Hypoactive sexual desire disorder, HSDD

Hypoactive Sexual Desire Disorder (HSDD) is the most common Female Sexual Dysfunction (FSD) affecting adult women of any age, including postmenopausal women. HSDD may have significant effects on the relationships and emotional balance of women and constitutes the most common form of FSD observed in clinical practice. HSDD is characterised by a deficiency or lack of sexual fantasies and desire for sexual activity, causing serious distress or interpersonal difficulties, and it is not exclusively caused by the effects of another psychiatric disorder, pathology or substance (such as medication). HSDD pathophysiology is not yet well understood, but it is thought to involve an imbalance between factors controlling inhibition and excitation of sexual desire in the brain. Many physicians are reluctant to discuss sexual desire problems with their patients for various reasons, such as insufficient knowledge of the field, an absence of efficient treatments and time constraints. Even though current treatment options are limited, a better understanding of the physiopathology behind HSDD may help develop new therapies.     

Differences between pre- and postmenopausal women in cues for sexual desire

IntroductionRecently, McCall and Meston presented an assessment tool for empirically categorizing stimuli associated with sexual desire in women. Significant differences in cues resulting in sexual desire were found between women with and without hypoactive sexual desire disorder (HSDD).AimThe present study examined differences in cues resulting in sexual desire between pre- and postmenopausal women with and without sexual desire concerns using the Cues for Sexual Desire Scale (CSDS) which assesses four distinct aspects of desire motivators: (i) Love/Emotional Bonding Cues; (ii) Erotic/Explicit Cues; (iii) Visual/Proximity Cues; and (iv) Implicit/Romantic Cues.Main Outcome MeasuresThe Female Sexual Function Index and the CSDS.MethodsWomen included premenopausal women with no sexual concerns (N = 35), premenopausal women with low sexual desire (N = 30), postmenopausal women with no sexual concerns (N = 21), and postmenopausal women with low sexual desire (N = 39).ResultsConsistent with prior findings, women with low sexual desire reported significantly less Love/Emotional Bonding Cues, Erotic/Explicit Cues, Implicit/Romantic Cues, and had significantly lower CSDS total scores as compared with women with no sexual difficulties. Postmenopausal women were more likely to report cues associated with Love/Emotional Bonding as compared with premenopausal women.ConclusionsThere were significant differences between women with and without sexual desire concerns in Love/Emotional Bonding Cues, Erotic/Explicit Cues, Implicit/Romantic Cues, and CSDS total scores. There were no significant differences between pre- and postmenopausal women in Erotic/Explicit Cues, Visual/Proximity Cues, or Implicit/Romantic Cues. Interestingly, postmenopausal women with and without HSDD endorsed more Love/Emotional Bonding Cues resulting in feelings of sexual desire as compared with premenopausal women. McCall K, and Meston C. Differences between pre- and postmenopausal women in cues for sexual desire.     

Methods to determine the minimum important difference for a sexual event diary used by postmenopausal women with hypoactive sexual desire disorder

IntroductionRecently, there has been much discussion in the literature about how to determine the meaningfulness of results generated from a patient-reported outcome measure. A number of reviews have shown that there are two main approaches: anchor- and distribution-based approaches for determining the minimum important difference (MID) for a new measure. There are issues with calculating an MID using each method: Will the two approaches give the same estimate? If the estimates differ, how do you decide on one estimate? Would asking patients directly be more beneficial?AimA case study was presented to address these issues based on a newly developed diary assessing number of satisfactory sexual events (SSEs) per week in women with hypoactive sexual desire disorder (HSDD).MethodsAnchor- and distribution-based estimates were generated from data gathered in two double-blind, placebo-controlled, parallel group trials for the treatment of HSDD (N = 788). A novel interview study was used to ask women directly about an MID for SSEs (N = 77).Main Outcome MeasuresDefining the MID for an SSE diary in women with HSDD.ResultsThe estimates varied, producing a range of mean MID estimates between 0.04 and 0.46 SSEs per week.ConclusionsWe recommend that rather than defining the MID, a range should be selected from the set of estimates formed by the limits of the 95% confidence intervals. Symonds T, Spino C, Sisson M, Soni P, Martin M, Gunter L, and Patrick DL. Methods to determine the minimum important difference for a sexual event diary used by postmenopausal women with hypoactive sexual desire disorder.     

Loss of sexual desire in the postmenopausal woman

IntroductionHypoactive sexual desire disorder (HSDD) is a common clinical problem that may bother women.AimTo provide a clear clinical pathway for the assessment and management of women presenting with symptoms of loss of sexual interest and desire (HSDD).Main Outcome MeasuresPatient self-report of sexual satisfaction and quality of life.MethodsA multidisciplinary team of experts reviewed a clinical case summary. The contribution of physical, pharmacological, psychological, and psychiatric as well as interrelational factors as potential contributors to the condition are described.ResultsA multifactorial assessment with a combination of psychosocial, physical, and hormonal interventions may be a useful model in offering treatment pathways for symptoms of HSDD. A favorable outcome was reported.ConclusionMultidisciplinary teamworking that allows a thorough assessment and package of interventions is often necessary to support women with HSDD. Wylie K, Daines B, Jannini EA, Hallam-Jones R, Boul L, Wilson L, Athanasiadis L, Brewster M, and Kristensen E. Loss of sexual desire in the postmenopausal woman.     

Content validity of the Female Sexual Function Index (FSFI) in pre- and postmenopausal women with hypoactive sexual desire disorder

IntroductionThe Female Sexual Function Index (FSFI) has consistently been shown to have discriminant validity, test–retest reliability, and internal consistency as a measure of female sexual function. However, the content validity (relevance, clarity, comprehensiveness) of the instrument in women with hypoactive sexual desire disorder (HSDD) must also be established.AimThe aim of this study were to assess the content validity of the FSFI, specifically the FSFI desire domain, in pre‐ and postmenopausal women with HSDD.MethodsTwo single‐visit content validation studies were conducted in the United States. Eligible premenopausal (both studies) and postmenopausal (second study only) women with HSDD completed the FSFI followed by one‐on‐one, face‐to‐face cognitive debriefing interviews including open‐ended questions to capture information on their perceptions of the instrument. Information on women's experiences of decreased sexual desire was also captured.Main Outcome MeasuresThe main outcome measures of this study were the women's ratings of the clarity, ease of understanding, comprehensiveness, and relevance of the 19 items of the FSFI.ResultsInterviews with 15 premenopausal women (first study), and 30 pre‐ and 31 postmenopausal women (second study), were analyzed. Across the whole sample, most women (80–100%) found every item of the FSFI clear and easy to understand. The majority (53–70%) felt that the FSFI captured all their feelings about decreased sexual desire and other sexual problems, and most (84–90%) indicated that additional questions were unnecessary. Most women in both studies (93–100%) reported that the two items comprising the FSFI desire domain were clear, easy to understand, and were relevant to them. The majority of women thought that a recall period of ≥7 days is most relevant for recall of their sexual desire.ConclusionsThese studies establish the content validity of the FSFI in pre‐ and postmenopausal women with HSDD, supporting the use of this instrument as a measure of sexual function in women with this condition. Revicki DA, Margolis MK, Bush EN, DeRogatis LR, and Hanes V. Content validity of the female sexual function index (fsfi) in pre‐ and postmenopausal women with hypoactive sexual desire disorder (HSDD). J Sex Med 2011;8:2237–2245.     

Predictors of sexual desire disorders in women

IntroductionA historic belief was that testosterone was the “hormone of desire.” However, recent data, which show either minimal or no significant correlation between testosterone levels and women's sexual desire, suggest that nonhormonal variables may play a key role.AimTo compare women with hypoactive sexual desire disorder (HSDD) and those with the recently proposed more symptomatic desire disorder, Sexual Desire/Interest Disorder (SDID), on the relative contribution of hormonal vs. nonhormonal variables.MethodsWomen with HSDD (N = 58, mean age 52.5) or SDID (N = 52, mean age 50.9) participated in a biopsychosocial assessment in which six nonhormonal domains were evaluated for the degree of involvement in the current low desire complaints. Participants provided a serum sample of hormones analyzed by gas chromatography‐mass spectrometry or liquid chromatography/mass spectrometry/mass spectrometry.Main Outcome MeasuresLogistic regression was used to assess the ability of variables (nonhormonal: history of sexual abuse, developmental history, psychosexual history, psychiatric status, medical history, and sexual/relationship‐related factors; hormonal: dehydroepiandrosterone [DHEA], 5‐diol, 4‐dione, testosterone, 5‐α‐dihydrotestosterone, androsterone glucuronide, 3α‐diol‐3G, 3α‐diol‐17G, and DHEA‐S; and demographic: age, relationship length) to predict group membership.ResultsWomen with SDID had significantly lower sexual desire and arousal scores, but the groups did not differ on relationship satisfaction or mood. Addition of the hormonal variables to the two demographic variables (age, relationship length) did not significantly increase predictive capability. However, the addition of the six nonhormonal variables to these two sets of predictors significantly increased ability to predict group status. Developmental history, psychiatric history, and psychosexual history added significantly to the predictive capability provided by the basic model when examined individually.ConclusionsNonhormonal variables added significant predictive capability to the basic model, highlighting the importance of their assessment clinically where women commonly have SDID in addition to HSDD, and emphasizing the importance of addressing psychological factors in treatment. Brotto LA, Petkau AJ, Labrie F, and Basson R. Predictors of sexual desire disorders in women. J Sex Med 2011;8:742–753.     

Neural bases of hypoactive sexual desire disorder in women: an event-related FMRI study

IntroductionAlthough there is an abundant debate regarding the mechanisms sustaining one of the most common sexual complaints among women, i.e., female hypoactive sexual desire disorder (HSDD), little remains known about the specific neural bases of this disorder.AimThe main goal of this study was to determine whether women with HSDD showed differential patterns of activation within the brain network that is active for sexual desire in subjects without HSDD.MethodsA total of 28 right‐handed women participated in this study (mean age 31.1 ± 7.02 years). Thirteen out of the 28 women had HSDD (HSDD participants), while 15 women reported no hypoactive sexual desire disorder (NHSDD participants). Using event‐related functional magnetic resonance imaging (fMRI), we compared the regional cerebral blood flow responses between these two groups of participants, while they were looking at erotic vs. non‐erotic stimuli.Main Outcome MeasureBlood‐oxygenation level dependent (BOLD) signal changes in response to erotic stimuli (compared with non‐erotic stimuli). Statistical Parametric Mapping was used to identify brain regions that demonstrated significant differential activations between stimuli and between groups.ResultsAs expected, behavioral results showed that NHSDD participants rated erotic stimuli significantly higher than HSDD participants did on a 10‐point desirable scale. No rating difference was observed for the non‐erotic stimuli between NHSDD and HSDD participants. Our functional neuroimaging results extended these data by demonstrating two distinct types of neural changes in participants with and without HSDD. In comparison with HSDD participants, participants without HSDD demonstrated more activation in brain areas involved in the processing of erotic stimuli, including intraparietal sulcus, dorsal anterior cingulate gyrus, and ento/perirhinal region. Interestingly, HSDD participants also showed additional activations in brain areas associated with higher order social and cognitive functions, such as inferior parietal lobule, inferior frontal gyrus, and posterior medial occipital gyrus.ConclusionTogether, these findings indicate that HSDD participants do not only show a hypo activation in brain areas mediating sexual desire, but also a different brain network of hyper activation, which might reflect differences in subjective, social, and cognitive interpretations of erotic stimuli. Collectively, these data are in line with the incentive motivation model of sexual functioning. Bianchi‐Demicheli F, Cojan Y, Waber L, Recordon N, Vuilleumier P, and Ortigue S. Neural bases of hypoactive sexual desire disorder in women: An event‐related fMRI study. J Sex Med 2011;8:2546–2559.     

Inhibited sexual desire and orgasmic dysfunction in women

Desire phase dysfunction and orgasmic dysfunction are frequently brought to the attention of the gynecologist. While a variety of psychosocial and organic factors may be involved, the clinician can be helpful in a number of ways. Specific techniques of sexual counsel for both ISD and orgasmic dysfunction have been presented. Recognition and treatment of sexual dysfunction can be a somewhat time-consuming but rewarding aspect of comprehensive women's health care.     

Gepirone-ER treatment of hypoactive sexual desire disorder (HSDD) associated with depression in women

IntroductionThere is currently no Food and Drug Administration (FDA)-approved treatment for hypoactive sexual desire disorder (HSDD). FDA approval of products utilizing testosterone has been delayed due to possible safety concerns. Flibanserin, a 5-HT_1A agonist, 5-HT₂ antagonist, and gepirone-ER, a 5-HT_1A agonist, have been shown to have activity in treatment of HSDD. However, more recently, the FDA issued a non-approval letter for flibanserin.AimTo study the effect of gepirone-ER on HSDD in women with major depressive disorder (MDD).MethodsAt baseline and post-treatment visits, a trained psychiatrist made diagnoses of HSDD based on Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) criteria. Subjects meeting criteria for HSDD were followed to observe the effect of gepirone-ER (20–80 mg/day), comparator antidepressants (fluoxetine, 20–40 mg/day or paroxetine, 10–40 mg/day), or placebo in reversing DSM-IV diagnosis. A subpopulation of women with Hamilton Depression Rating Scale (HAMD-17) entry scores of 18 or less was evaluated. Adverse events (AEs) of sexual dysfunction were also collected.Main Outcome MeasureNumber (%) of patients who no longer met criteria for HSDD (percent resolved).ResultsEight hundred seventy-five women (18–64 years of age, average 38 years old, ～80% premenopausal) entered three studies; 668 (72.5%) completed. Only 161 (18.4%) met DSM-IV criteria for HSDD. Cumulatively, 63% of gepirone-ER-treated patients reversed their diagnosis of HSDD compared to 40% of placebo-treated patients at end point (8 weeks) (P = 0.007). Selective serotonin reuptake inhibitor-treated patients were not different from placebo. Significant results for gepirone-ER occurred by week 2 (P = 0.0001). Patients who were mildly depressed (HAMD scores of 18 or less) also improved at week 2 (P = 0.01) and week 8 (P = 0.07). Sexual dysfunction AEs were significantly less in gepirone-ER-treated patients than placebo (P = 0.013).ConclusionsGepirone-ER may have efficacy in the treatment of HSDD among depressed and possibly nondepressed women. Efficacy occurs by week 2, and does not seem to be purely an antidepressant effect. Fabre LF, Brown CS, Smith LC, and DeRogatis LR. Gepirone-ER treatment of hypoactive sexual desire disorder (HSDD) associated with depression in women.