Tag Archives: female sexual dysfunction

Treatment of decreased sexual desire in women

About a third of women in the United States experience decreased sexual desire (DSD), a symptom that may be part of a more complex diagnosis. The author discusses DSD with respect to background information, screening, and diagnosis, and then focuses on treatment of this common, oftentimes perplexing, problem. Continue reading »

Female sexual dysfunction: Why is it so difficult to treat?

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By Brooke M. Faught, MSN, WHNP-BC, IF

Many healthcare providers avoid addressing and treating sexual problems in women for a multitude of reasons, including the paucity of FDA-approved medications for female sexual dysfunction (FSD), concern about the additional time required during the patient visit, and confusion over billing and coding, leading to challenges regarding reimbursement. In this column, I describe the common barriers and misconceptions that impede successful evaluation and treatment of FSD.

Over recent years, multiple studies have demonstrated the high prevalence of sexual complaints in women. In fact, more women than men report problems with sexual functioning, including problems related to libido, arousal, orgasm, and pain. In the National Health and Social Life Survey, 43% of women reported one or more sexual problems, compared with 31% of men.1 Nearly 10 years later, the PRESIDE study demonstrated a 44% prevalence of female sexual dysfunction (FSD) in the United States.2 Despite these compelling statistics, research regarding treatments for sexual dysfunction and marketing for products designed to improve sexual function have been primarily geared toward men, not women. Although the focus may finally be shifting to women, why is FSD still so difficult to treat?

#1: Few FDA-approved treatments for FSD

In 1998, the FDA approved sildenafil (Viagra®) as the first medication for the treatment of erectile dysfunction (ED) in men, initiating a new kind of sexual revolution. Men with ED who had previously been rendered virtually abstinent were now able to resume satisfying sexual activity. Since that time, 27 medications have been approved by the FDA for the direct or indirect enhancement of sexual functioning in men. Until 2 months ago, the total number of FDA-approved medications for the treatment of low sexual desire in women was zero. But on August 18, 2015, the FDA made history by approving flibanserin (Addyi™), the first-ever medication for the treatment of hypoactive sexual desire disorder in women.3

#2: Too time consuming to address

One of the biggest complaints that I hear from healthcare providers (HCPs) regarding addressing their female patients’ sexual concerns is that it takes too much time in an already busy clinic setting. I recommend the use of any of the following validated questionnaires, which can facilitate discussions about this sensitive and complicated topic.

  • Sexual Function Questionnaire4
  • Female Sexual Function Index5
  • Female Sexual Distress Scale-Revised6
  • Decreased Sexual Desire Screener7
  • Hypoactive Sexual Desire Disorder Screener8
  • Abbreviated Sexual Function Questionnaire9
  • Sexual Quality of Life-Female10

#3: Not a profitable specialty

Although billing based on time spent face-to-face with a patient is not typically a lucrative method for running a practice, HCPs do have ways to enhance reimbursement when treating female patients with sexual complaints. For instance, offering services such as colposcopy, vulvovaginal biopsy, biothesiometry, perineometry, and trigger-point injections can provide a major increase in revenue when utilizing procedural modifiers. Even minor tests such as urinalysis, wet preps, and vaginal pH analysis can add profit to a patient encounter. When applicable, providing urogynecologic services such as urodynamics, tibial nerve stimulation and pessary placement/maintenance can further boost clinic revenue.

#4: Prevalence versus “distress”

Although nearly half of all surveyed women in the two aforementioned studies reported sexual complaints,1,2 only 12% reported experiencing distress related to their sexual problems.2 In order for a woman to meet criteria for an FSD diagnosis, she needs to be bothered by her condition. If she does not experience such distress, then treatment is unnecessary and unlikely to prove beneficial. HCPs need not create a diagnosis where none exists. At the same time, FSD is a true entity that deserves attention when warranted.

#5: Multifactorial etiology of FSD

Many factors affect female sexual functioning, including overall health, medication use, stress, pregnancy, menopause, drug and alcohol abuse, mental health, relationship status, and socioeconomic status. Existence of all these contributing factors necessitates that history taking in women with FSD be thorough. Although this list is not exhaustive, relevant health conditions for which to screen in women reporting sexual complaints include depression, diabetes, thyroid disease, hyperprolactinemia, cardiovascular disease, neurologic disease, androgen insufficiency, and estrogen deficiency.11 The Table lists commonly prescribed medication classes that can increase
FSD risk.11

FSH_Table

#6: Lack of provider training

In 2010, the Journal of Sexual Medicine published proceedings from the International Consultation in Sexual Medicine, which included this quote: Current sexual health education for undergraduate and practicing physicians is inadequate to meet the advancing science and technology and increasing patient demand for high-quality sexual health care.12 That being said, many academic programs for prospective physicians, nurse practitioners, and physician assistants are beginning to incorporate more sexual health training into their curricula, which will arm HCPs with the knowledge and confidence needed
to manage patients’ sexual problems or refer them to another provider when appropriate.

#7: Social stigma and patient unwillingness to discuss sensitive topics

In a study presented in 2010, Parish et al13 evaluated 75 videotaped patient–provider interactions regarding distressing low desire (DLD). HCPs underestimated the prevalence of distress in 82% of women who described themselves as very distressed with respect to their low desire. In this same study, 69% of women minimized their distress during the encounter with the provider but then acknowledged their distress after the visit. Although the impact of DLD was not addressed in any of the 75 interactions, after the visit, 95% of the patients reported that DLD affected their relationship and 98% reported that it affected their partners.

Conclusion

Considering the high prevalence of FSD, and the likelihood that it is distressing to at least a sizable minority of women who have it, HCPs must aim to identify it and treat it—despite the barriers that still exist. Addressing patients’ concerns in a holistic manner, establishing rapport, and providing a nonjudgmental environment for discussion about sensitive topics is the best method to facilitate success in this patient population.

Brooke M. Faught is a nurse practitioner and the Clinical Director of the Women’s Institute for Sexual Health (WISH), A Division of Urology Associates, in Nashville, Tennessee. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

References
1. Laumann, EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;
281(6):537-544.

2. Shifren, Monz BU, Russo PA, et al. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol. 2008;112(5):970-978.

3. FDA News Release. FDA Approves First Treatment for Sexual Desire Disorder. August 18, 2015. fda.gov/News
Events/Newsroom/PressAnnouncements/ucm458734.htm

4. Quirk FH, Heiman JR, Rosen RC, et al. Development of a sexual function questionnaire for clinical trials of female sexual dysfunction. J Womens Health Gend Based Med. 2002;11(3):277-289.

5. Quirk F, Haughie S, Symonds T. The use of the sexual function questionnaire as a screening tool for women with sexual dysfunction. J Sex Med. 2005;2(4):469-477.

6. Derogatis L, Clayton A, Lewis-D’Agostino D, et al. Validation of the female sexual distress scale-revised for assessing distress in women with hypoactive sexual desire disorder. J Sex Med. 2008;5(2):357-364

7. Clayton AH, Goldfischer ER, Goldstein I, et al. Validation of the decreased sexual desire screener (DSDS): a brief diagnostic instrument for generalized acquired female hypoactive sexual desire disorder (HSDD). J Sex Med. 2009;6(3):730-738.

8. Leiblum S, Symonds T, Moore J, et al. A methodology study to develop and validate a screener for hypoactive sexual desire disorder in postmenopausal women. J Sex Med. 2006;3(3):455-464.

9. Williams K, Abraham L, Symonds T. Psychometric validation of an abbreviated version of the sexual function questionnaire (ASFQ). Value in Health. 2010;13(7):A381.

10. Symonds T, Boolell M, Quirk F. Development of a questionnaire on sexual quality of life in women. J Sex Marital Ther. 2005;31(5):385-397.

11. Kingsberg SA, Janata JW. Female sexual disorders: assessment, diagnosis, and treatment. Urol Clin North Am. 2007;34(4):497-506.

12. Parish SJ, Rubio-Aurioles E. Education in sexual medicine: proceedings from the international consultation in sexual
medicine, 2009. J Sex Med. 2010;7(10):3305-3314.

13. Parish SJ, Hahn SR, Kingsberg SA, et al. Doctor-patient communication about desire with women who have distressing low desire in primary care and general OB/GYN practice. Presented at: The International Society for the Study of Women’s Sexual Health; 2010; St. Petersburg, Florida.

Will the first medication to treat low sexual desire in women be approved?

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By Susan Rawlins, RN, MS, WHNP-BC

Female sexual dysfunction (FSD) affects an estimated 43% of women in the United States.1 FSDs include impaired sexual interest/arousal disorder, sexual pain disorder, and orgasmic disorder. But the most common FSD by far is hypoactive sexual desire disorder (HSDD), reported by as many as 1 in 10 women.2 HSDD can be definitively diagnosed with reliable and validated screening tools.3 Women’s healthcare providers are on the front line in terms of caring for women with HSDD, but we lack FDA-approved options to provide relief for them.

But now there is hope. As the August 2015 issue of Women’s Healthcare: A Clinical Journal for NPs goes to press, the FDA will have made its decision regarding whether to approve flibanserin for the treatment of HSDD in premenopausal women. Flibanserin, a non-hormonal drug, is thought to work by correcting an imbalance in the levels of neurotransmitters in the brain that affect sexual desire.4 More specifically, flibanserin increases dopamine and norepinephrine, both of which drive sexual excitement, and transiently decreases serotonin, which drives sexual satiety/inhibition.

Two months ago, an FDA advisory committee voted to recommend approval of flibanserin to treat HSDD in premenopausal women. Although the FDA is not required to accept the advisory committee’s recommendation, the agency agreed to consider it as part of the new drug application review. Readers can check www.npwh.org for the latest information on the FDA decision.

During the open comment portion of the hearing prior to this vote, Gay Johnson, CEO of NPWH, spoke on behalf of the association and in support of both women with HSDD and the providers who struggle to treat these women every day. In her statement, Ms. Johnson said, “Women’s sexual health is complex and multidimensional and often overlooked in primary care because of many factors, including cultural conditioning of women and providers. Historically, women’s sexuality has been viewed as something tied to the obligation to have sexual relations for reproduction, but not the desire to have sexual relations to achieve personal pleasure. Thankfully, now, in the 21st century, women’s sexual health is seen as a valid component of overall wellness. Women’s sexual dysfunction is now recognized as a real health condition, of real women, that decreases quality of life and negatively impacts relationships.”

Ms. Johnson clarified that NPWH is not advocating for the approval of any specific drug. She stated, “Each HSDD medical treatment option should receive fair consideration and the side effect/adverse event profile evaluated while considering the significant impact of the condition. Women are intelligent, insightful decision makers and can be trusted to evaluate the risks of side effects/adverse events and the benefits of any treatment according to the impact of HSDD on their personal lives and relationships.”

In both its educational and advocacy endeavors, NPWH supports nurse practitioners in providing high-quality healthcare for women, which includes addressing their sexual health concerns. Our Women’s Sexual Health Course for NPs, offered for the first time in June 2014 and again in June 2015, has been extremely well received, filling to capacity several weeks ahead of time and garnering positive feedback from participants. Women’s Healthcare, our journal, includes a Focus on Sexual Health department article in each issue, and our annual conference always includes courses on sexual health topics. Our advocacy work is ever-present as we actively support evidence-based treatments for all FSDs.

As such, we applaud the FDA’s recognition of HSDD as a health problem that merits pharmacologic treatment and we encourage the FDA to consider approval of medications that have demonstrated efficacy and safety in treating women’s most common sexual complaint.

Susan Rawlins is Director of Education for the National Association of Nurse Practitioners in Women’s Health and a women’s health nurse practitioner at the Greater Texoma Health Clinic in Denison, Texas. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281(6):537-544.

2. Parish SJ, Rubio-Aurioles E. Education in sexual medicine: proceedings from the International Consultation in Sexual Medicine, 2009. J Sex Med. 2010;7(10):3305-3314.

3. Kingsberg SA, Woodard T. Female sexual dysfunction: focus on low desire. Obstet Gynecol. 2015;125(2):477-486.

4. Sprout Pharmaceuticals, Inc. FDA Advisory Committee Recommends Approval for Sprout Pharmaceuticals’ ADDYI™ (flibanserin) to Treat Hypoactive Sexual Desire Disorder in Premenopausal Women. June 5, 2015. http://www.sproutpharma.com/news-center/

Managing female sexual dysfunction

 

By Casey B. Giebink, MSN, NP-C, WHNP-BC and Ivy M. Alexander, PhD, APRN, ANP-BC, FAAN

Although about one-third of women report concerns with sexual functioning, many healthcare providers (HCPs) do not feel comfortable screening for, diagnosing, or managing female sexual dysfunction (FSD). The authors offer guidance to HCPs for screening and diagnosing a variety of FSD disorders. In addition, the authors discuss pharmacotherapeutic options for managing these conditions, as well as these agents’ benefits, risks, and monitoring parameters.

Key words: female sexual dysfunction, estrogen, testosterone, bupropion, ospemifene, flibanserin

Female sexual dysfunction (FSD) is highly prevalent among women in the United States, yet patients rarely discuss sexual concerns with their healthcare provider (HCP). Investigators of the Women’s International Study of Health and Sexuality sent questionnaires to 2,050 U.S. women regarding health status, sexual desire, and distress caused by low desire.1 The study showed that 24%-36% of women aged 20-70 years could be classified as having low sexual desire. This prevalence highlights the need for HCPs to know how to communicate with, identify, and manage patients’ sexual concerns. To this end, the authors provide evidence-based recommendations drawn from the current literature regarding assessment and diagnosis of FSD, with an emphasis on pharmacologic options available to treat FSD. Most of the pharmacologic options for desire, arousal, and orgasm problems are prescribed off label.

Common barriers to identifying and managing FSD

Despite the high prevalence of FSD, many women do not broach the topic with their HCP, and many HCPs do not screen their patients for sexual disorders.2 In fact, fewer than 20% of HCPs ask about their patients’ sexual activity, including difficulties, enjoyment, and frequency.3

Urologists, gynecologists, and psychiatrists are the HCPs most likely to inquire about sexual functioning.4 However, one study showed that among 187 urologists, only 10% asked every patient about sexual function on a regular basis, as opposed to 87% who asked about sexual activity when the chief complaint was related to abdominal pain, urgency/frequency, incontinence, or a urinary tract infection.5 A survey of the attitudes of nurse practitioners (NPs) and physician assistants (PAs) toward management of sexual dysfunction revealed that only one-half felt comfortable discussing the topic and only 21% of NPs and 11% of PAs felt confident in managing FSD.6 Nevertheless, most NPs and PAs had a positive attitude toward the possibility of evaluating and managing their female patients’ sexual concerns.6

Various factors may hinder HCP–patient communication regarding sexual concerns. Potential barriers for HCPs include lack of time, lack of knowledge about FSD management options, and lack of training in how to communicate about FSD; barriers for patients include embarrassment and a belief that their HCP cannot help them.7 Some HCPs fear embarrassing or offending patients if they raise the topic,3 although most patients will discuss their sex practices if the HCP initiates the conversation.8

Even if a patient does discuss her sexual problems with her HCP, her concerns may not be properly addressed. One survey showed that among 3,807 women who considered seeking help for sexual dysfunction, fewer than half reported feeling hope, relief, validation, or satisfaction after discuss­ing their concerns with a provider.9 In addition, patients were disappointed by their HCPs’ inability or unwillingness to evaluate, treat, and follow up on their complaints.9

Overcoming the barriers

Healthcare providers can increase the likelihood that FSD will be identified and addressed by initiating the conversation with patients, which will strengthen the HCP–patient relationship and help normalize patients’ concerns.9 Once both parties are comfortable, the HCP can take a sexual history, perform a thorough physical examination, and order appropriate laboratory tests.

History
To transition smoothly into taking a sexual history, HCPs can incorporate questions into the genitourinary/gynecologic/obstetric review of systems.10 Some patients may feel uneasy answering these questions, so HCPs can explain why such questions are being posed. For example, one can say, “I will be asking you some questions about your sexual activity to get a better idea of you as a whole and to ensure we are providing the most comprehensive care possible.” Informing women that FSD is common can facilitate a frank conversation.10

Screening for FSD with just a few questions can be informative. A literature review by Giraldi et al11 indicated that although multiple FSD screening tools are available, few standardized and culturally acceptable questionnaires are validated in general populations and can be used to assess for FSD in women with or without a partner and independent of the partner’s gender. As a result, HCPs can develop their own unbiased FSD screening questions based on their unique patient population. A patient’s sexual orientation should not be assumed; instead, HCPs need to ask about any and all sexual partners. Brief questions regarding sexual satisfaction and pain and the ability to reach an orgasm can determine if further screening is warranted.12 Three targeted questions include the following13:

• Do you have any questions or concerns about your sexual activity?
• Have you experienced any changes in sexual response, lubrication, or pain with sexual activity?
• Are you aware of any changes in your level of interest or desire for sexual activities?

If a woman—premenopausal or postmenopausal—answers “yes” to any of these questions, then further investigation is needed.

For a specific problem, HCPs need to explore the nature of the problem, its severity and duration, the degree of distress it causes, and any history of similar problems.13 The patient is asked to use her own words to describe any sexual difficulties she may be having.14 Because sexual functioning is multifaceted, HCPs need to consider a woman’s physical, surgical, medication, and social histories to uncover all possible factors causing or contributing to the sexual dysfunction (Table 1).14-16Physical examination
A physical exam is conducted to identify or exclude conditions that might cause or exacerbate FSD. This exam includes a general systemic survey with a focused cardiovascular exam, which can uncover systemic perfusion abnormalities that might contribute to FSD.15 A neurologic assessment of the effects of light touch and pressure on the external genitalia may reveal locations with hypersensitivity. A genitourinary exam is done to evaluate for structural abnormalities such as an imperforate hymen or vaginal septum and to look for signs of estrogen depletion (e.g., loss of vaginal rugae, pale mucosa, thin lining).15 An evaluation of pelvic muscle tone is important; both high tone and low tone can be associated with FSD. This evaluation is best done using a perineometer, a device placed within the vagina that provides feedback on the tone of the levator ani complex and obturator internus muscles.17 In the absence of this device, HCPs can evaluate tone during an internal exam by asking the woman to squeeze and relax the vaginal muscles.17 Of note, many women with FSD have normal physical exam findings.

Laboratory testing
Evaluating certain lab values can aid in identifying health conditions that may be contributing to sexual dysfunction. These lab tests include a complete blood count, fasting prolactin, a lipid profile, blood glucose, and thyroid hormone levels.18 Abnormal test results may reveal an underlying condition (e.g., anemia, thyroid disease, dyslipidemia, metabolic disorders, hormonal imbalances) causing or exacerbating the FSD.19 Evaluating the calculated free androgen index can also help in classifying sexual complaints; age-based normative values have been established.20 When a patient’s primary complaint is dyspareunia, vaginal, cervical, and/or vulvar cultures can be obtained to rule out infectious causes.14

DSM-5 changes to FSD diagnoses

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which was published by the American Psychiatric Association in 2013, includes revisions to previous editions based on new research.21 Specific to the category of sexual dysfunction, the DSM-5 now requires that symptoms be present for at least 6 months. In addition, the DSM-5 includes gender-specific diagnoses, combines disorders that were previously separate, and removes the subtype of FSD due to psychological factors versus combined factors. Research suggests that sexual response cannot be categorized into specific stages and is not always linear. As a result, the DSM-5 combines sexual arousal disorder and sexual desire disorder into female sexual interest/arousal disorder. Another combined disorder in the DSM-5 is genito-pelvic pain/penetration disorder, which was developed because of the difficulty distinguishing between vaginismus and dyspareunia.

Treatment approaches

Initial management of FSD requires treating any contributing underlying physical conditions. If treatment of these conditions does not result in restoration of sexual function, other interventions for FSD are considered. Although this article focuses on pharmacotherapeutic options, patients can try nonpharmacologic interventions such as cognitive behavioral therapy (CBT), sex therapy, self-stimulation, and lubricating gels (Table 2).22,23 If nonpharmacologic therapies do not offer relief, pharmacologic options are considered.

Estrogen
Declining estrogen levels after menopause can lead to vulvovaginal atrophy (VVA), which can result in vaginal dryness, itching, and pressure and can lead to pain during sexual activity.24 Painful intercourse (dyspareunia) can diminish sexual pleasure and desire for sex. Exogenous estrogen therapies, both systemic and topical, are used to increase vaginal lubrication and promote a more pleasurable sexual experience.25

Compared with systemic estrogen products, vaginal estrogen products have been found to heighten genital vasculature (despite resulting in lower systemic levels of estrogen); systemic estrogen is more useful for relieving vasomotor symptoms (VMS) accompanying menopause.25 Conjugated estrogens vaginal cream (Prem­arin® Vaginal Cream) has an FDA indication for treatment of moderate to severe dyspareunia, a symptom of VVA due to meno­pause.26 Although estrogen therapies alone have not been found to directly increase sexual desire, they diminish dyspareunia, which may indirectly increase a woman’s interest in sexual activity.25

Many formulations of systemic and vaginal estrogen are available. If a woman’s FSD complaint is related to VVA, a vaginal formulation is preferred.27 Three vaginal estrogen formulations are available: creams, a ring, and a tablet (Table 3).27 For the tablet and creams, a higher dose and/or dosing frequency is typically used for 1-2 weeks until relief is achieved; a tapered dose can then be used for maintenance.27 Whereas most women find relief after 3 weeks of treatment, some may require up to 4-6 weeks.28 Low-dose vaginal estrogen therapy can be used indefinitely because of the low adverse effect profile; however, given limited data on use beyond 1 year, women should be evaluated annually to determine the need for continued treatment.29

The most common side effects of topical estrogen cream are headache, breast pain, pelvic pain, vasodilation, leukorrhea, metrorrhagia, vaginitis, and vulvovaginal disorder.26 Most side effects subside with ongoing use. Although systemic estrogen use has been linked to an increased risk for endometrial hyperplasia, venous thromboembolism, and breast cancer, little evidence suggests an increased risk with topical estrogen use.27 The North American Menopause Society (NAMS) released new guidelines for prescribing hormone therapy.30 According to these 2012 guidelines, topical estrogen is less likely than standard-dose oral estrogen to cause blood clots or stroke; however, more research is needed to reach definitive conclusions. A Cochrane review showed no increase in endometrial proliferation with vaginal estrogen versus placebo.27 Nevertheless, local estrogens can be absorbed into the bloodstream and increase the amount of systemic estrogen. Given the limited research, HCPs need to use clinical judgment when prescribing estrogen and monitor women closely for vaginal spotting/bleeding and other worrisome complaints.

Testosterone
If estrogen alone does not ease FSD symptoms, off-label addition of testosterone to estrogen therapy (ET) may increase libido and enhance sexual response.31 Use of testosterone in women is off label; this agent is prescribed with caution after patients are educated about the risks. A 2005 Cochrane review of 23 trials concluded that addition of testosterone therapy (TT) to ET improved sexual desire in postmenopausal women.32 The likely mechanism of action of combined therapy was related to the fact that use of exogenous testosterone increases circulating free testosterone and decreases sex hormone-binding globulin (SHBG). The subsequent increase in bioavailable testosterone may correlate with increased sexual desire.

Limited data on the long-term effects of TT led the FDA to reject a proposed testosterone patch for women with FSD. However, a 1% testosterone gel, FDA-approved for use in men only, is often prescribed off label to postmeno­pausal women with sexual dysfunction.33 One study showed that a dosage of 10 mg/day, applied in a thin layer to 15 cm2 of the inner thigh, led to mean testosterone levels of 3.0 nmol/L, which is in the high-normal range for premenopausal women (?2.5-3.0 nmol/L).33 The advantage of the transcutaneous route of administration over other routes (e.g., subcutaneous implant, intramuscular injection) is that it avoids the high hormone levels in the hepatic portal vein, which helps minimize assault to the liver.33

The most common short-term side effects of TT in women are hirsutism, acne, and a deepened voice, all of which are mild and reversible.34 Long-term side effects of concern are cardiovascular disease (CVD) and breast cancer. Preliminary studies have shown that TT reduces high-density lipoprotein cholesterol levels and increases low-density lipoprotein cholesterol levels; however, no study has looked at the correlation between TT in women and CVD.32 Studies examining the effects of TT on breast cancer risk are incon­clu­sive.32 Absolute contraindications to TT include a history of breast cancer, endometrial cancer, veno­thrombotic events, or CVD.14

When prescribing TT, HCPs should ask women to undergo baseline and annual breast exams and mammography, along with a pelvic exam—with special consideration paid to abnormal bleeding.14 In addition, women must be regularly evaluated for acne, hirsutism, and androgenic alopecia.14 Laboratory parameters monitored at baseline, after 3-6 months of use, and then periodically thereafter include SHBG, total testosterone, fasting lipid panel, and liver function tests.14

In 2005, NAMS published a position statement regarding the role of TT in postmenopausal women. The society concluded that TT is a valuable pharmacologic option for postmenopausal women who pre­sent with symptoms of decreased sexual desire.35 Nevertheless, NAMS cautions that insufficient data are available regarding the safety and efficacy of TT in women for longer than 6 months.35 Given these data, testosterone is prescribed with caution, with extensive patient education.

Bupropion
Bupropion is a norepinephrine and dopamine reuptake inhibitor antidepressant without serotonergic effects.36 Although bupropion is most commonly used as an antidepressant, this agent is used off label to treat sexual dysfunction in non-depressed women.37 The exact mechanism of bupropion’s efficacy for this indication is unknown but may be related to increased uptake of dopamine and norepinephrine, both of which are correlated with increased sexual responsiveness.36

The prescribed dosage of bu­pro­pion should not exceed 400 mg/day for the sustained-release formulation or 450 mg/day for the immediate- or extended release formulations; higher dos­ages can increase the incidence of side effects such as headache, agitation, insomnia, nausea, and possibly seizures.38 Bupropion is not prescribed to patients with a history of anorexia, bulimia, or seiz­ure disorders. Bupropion users must be monitored for neuro­psychiatric changes such as hostility, agitation, depression, and suicidality.39 Patients are counseled that treatment efficacy may not occur for 4-6 weeks.

Bupropion is a promising non-hormonal treatment option for FSD. Preliminary studies have shown encouraging results; however, more extensive research is needed before FSD can be listed as an indication for bupropion use.40Ospemifene
In 2013, the FDA approved ospemifene (OsphenaTM) for treatment of moderate to severe dyspareunia caused by VVA in menopausal women.41 Ospemi­fene, an oral selective estrogen receptor modulator, is the only non-estrogen compound approved in the U.S. to treat moderate to severe dyspareunia.42 This medication can be offered to women who are not candidates for ET but who have FSD related to dyspareunia. In two 12-week phase III clinical trials, ospemifene significantly improved vaginal dryness and dyspareunia, vaginal maturation index, and vaginal pH.43 The most effective dosage is 60 mg/day.43

The most common adverse effect of ospemifene is VMS.43 This agent is contraindicated in women with genital bleeding of unknown cause, estrogen-dependent neoplasia, personal history of deep vein thrombosis, pulmonary embolism, stroke, or myocardial infarction. Ospemifene should not be prescribed to women with a history of breast cancer or who are at high risk for breast cancer. Pre-clinical and clinical trials show a promising effect of ospemifene on bone density and breast tissue, but long-term data on the safety of this medication are limited.42Flibanserin
Flibanserin, an oral agent proposed for treatment of premeno­pausal hypoactive sexual desire disorder, has been shown to significantly increase sexual desire and the number of sexually satisfying events among women taking 100 mg at bedtime.44 The FDA initially rejected this medication in 2010.44 When Sprout Pharmaceuticals reapplied for approval in 2013, flibanserin was once again rejected; this time, the FDA indicated that additional studies in healthy subjects were needed to evaluate drug interactions and the drug’s possible adverse effect on driving.45 Sprout is expecting to resubmit the proposal by the end of the first quarter of 2015.45 No more information on the proposal was available as this article went to press.

Conclusion

Given the prevalence of FSD, HCPs must know how to screen for and diagnose FSD, and then manage it or know when to refer. HCPs need to take a short sexual history in all women, and ask them whether they have concerns about their sexual activity or about changes in their sexual desire or response. If the history uncovers a possibility of FSD, a thorough physical exam and lab testing are done. For women in whom FSD is diagnosed, nonpharmacologic interventions include CBT, sex therapy, self-stimulation, and lubricants. Two medications—conjugated estrogens vaginal cream and ospemifene —have a specific indication for dyspareunia. Although no pharmacologic agent has been approved by the FDA to treat desire, arousal, or orgasmic dysfunction in women, interest in such agents is growing. In each case, HCPs weigh the risks and benefits of specific treatments, offer extensive patient counseling, and provide close follow-up.

Casey B. Giebink is an adult and women’s health nurse practitioner at Medstar Georgetown University Hospital, Department of Ob&Gyn in Washington, DC. Ivy M. Alexander is an adult nurse practitioner specializing in midlife women’s health at the University of Connecticut Health Center in Storrs and Clinical Professor at the University of Connecticut School of Nursing. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Leiblum SR, Koochaki PE, Rodenberg CA, 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(1):46-56.

2. Harsh V, McGarvey EL, Clayton AH. Physician attitudes regarding hypoactive sexual desire disorder in a primary care clinic: a pilot study. J Sex Med. 2008;5(3):640-645.

3. Loeb DF, Aagaard EM, Cali SR, Lee RS. Modest impact of a brief curricular intervention on poor documentation of sexual history in university-based resident internal medicine clinics. J Sex Med. 2010; 7(10):3315-3321.

4. Tsimtsiou Z, Hatzimouratidis K, Nakopoulou E, et al. Predictors of physicians’ involvement in addressing sexual health issues. J Sex Med. 2006;3(4):583-588.

5. Bekker M, Beck J, Putter H, et al. The place of female sexual dysfunction in the urological practice: results of a Dutch survey. J Sex Med. 2009;6(11):2979-2987.

6. Mansell D, Salinas G, Sanchez A, Abdolrasulnia M. Attitudes toward management of decreased sexual desire in premenopausal women: a national survey of nurse practitioners and physician assistants. J Allied Health. 2011;40(2):64-71.

7. Roos A-M, Thakar R, Sultan A, Scheer I. Female sexual dysfunction: are urogynecologists ready for it? Int Urogynecol J. 2009;20(1):89-101.

8. Julien JO, Thom B, Kline NE. Identification of barriers to sexual health assessment in oncology nursing practice. Oncol Nurs Forum. 2010;37(3):E186-E190.

9. Berman L, Berman J, Felder S, et al. Seeking help for sexual function complaints: what gynecologists need to know about the female patient’s experience. Fertil Steril. 2003;
79(3):572-576.

10. Peck SA. The importance of the sexual health history in the primary care setting. J Obstet Gynecol Neonatal Nurs. 2001;30(3):269-274.

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