounding pharmacist.^4-6

A conservative dosing program could begin with natural testosterone 5mg/g cream, with 1g applied three times per week to the lower abdomen, mons area, buttocks, or inner thighs. Care should be taken in choosing a site of application because women may experience fine hair growth at the site of application. Results are often seen within 6 to 12 weeks and may begin as erotic dreams and nocturnal arousal. Hormone levels are rechecked approximately every 3 months during supplementation and should be rechecked at the same lab from which baseline levels were obtained, at approximately the same time in the menstrual cycle.⁵

Potential benefits of topical testosterone include increased clitoral sensitivity, increased vaginal lubrication, increased libido, and heightened arousal. Potential side effects from topical testosterone include weight gain, menstrual irregularities, growth of facial and body hair, clitoral enlargement, acne, and hypercholesteremia. Since testosterone can undergo metabolic pathways that convert it to estrogen, careful monitoring of estradiol levels after dose increases is paramount.¹

As a final note, although testosterone cream can be of great benefit to some women, it should not be considered a panacea. Recent pilot research suggests that equal or greater libidinal enhancement can be achieved by L-arginine containing nutraceutical compounds or standardized DHEA products.^7,8 Female sexual function is becoming a priority for many pharmaceutical companies, and it is likely that more research and new product offerings for HSDD will be forthcoming.

REFERENCES

1. Berman JR, Berman L, Goldstein I. Female sexual dysfunction: Incidence, pathophysiology, evaluation and treatment options. Urology. 1999;54:385-391.
2. Levy BS. Break the silence: Discuss sexual dysfunction. OBG Management. 2002;14(3):70-83.
3. Maurice WL. Sexual Medicine in Primary Care. St Louis, Mo: Mosby, Inc; 1999.
4. Davis S. The clinical use of androgens in female sexual disorders. J Sex Marital Ther. 1998;24:153-163.
5. McCormick K. Testosterone–It's not just for men anymore. Women's Health Connection. 2000;7(6):1-6.
6. Guay A, Munariz R, Spark R, Goldstein I, Jacobson J, Talakopub L. Serum androgen and androgen precursor hormone levels in women with and without sexual dysfunction. Proceedings from the Female Sexual Function Forum, Boston, Mass. 2001.
7. Muniarriz R, Talakoub L, Garcia SP, et al. Dehydroepiandrosyerone (DHEA) treatment for female androgen sufficiency and sexual dysfunction: Baseline and post-treatment sexual questionnaire outcome data in patients with restored androgen levels. Proceedings from The Female Sexual Function Forum, Boston, Mass.2001.
8. Trant AS, Polan ML. (2000). Clinical study on a nutraceutical supplement for the enhancement of female sexual function. Proceedings from The Female Sexual Function Forum, Boston, Mass. 2000.

Susan Kellogg-Spadt, CRNP, PhD, is an OB/GYN nurse practitioner, sexologist, and director of sexual medicine, The Pelvic Floor Institute, Graduate Hospital, Philadelphia, Pa. Jennifer L. Giordano, EdD, NCC, is a sexologist and intimacy management specialist, The Pelvic Floor Institute, Graduate Hospital, Philadelphia, Pa.

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