S16 From whence comes HSDD? - The Journal of Family Practice

Supplement toFREE1.25 CMECREDITS} Release date: July 15, 2009} Expiration date: July 15, 2010Available at www.jfponline.com Vol 58, No 7 / July 2009S16 From whence comes HSDD?Sharon J. Parish, MDS22 Identifying HSDD in the familymedicine settingSheryl A. Kingsberg, PhDS26 Opportunities for interventionin HSDDJames A. Simon, MD, CCD, NCMP, FACOGS31 Case study:Challenges in the identificationand management of HSDDSharon J. Parish, MDS33 PosttestS35 EvaluationThis supplement was submitted byDIME and was edited and peer reviewedby The Journal of Family Practice.

HypoactiveSexual Desire Disorderin WomenImplications for Family PracticeAvailable at www.jfponline.com Vol 58, No 7 / July 2009ChairpersonSharon J. Parish, MDFacultySheryl A. Kingsberg, PhDJames A. Simon, MD, CCD, NCMP, FACOGEditorsNatasha Mitchner, PhDScientific Director, DIMEChicago, IllinoisNancy BaxterDIMEChicago, IllinoisTarget AudienceThis activity is targeted to family and general practitionersin primary care.Activity PurposeDIME’s educational goal is to assist participantswith the diagnosis and treatment of HSDD byincreasing knowledge of screening tools, strategiesfor patient–provider communication, and treatmentoptions.This activity may be accessed via the Internet onwww.jfponline.com.Term of OfferingThis activity has a release date of July 15, 2009, and isvalid for 1 year. Requests for credit must be receivedno later than July 15, 2010.A review committee has agreed that this materialcan be completed in 1.25 hours. This estimatedstudy time in turn has determined the credit hoursbeing offered.All inquiries should be directed to:DIME222 Merchandise Mart PlazaSuite 4-160Chicago, IL 60654DIMEinfo@DIMedEd.orgwww.DiMedEd.orgAccreditation AND DESIGnation StatementDIME is accredited by the Accreditation Council forContinuing Medical Education (ACCME) to providecontinuing medical education for physicians.DIME designates this educational activity for amaximum of 1.25 AMA PRA Category 1 Credits TM .Physicians should only claim credit commensuratewith the extent of their participation in the activity.continuing education creditThis activity includes a posttest and evaluation,which must be completed to receive continuingeducation credit.There is no fee for participating in the programor for the generation of the certificate.instructions for receiving creditContinuing Education CreditThere are 2 options for receiving CME credit:Option 1: The DIME online enrollment systema. Please visit the url: http://www.DIMedEd.org/updates/HSDDFamilyPractice.htmlb. Complete the enrollment form, posttest, andevaluation.c. Successful completion of the self-assessment isrequired to earn Category 1 CME credit. Successfulcompletion is defined as a cumulative score ofat least 70% correct. If you receive a passing score,your certificate of credit will be made available toyou immediately.If you have difficulty accessing the link, pleasecontact the DIME office at (312) 553-8000 ordimeservices@DIMedEd.orgOption 2: Complete this enrollment form, posttest,and evaluation form and mail them to:DIME 17771222 Merchandise Mart Plaza, Suite 4-160Chicago, IL 60654A certificate of credit will be e-mailed or mailed toyou within 6 weeks.Statement of NeedHypoactive sexual desire disorder (HSDD), thepersistent or recurrent lack of sexual fantasies,thoughts, and desires resulting in personal distress,is one of 4 categories of female sexual dysfunction.Providers are known to consistently underestimateand underrecognize their patients’ sexual problems.A stigma associated with communicatingabout sex, cultural embarrassment, and avoidanceof discussion of sexual dysfunction in theclinical environment are common barriers thatprevent providers and patients from talking aboutsex. In addition, type of sexual dysfunction, duration,and frequency of satisfying sexual events aredifficult to track and quantify and are limited byprovider emphasis and patient adherence to tracking.The causal dimensions of HSDD are extremelybroad and are not fully understood. The clinicalevaluation of HSDD should consider biological,interpersonal, and psychological factors. Providersmay perceive that there is simply a lack of scheduledoffice time to discuss sexual concerns, especially ifthe provider believes that a good assessment requiresa substantial investment of time. Stigma,fear, embarrassment, discomfort (or a provider’soverconfidence in the patient’s comfort level), andeven the gender difference between the patient andprovider may alter the interpersonal dynamics ofthe office visit. Approaches are needed to overcomebarriers to recognizing sexual dysfunction andHSDD and to establish more effective dialogue andfacilitate referral to appropriate resources.Learning ObjectivesOn completion of this activity, participants shouldbe able to:• Define HSDD and identify the factors associatedwith it or that may contribute to it• Describe the steps required for taking a thoroughand clinically pertinent sexual history• Explain how to screen patients for HSDD, howto identify and diagnose patients at risk forHSDD, and how to refer them to appropriateresources• Identify interventions and pharmacologic treatmentsfor HSDD and provide evidence of theireffectiveness• Discuss patient and provider obstacles to therecognition and management of HSDD andidentify strategies for overcoming these barriersThis activity is funded through an independenteducational grant from Boehringer IngelheimPharmaceuticals, Inc. The activity content was developedindependently by the contributing facultyor editors. The materials included in this activityhave undergone peer review by the chairperson(s)or editor(s). All materials are included with the permissionof the authors. The opinions expressed arethose of the faculty and are not to be construed asthose of the publisher or grantor.DisclosuresIn accordance with DIME policies regarding financialand off-label disclosure, the learner is advisedthat this CME activity may contain references to offlabelor unapproved uses of drugs or devices. Theuse of these agents outside currently approved labelingis considered experimental, and participantsare advised to consult prescribing information forthese products. This CME activity was planned andproduced in accordance with ACCME EssentialAreas and Policies.DIME requires that all persons who were in aposition to control or influence the content of thisCME activity disclose all relevant financial relationshipswith any commercial interest. This informationis used to: (1) determine whether a conflictexists, (2) resolve the conflict by initiating a contentvalidation process, and (3) advise learners of thisinformation.ChairpersonSharon J. Parish, MDSources of Funding for Research: NoneConsulting Agreements: Boehringer IngelheimPharmaceuticals, Inc.; Wyeth PharmaceuticalsFinancial Interests/Stock Ownership: NoneSpeakers’ Bureau/Honorarium Agreements: NoneDiscussion of Off-Label, Investigational, or ExperimentalDrug Use: Androgen therapy, includingtestosterone and DHEA for hypoactive sexualdesire.FacultySheryl A. Kingsberg, PhDSources of Funding for Research: BioSante Pharmaceuticals;Boehringer Ingelheim Pharmaceuticals,Inc.; Procter & Gamble PharmaceuticalsConsulting Agreements: Boehringer IngelheimPharmaceuticals, Inc.; Wyeth PharmaceuticalsFinancial Interests/Stock Ownership: NoneSpeakers’ Bureau/Honorarium Agreements: Eli Lillyand Company; Johnson & JohnsonDiscussion of Off-Label, Investigational, or ExperimentalDrug Use: Testosterone for postmenopausalwomen.James A. Simon, MD, CCD, NCMP, FACOGSources of Funding for Research: BioSante Pharmaceuticals;Boehringer Ingelheim Pharmaceuticals,Inc.; FemmePharma Global Healthcare, Inc.; Glaxo-SmithKline; Nanma/Tripharma/Trinity; NovartisPharmaceuticals Corp; Procter & Gamble PharmaceuticalsConsulting Agreements: Allergan Inc.; Alliance forBetter Bone Health; Amgen Inc.; Ascend Therapeutics,Inc.; Barr Pharmaceuticals, Inc.; BayerHealthCare Pharmaceuticals; BioSante Pharmaceuticals;Boehringer Ingelheim Pharmaceuticals,Inc.; Concert Pharmaceuticals, Inc.; Corcept TherapeuticsIncorporated; Depomed, Inc.; GlaxoSmith-Kline; KV Pharmaceutical Company; MeditrinaPharmaceuticals, Inc.; Merck & Co., Inc.; MerrionPharmaceuticals, Inc.; Nanma/Tripharma/Trinity;Novogyne Pharmaceuticals; Novo Nordisk A/S;Pear Tree Pharmaceuticals; QuatRx PharmaceuticalsCompany; Roche; Schering-Plough Corporation;Sciele Pharma, Inc.; Solvay Pharmaceuticals,Inc.; Ther-Rx Corporation; Warner Chilcott; WyethPharmaceuticalsFinancial Interests/Stock Ownership: NoneSpeakers’ Bureau/Honorarium Agreements: AmgenInc.; Ascend Therapeutics, Inc.; Barr Pharmaceuticals,Inc.; Bayer HealthCare Pharmaceuticals;Boehringer Ingelheim Pharmaceuticals, Inc.;GlaxoSmithKline; KV Pharmaceutical Company;Merck & Co., Inc.; Novartis Pharmaceuticals Corp;Novogyne Pharmaceuticals; Sciele Pharma, Inc.;Ther-Rx Corporation; Warner Chilcott; Wyeth PharmaceuticalsDiscussion of Off-Label, Investigational, or ExperimentalDrug Use: Testosterone for postmenopausalwomen.EditorsNatasha Mitchner, PhDSources of Funding for Research: NoneConsulting Agreements: NoneFinancial Interests/Stock Ownership: Procter &Gamble PharmaceuticalsSpeakers’ Bureau/Honorarium Agreements: NoneDiscussion of Off-Label, Investigational, or ExperimentalDrug Use: NoneNancy BaxterSources of Funding for Research: NoneConsulting Agreements: NoneFinancial Interests/Stock Ownership: NoneSpeakers’ Bureau/Honorarium Agreements: NoneDiscussion of Off-Label, Investigational, or ExperimentalDrug Use: NoneThis activity is sponsored by DIME and fundedthrough an independent educational grant fromBoehringer Ingelheim Pharmaceuticals, Inc.image © Michael MorgesternS14 July 2009 / Vol 58, No 7 / Supplement to The Journal of Family Practice Copyright © 2009 Dowden Health Media and DIME www.jfponline.comSupplement to The Journal of Family Practice / Vol 58, No 7 / July 2009 S15

Supplement toFrom whence comes HSDD?Sharon J. Parish, MDAssociate Professor ofClinical MedicineDepartment of MedicineAlbert Einstein Collegeof MedicineDirector of PsychosocialTrainingDepartment of MedicineMontefiore Medical CenterBronx, New YorkFemale sexual dysfunction (FSD) encompasses a group of highly prevalentdisorders characterized by problems related to sexual desire, arousal, orgasm,or pain. 1,2 Among these is hypoactive sexual desire disorder (HSDD),a condition that causes marked distress and interpersonal difficulties. 1 In viewof the complexity of factors contributing to the various types of FSD, the identificationof HSDD requires that it be carefully differentiated from other forms ofsexual dysfunction. An understanding of the definitions of FSD and HSDD, theirprevalence in various subpopulations of women, and their impact on quality oflife can increase awareness of the importance of these disorders. Such knowledgewill also help family physicians appreciate the place of HSDD within thespectrum of FSD and become better equipped to recognize this disorder in clinicalpractice.Definitions of FSD and HSDDThe definition of FSD in the American Psychiatric Association’s Diagnostic andStatistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) isbased on a traditional linear model of human sexual response. 1 Sexual dysfunctionis classified as disorders of desire, arousal, orgasm, and pain (Table 1). 1 Aninterdisciplinary consensus panel convened by the American Foundation forUrological Disease (AFUD) developed a classification system that retained theframework of the DSM-IV-TR categories but expanded them to include organiccauses of sexual dysfunction (Table 2). 2 This system is also based on the linearmodel of sexual response. In both the DSM-IV-TR and AFUD classifications,HSDD is placed under the general category of sexual desire disorders. The definitionsrequire that HSDD be marked by persistent or recurrent deficient (or absent)sexual fantasies and desire for sexual activity that causes marked distressor interpersonal difficulty. 1,2 The category of HSDD can be further divided intosubtypes: general (a general lack of sexual desire) vs situational (a woman previouslyhad sexual desire for her current partner but now lacks sexual interestin that individual, although she still has desire for sexual stimulation alone orwith someone other than her present partner), and acquired (beginning after aperiod of normal sexual function) vs lifelong (in a woman who has always hadlow or no sexual desire). 1Definitions of FSD derived from a linear model have been criticized as beingmore characteristic of men than women. 3 Newer models depict the sexual responsein women as a circular sequence of events that may involve overlappingphases in a variable order. 4,5 Women may not have a sense of desire at the initiationof a sexual encounter. 5 Nonetheless, the absence of desire does not precludea satisfactory sexual experience. 6,7 The model shown in the Figure (page S20)demonstrates that desire can be triggeredlater during a sexual experienceonce the woman has become subjectivelyaroused. 4,5The DSM-IV-TR definition ofHSDD has also been criticized becauseit considers sexual fantasies aprimary trigger for sexual behavior.Research has shown that spontaneoussexual thoughts or fantasies maybe characteristic of women in newrelationships but occur much lessfrequently among sexually healthywomen in longer-term relationships. 8Moreover, a woman’s desire for sexualactivity may be prompted by factorsnot addressed by current definitions,such as wanting to experience tendernessand appreciation by her partnerand feeling desirable. 9Since lack of sexual desire at thebeginning of a sexual encounter doesnot necessarily indicate HSDD, expertshave suggested that the definitionbe refined to indicate a recurrent,consistent lack of ability to experienceany desire or arousal. 5 Such criteriawould reflect the fact that desireproblems are usually associated withdifficulties in all phases of the sexualresponse cycle. For instance, orgasmcannot occur without arousal, and alack of arousal often results in a lackof desire because sexual activity isnot enjoyable. Sexual pain disordersand lack of sexual arousal may also belinked, as intercourse without arousaland associated lubrication can bepainful and lead to the avoidance ofsexual activity.EpidemiologyTable 1FSDPrevalence estimates of FSD vary based on the patientpopulation and methodology employed. For example,age and age-group categorizations have differed amongmany studies, and inclusion criteria are often limited toDSM-IV-TR classification of female sexual dysfunction 1ClassificationSexual desire disordersHypoactive sexual desire disorderSexual aversion disorderSEXUAL AROUSAL DISORDERSFemale sexual arousal disorderORGASMIC DISORDERSFemale orgasmic disorderPAIN DISORDERSDyspareuniaVaginismusSymptomsAbsence or deficiency of sexual interest and/or desireAversion to and avoidance of genital contact witha sexual partnerInability to attain or maintain adequate lubricationswellingresponse of sexual excitementDelay in or absence of orgasm after a normal sexualexcitement phaseGenital pain associated with sexual intercourseInvoluntary contraction of the perineal muscles, preventingvaginal penetrationDSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders 4th edition, text revision.Table 2AFUD classification of female sexual dysfunction 2ClassificationSexual desire disordersHypoactive sexual desire disorderSexual aversion disorderSEXUAL AROUSAL DISORDERSFemale sexual arousal disorderORGASMIC DISORDERSFemale orgasmic disorderPAIN DISORDERSDyspareuniaVaginismusNoncoital painAFUD, American Foundation for Urological Disease.SymptomsAbsence of sexual fantasies, thoughts, and/or desire for,or receptivity to, sexual activity, which causes personaldistressPhobic aversion to and avoidance of sexual contact witha sexual partner, which causes personal distressInability to attain or maintain sufficient sexual excitement,causing personal distress, which may be expressed as a lackof subjective excitement, or genital (lubrication-swelling) orother somatic responsesDelay in or absence of attaining orgasm following sufficientsexual stimulation and arousal, which causes personaldistressGenital pain associated with sexual intercourseInvoluntary spasm of the musculature of the outer thirdof the vagina that interferes with vaginal penetration,which causes personal distressGenital pain induced by noncoital sexual stimulationwomen in sexual or stable relationships, omitting significantnumbers of women. Cultural differences, avoidanceof a dialogue surrounding sexual complaints, and spanof recall also may confound epidemiologic studies. 10 TheS16 July 2009 / Vol 58, No 7 / Supplement to The Journal of Family Practice Copyright © 2009 Dowden Health Media and DIME www.jfponline.comSupplement to The Journal of Family Practice / Vol 58, No 7 / July 2009 S17

From whence comes HSDD?Table 3Medical conditions and drugs associatedwith decreased sexual desire and subjectivearousal in women 5Medical conditions• Bilateral oophorectomy• Hypoprolactinemia• Lower urinary tract symptoms• Adrenal disease• Diabetes• Renal failure• Coronary artery disease• Cerebrovascular disease• Neurological disease• Parkinson’s disease• Multiple sclerosis• Head injury• DepressionDrugs• Antiandrogens• Antidepressants (eg, selectiveserotonin reuptake inhibitors)• Antihypertensives (eg, betablockers)• Antipsychotics• Antiepileptics• Narcoticslack of standardized definitions of FSD precludes directcomparison, and few studies have included validatedquestionnaires or instruments for assessing FSD. 10 Also,few studies have used questionnaires that assess both thepresence of sexual dysfunction and distress. 10 Nonetheless,accumulating data demonstrate the extent and impactof FSD.The 1992 National Health and Social Life Survey(NHSLS) was the first study to examine female sexualproblems in a nationally representative population. Inthis survey, a probability sample of US adults between theages of 18 and 59 years, respondents answered a seriesof questions relating to sexual symptoms or problems inthe preceding 12 months. 11 Sexual dysfunction was moreprevalent in women compared with men (43% vs 31%).Lack of interest in sex was the most frequently reportedsexual complaint (32%), followed by orgasmic dysfunction(28%) and painful sex (21%). In the National SocialLife, Health, and Aging Project, Lindau et al examined thesexuality and health of older adults in a probability sampleof US adults aged 57-85 years who were interviewedbetween 2005 and 2006. 12 Age-related decreases in sexualitywere observed in both men and women; 62%, 40%,and 17% of women aged 57 to 64, 65 to 74, and 75 to 85years, respectively, reported sexual activity with a partnerin the previous 12 months. Approximately half the womenreported a sexual complaint, with 61% stating that theywere bothered by a lack of interest in sex.The recent Prevalence and Correlates of Female SexualDisorders and Determinants of Treatment Seeking(PRESIDE) study estimated the prevalence of self-reportedproblems with desire, arousal, and orgasm in a crosssectional,population-based survey of US adult females. 13The presence of any sexual problem was reported by44.2% of PRESIDE participants. Further, prevalence ratesincreased with age. Low sexual desire was the most commonsexual problem (38.7%), followed by low arousal(26.1%) and orgasm difficulties (20.5%). Sexually relatedpersonal distress was reported by 22.8% of respondents.In spite of an age-related increase in rates of sexual dysfunction,the prevalence of personal distress decreasedwith older age, occurring in 12.6% of women ≥65 years ofage compared with 24.4% of those aged 18 to 44 years and25.5% of those aged 45 to 64 years. These findings also illustratethe fact that, regardless of age, many women withsexual problems are not bothered enough by them to beclassified as being distressed, precluding a diagnosis ofHSDD.HSDDA number of recent studies have focused on the prevalenceof low sexual desire and HSDD. Estimates of theprevalence of HSDD have been found to vary, dependingon the type of instrument used. In a survey of womenaged 20 to 70 years, HSDD was present in 16% accordingto the combined Sexual Function Questionnaire andFemale Sexual Desire Scale (SFQ-FSDS). 10 In contrast, useof the SFQ alone or 2 instruments based on simple questionsproduced prevalence estimates ranging from 32% to58%. The rates obtained with each of these instrumentswere significantly higher than those associated with theSFQ-FSDS (P < .0001).In the Women’s International Study of Health and Sexuality(WISHeS), women 20 to 70 years old from the UnitedStates and the European Union completed a questionnairethat included the Profile of Female Sexual Function andPersonal Distress Scale, 2 validated patient-based instruments.14,15 The prevalence of low sexual desire showed anonsignificant trend toward age-related increases in USwomen: 22% among those 20 to 29 years old vs 32% ofthose 60 to 70 years old. 14 In contrast, the proportion ofEuropean women with low desire increased significantlywith age, from 11% to 53% in these 2 age groups, respectively.The prevalence of HSDD, defined as the presence ofboth low sexual desire and personal distress, ranged from12% to 19% in US women and from 6% to 13% in Europeanwomen. Among subjects in their 30s, the prevalence of lowdesire was higher in US than in European women (29% vs16%, respectively), and more US women with this conditionwere distressed by it (65% vs 38%, respectively). Thesedifferences translated into a higher prevalence of HSDDamong US women as compared to European women inthis age group (19% vs 6%, respectively). Among women 60to 70 years old, the prevalence of low desire was lower inUS than European participants (32% vs 53%, respectively),but the proportions of women who were distressed by thiscondition did not differ greatly between the 2 populations(22% vs 37%, respectively), and the prevalence of HSDDwas identical (12%). The WISHeS investigators pointed outthat a variety of factors that differ between US and Europeanwomen may explain the observed differences in sexualdesire and distress. Such factors might include the overallhealth of the women, use of hormone therapies and othermedications, and cultural and social factors such as sexualexpectations.In a separate analysis of the data from WISHeS,Leiblum et al reported on the prevalence of low sexualdesire and HSDD in US women by reproductive statusand age. 16 For ages 20 to 49 years, low sexual desire waspresent in 26% of surgically postmenopausal women vs14% of premenopausal women. Surgically postmenopausalwomen in this age group demonstrated a likelihoodof HSDD (which included low sexual desire andpersonal distress) that was nearly 3 times higher than thepremenopausal group (odds ratio, 2.7; 95% confidenceinterval, 1.5 to 5.0; P < .002). In the group aged 50 to 70years, the prevalence of HSDD (including low desire anddistress) was 14% in surgically postmenopausal womenvs 9% in those who were naturally postmenopausal, anonsignificant difference.Other data from the WISHeS study shed light on theassociation between decreased sexual desire and personaldistress. 16,17 Similar to the observations in the PRESIDEstudy of women with FSD, WISHeS found that despite anage-related increase in low sexual desire, older womenwere less likely to report distress, precluding a diagnosisof HSDD. 16,17 Younger women were 3 times more likelyto report sexually related distress, compared with olderwomen in this study.Etiologic dimensions of FSD and HSDDThe etiologies of FSD and HSDD likely involve a complexinterplay among biological, psychological, socioeconomic,and interpersonal components. In PRESIDE,for example, poor health, thyroid conditions, urinaryTable 4Medical and psychosocial effects of diseaseon female sexual functionMedical factors resulting from disease, treatment, or both• Fatigue, pain, incontinence, or changed anatomy of sexual organs• Reduced mobility, which limits ability to caress, stimulate self orpartner, or engage in intercourse• Changed physical sensations, such as itching, irritation, insensitivity, orhypersensitivity• Interruption of sexual response, infertility, dyspareunia, or painfulorgasm• Angina or dyspnea from sexual stimulationPsychological response to illness or sexual dysfunction• Fear that sex could be dangerous and provoke myocardial infarctionor cerebral vascular event• Fear of infection or conviction that illness was caused by sexual activity(eg, cancer as punishment)• Preoccupation with illness or loss of control and independence• Disrupted sexual self-image or feeling of failure as a sexual partneror potential parent• Anxiety, depression, anger, shame, guilt, stress, or emotional lability• Avoidance behavior, fearing pain or rejection due to disfigurementor stomas• Repeatedly remembering traumatic medical procedures to sexual partsPersonal psychological factors• Limited coping mechanisms or negative attitude• History of limited or unrewarding sexual experiences• Past abuse (sexual, physical, or emotional)Relationship and social factors• Lack of intimacy, trust, or freedom from abuse• Difficulties with communication, power regulation, or role changes• Partner’s negative reactions to illness• Partner’s sexual dysfunction• Inability to meet a partner or lack of information about sexualrehabilitation• Social obstruction by third parties (eg, at a hospital or nursing home)• Cultural nonacceptance of sexuality when ill or oldReprinted from The Lancet, 369, Basson R, Schultz WW, Sexual sequelae of general medicaldisorders, 409-424, 2007, with permission from Elsevier.incontinence, depression, anxiety, and low educationlevel were found to be associated with distressing sexualcomplaints. 13 There is also significant overlap among theconstellation of factors involved, such that a comorbiddysfunction evolves over time. The diagnostic processmust incorporate assessment of the primary and any secondaryconditions and identification of those factors thatare amenable to intervention.Biological factorsOverall, poor health has a negative impact on sexualS18 July 2009 / Vol 58, No 7 / Supplement to The Journal of Family Practice Copyright © 2009 Dowden Health Media and DIME www.jfponline.comSupplement to The Journal of Family Practice / Vol 58, No 7 / July 2009 S19

From whence comes HSDD?FigureMedical and psychosocial effects of disease onfemale sexual functionOther rewards, eg,emotional intimacy,increased well-beingArousal triggersdesireSexual satisfaction andabsence of painMultiple motivationsInitialsexual desire(variable)Subjective arousal andautonomic nervoussystem responseCircular model of female sexual response showing cycle of overlapping phases.Reprinted from The Lancet, 369, Basson R, Schultz WW, Sexual sequelaeof general medical disorders, 409-424, 2007, with permission from Elsevier.Deliberate attentionto stimuliBiological factorsProcessing of stimuliPsychological factorson sexual function are summarized inTable 4 and the figure. 6Psychosocial factorsMany different types of psychosocialfactors can influence attitudes towardsexuality. For instance, a history ofsexual abuse or assault can give rise tofeelings of shame or guilt associatedwith sexual activity. 21 Untreated depression,anxiety, and other mood disordershave been linked to problemswith sexual desire and arousal. 9,22,23In addition, self-consciousness aboutbody image and doubts about sexualdesirability have been found to reducesexual esteem and sexual function inwomen. 24,25 Sexual difficulties suchas erectile dysfunction or prematureejaculation on the part of the woman’spartner are also known to increase therisk for problems with female sexualdesire and arousal. 9without decreased sexual desire. 16 Women with HSDDwere also more likely to report feelings of frustration, hopelessness,and anger, as well as loss of femininity and alteredself-esteem. 16,28Obstacles to Identifying HSDDPatients and physicians alike are reluctant to initiate a dialogueabout sexuality. In the NHSLS, only 20% of womenreporting a sexual complaint had sought medical assistancefor their problem. 11 Survey data indicate that patientsdo not address sexual concerns due to fears that the physicianwould be uncomfortable and dismiss their concern. 29Physicians report low knowledge and comfort levels withFSD due to limited training, embarrassment, time constraints,and lack of effective treatments. 30 The great majority of respondentsin a small survey of primary care physicians hadnot screened a patient for HSDD (90%). 31 Furthermore, 90%reported little confidence in making a diagnosis of HSDD,and 98% had not prescribed pharmacotherapy for HSDD.Another obstacle to the identification of HSDD isthe considerable overlap in symptoms of various types ofFSD. 32 For instance, some women who complain of HSDDalso have components of sexual aversion, although theymay not manifest the phobic avoidance associated withthe latter disorder. 32 Moreover, there is substantial overlapbetween the symptoms of desire disorders and arousaldisorders. Conceivably, then, a given patient may havecharacteristics of HSDD and sexual arousal disorder thatmay manifest in different ways at different times. 32ConclusionData attesting to the considerable prevalence and impactof HSDD argue in favor of greater awareness of the disorderand its consequences. Current definitions provide a usefulconceptual framework for HSDD but have been criticizedfor their shortcomings in fully describing the nature of suchdysfunction in women. As definitions of HSDD continue toevolve, their clinical utility will hopefully improve. nDisclosureDr. Parish is a consultant for Boehringer Ingelheim Pharmaceuticals, Inc.,and Wyeth.function. 12,13 Illnesses that interfere with endocrine systemsare particularly important in the impairment of femalesexual desire. Several lines of evidence have revealeda link between sexual desire and levels of androgens inwomen. 9 Consequently, disorders of ovarian functionand of the hypothalamic-pituitary-adrenal axis have beenassociated with decreased sexual desire and arousal. 18As discussed earlier, data from recent studies, includingWISHeS, show that surgical menopause is a stronger riskfactor for HSDD than is natural menopause. 16,19 Reductionsin estrogen levels may decrease vaginal lubricationand cause atrophy of vaginal tissue, which may also affectdesire. 9 Androgens are believed to be involved in maintainingsexual desire and mood, but their relative importanceamong the various factors contributing to femalesexual desire remains controversial. 9In addition to endocrine factors, a range of othermedical conditions as well as psychological disordersand pharmacologic therapies have been associatedwith reduced sexual desire and arousal (Table 3 on pageS18). 5 Some specific medical conditions (such as multiplesclerosis and spinal cord injury) and drugs (especiallyselective serotonin reuptake inhibitors andantipsychotics) have also been linked to orgasm disorders.5,20 The medical and psychosocial effects of diseaseImpact of FSD and HSDDon quality of lifeAn international survey conducted in 27 countries determinedthat 80% of US women feel that sex is a necessarycomponent of a fulfilling life. 26 The National Social Life,Health, and Aging Project also revealed that many olderwomen remain sexually active and feel that sexuality isan important aspect of their well-being. 12 In addition, activeand satisfying sexual relationships have been linkedto emotional well-being, partner satisfaction, and qualityof life. 27FSDAll types of FSD were significantly correlated with low feelingsof physical and emotional satisfaction and low generalhappiness in women participating in the NHSLS. 11 It is importantto note that a causal relationship between FSD andemotional and psychological issues has not been established,since these may precede the development of FSD.HSDDThe WISHeS study found that women with HSDD weresignificantly more likely to report dissatisfaction with theirsex life and marriage or partner compared with womenReferences1. American Psychiatric Association. Diagnosticand Statistical Manual of Mental Disorders. 4thedition, text revision. Washington, DC: AmericanPsychiatric Press; 2000.2. Basson R, Berman J, Burnett A, et al. Report ofthe international consensus development conferenceon female sexual dysfunction: definitionsand classifications. J Urol. 2000;163:888-893.3. Basson R, Leiblum S, Brotto L, et al. Definitionsof women’s sexual dysfunction reconsidered:advocating expansion and revision. J PsychosomObstet Gynecol. 2003;24:221-229.4. Basson R. Human sex response cycles. J Sex MaritalTher. 2001;27:33-43.5. Basson R, Schultz WW. Sexual sequelae of generalmedical disorders. Lancet. 2007;369:409-424.6. Cain VS, Johannes CB, Avis NE, et al. Sexual functioningand practices in multi-ethnic study ofmidlife women: baseline results from SWAN. J SexRes. 2003;40:266-276.7. Meston C, Buss DM. Why humans have sex. ArchSex Behav. 2007;36:477-507.8. Cawood EH, Bancroft J. Steroid hormones, themenopause, sexuality and well-being of women.Psychol Med. 1996;26:925-936.9. Meston CM, Bradford A. Sexual dysfunctions inwomen. Annu Rev Clin Psychol. 2007;3:233-256.10. Hayes RD, Dennerstein L, Bennett CM, et al. Whatis the “true” prevalence of female sexual dysfunctionsand does the way we assess these conditionshave an impact? J Sex Med. 2008;5:777-787.11. Laumann EO, Paik A, Rosen RC. Sexual dysfunctionin the United States: prevalence and predictors.JAMA. 1999;281:537-544.12. Lindau ST, Schumm LP, Laumann EO, et al. A studyof sexuality and health among older adults in theUnited States. N Engl J Med. 2007;357:762-774.13. Shifren JL, Monz BU, Russo PA, et al. Sexualproblems and distress in United States women:prevalence and correlates. Obstet Gynecol.2008;112:970-978.14. Hayes R, Dennerstein L. The impact of aging onsexual function and sexual dysfunction in women:a review of population-based studies. J SexMed. 2005;2:317-330.15. McHorney CA, Rust J, Golombok S, et al. Profileof female sexual function: a patient-based, international,psychometric instrument for the assessmentof hypoactive sexual desire in oophorectomizedwomen. Menopause. 2004;11:474-483.16. Leiblum SR, Koochaki PE, Rodenberg CA, et al.Hypoactive sexual desire disorder in postmenopausalwomen: US results from the Women’s InternationalStudy of Health and Sexuality (WISHeS).Menopause. 2006;13:46-56.17. Hayes RD, Dennerstein L, Bennett CM, et al. Relationshipbetween hypoactive sexual desire disorderand aging. Fertil Steril. 2007;87:107-112.18. Guay AT, Spark R. Pathophysiology of sex steroidsin women. In: Goldstein I, Meston CM, Davis SR,et al, eds. Women’s Sexual Function and Dysfunction:Study, Diagnosis, and Treatment. New York:Taylor & Francis; 2006:218-227.19. Dennerstein L, Koochaki P, Barton I, et al. Hypoactivesexual desire disorder in menopausalwomen: a survey of Western European women. JSex Med. 2006;3:212-222.20. Nurnberg HG, Hensley PL, Heiman JR, et al. Sildenafiltreatment of women with antidepressant-associatedsexual dysfunction. JAMA. 2008;300:395-404.21. van Berlo W, Ensink B. Problems with sexuality aftersexual assault. Annu Rev Sex Res. 2000;11:235-237.22. Bonierbale M, Lancon C, Tignol J. The ELIXIRstudy: evaluation of sexual dysfunction in 4,557depressed patients in France. Curr Med Res Opin.2003;19:1114-1124.23. Kennedy SH, Dickens SC, Eisfeld BS, et al. Sexualdysfunction before antidepressant therapy inmajor depression. J Affect Disord. 1999;56:2001-2008.24. Dove NL, Wiederman MW. Cognitive distractionand women’s sexual functioning. J Sex MaritalTher. 2000;26:67-78.25. Wiederman MW. Women’s body image selfconsciousnessduring physical intimacy with apartner. J Sex Res. 2000;37:60-68.26. Mulhall J, King R, Glina S, et al. Importance ofand satisfaction with sex among men and womenworldwide: results of the global better sex survey.J Sex Med. 2008; 5:788-795.27. Rosen RC, Bachmann GA. Sexual well-being,happiness, and satisfaction, in women: the casefor a new conceptual paradigm. J Sex MaritalTher. 2008;34:291-297.28. Graziottin A. Prevalence and evaluation of sexualhealth problems—HSDD in Europe. J Sex Med.2007;4(suppl 3):211-219.29. Marwick C. Survey says patients expect little physicianhelp on sex. JAMA. 1999;281:2173-2174.30. Bachmann G. Female sexuality and sexual dysfunction:are we stuck on the learning curve? J SexMed. 2006;3:639-645.31. Harsh V, McGarvey EL, Clayton AH. Physicianattitudes regarding hypoactive sexual desire disorderin a primary care clinic: a pilot study. J SexMed. 2008;5:640-645.32. Carey JC. Disorders of sexual desire and arousal.Obstet Gynecol Clin N Am. 2006;33:549-564.S20 July 2009 / Vol 58, No 7 / Supplement to The Journal of Family Practice Copyright © 2009 Dowden Health Media and DIME www.jfponline.comSupplement to The Journal of Family Practice / Vol 58, No 7 / July 2009 S21

Supplement toIdentifying HSDD in the familymedicine settingSheryl A. Kingsberg, PhDAssociate ProfessorDepartments of ReproductiveBiology and PsychiatryCase Western ReserveUniversity School of MedicineChief, Division of BehavioralMedicineDepartment of Obstetrics andGynecologyUniversity Hospitals CaseMedical CenterMacDonald Women’s HospitalCleveland, OhioHypoactive sexual dysfunction disorder (HSDD) occurs among women ofall ages but continues to be underdiagnosed and undertreated. 1 A lack ofpatient-physician communication is a major reason underlying the failureto identify HSDD. Research has revealed that this problem represents a 2-waystreet: patients are reluctant to discuss sexual difficulties with their physicians,and physicians are reluctant to inquire about such issues. 2,3 Moreover, some physiciansare concerned that conversations about sexual function might consumetoo much time during the office visit. 4 An additional consideration is the fact thatmany physicians do not believe they have the requisite knowledge and experienceto diagnose and manage HSDD. 1 By recognizing the nature of these barriersand implementing strategies to overcome them, family physicians can play an importantrole in promoting more widespread screening for female sexual dysfunction(FSD), leading to greater use of diagnostic modalities designed to ascertainthe exact nature of the dysfunction.Obstacles to screening for HSDDStudies have found that the topic of sexual dysfunction may never come to light ifthe responsibility for initiating a discussion is left to the patient. 5 In 2000, a reportfrom a survey of women receiving routine gynecologic care from family practitionersrevealed that 87% struggled with lack of interest in sexual activity. 5 Yet, a 2004update of a 1999 survey found that only 8% of US women aged 45 to 49 years and12% of those aged 50 to 59 years had sought treatment from their personal physiciansfor a sexual problem. 6 Of particular note is the fact that the overall proportionof women who had sought treatment for sexual dysfunction from any healthprofessional remained consistent, at 10%, between the 1999 survey and the 2004update. 6 This finding suggests that little progress has been made in encouragingpatients to discuss such problems with their physicians.According to other studies, embarrassment is a key obstacle to patients’ abilityto broach the subject of sexual function with their physicians. 7 Apart from thepatients’ own embarrassment, a survey found that 68% of patients were actuallyafraid the physician would be embarrassed if they brought up sexual issues. 3 Ofinterest in this regard are data from a survey of nearly 2000 health care professionalswho cited embarrassment as a major obstacle to their initiating discussionsabout sexual health. 1 These providers also stated that limited time and trainingwere important barriers to their addressing sexual problems. Approximately 60%of respondents rated their knowledge and comfort level with the subject of FSDas only fair or poor.Identifying who should be screenedOvercoming obstacles to patient-provider communicationThe investigations described above suggest that directquestioning by physicians is often critical to uncoveringpatients’ concerns about sexual function. 1 Even ifthe patient offers information spontaneously, questionsinitiated by the physician will convey concern and letthe patient know that it is appropriate to discuss theseissues. 4Studies have demonstrated that training in communicationskills is the strongest predictor that a physicianwill take a sexual history. 8 Physicians should workon improving their communication abilities, both to putthemselves at ease and to put the patient at ease. 9 Table 1lists additional physician characteristics that patientsfind important in order to establish a comfortable discussionof sexual issues. 10 This information was obtained in asurvey of women receiving routine gynecologic care, 90%of whom stated that they believed these physician traitsmade it more comfortable for them to talk about sexualconcerns. 10Physicians’ concerns regarding the amount of timenecessary to address sexual disorders during the office visitare not well founded. 4 Indeed, just a few brief questions canallow the family physician to evaluate whether a woman isexperiencing sexual problems and should be screened forFSD (Table 2). 4,11,12Medical factors that should prompt screeningMany health-related conditions may be associated withthe development of sexual problems. Therefore, officevisits related to these circumstances provide vital opportunitiesto inquire about changes in sexual function. 11 Examplesof such situations include visits prior to surgeryfor uterine prolapse, hysterectomy, or oophorectomy;antenatal and postnatal visits; consultations regardinginfertility; and visits for the management of chronic conditionssuch as diabetes, renal failure, and coronary artery,cerebrovascular, neurological, or adrenal disease. 11,13The use of certain antidepressants (for instance, selectiveserotonin reuptake inhibitors), as well as depression itself,can lead to a decrease in sexual desire and subjectivearousal in women. 13 Other medications (for example,antihypertensives, antipsychotics, antiepileptics, antiandrogens,and narcotics) can also have such effects. 13Furthermore, in light of the fact that postmenopausalwomen embody a key population at increased risk ofFSD, the subject of sexual dysfunction should always beTable 1Physician characteristics that make it easierfor patients to discuss sexual concerns 10• Physician has seen the patient before• Physician knows the patient• Physician seems concerned about sexual wellness• Physician has professional demeanor• Physician appears comfortable• Physician seems kind and understandingTable 2Questions to prompt patients to discusssexual concerns 4,11,12• Are you currently involved in a sexual relationship?With men, women, or both?• How often do you engage in sexual activity?• Do you have difficulty with desire, genital or subjective arousal,or orgasm?• Are you satisfied with your current sexual relations?• Do you have any sexual concerns you would like to discuss?raised as a patient enters this crucial period. 11,14 Such aconversation can be initiated during a routine visit orduring a visit specifically dedicated to the management ofmenopause-related symptoms, including the discussionsof the pros and cons of hormonal therapy. 4Brief screening tools for FSD and HSDDOnce a woman has been identified as a candidate forFSD screening, she should be evaluated using formalscreening instruments. Several brief screening tools forFSD and HSDD are readily available for use in clinicalpractice (see examples listed in Table 3). 15-21 These validatedinstruments assess major categories of FSD, explorequantitative and qualitative aspects of the woman’ssexual experience, and evaluate past and current levelsof sexual desire. The screeners can often be self-administeredby the patient, are simple to understand, andtake little time to complete. For example, the DecreasedSexual Desire Screener (DSDS) was designed for use byclinicians with limited experience diagnosing HSDD. 17The DSDS, which is comprised of a series of questionsanswered by the patient and a multi-point question toassist the clinician with a diagnosis of HSDD, was recentlyvalidated for use in pre-, peri-, and postmenopausalwomen (Table 4). 17S22 July 2009 / Vol 58, No 7 / Supplement to The Journal of Family Practice Copyright © 2009 Dowden Health Media and DIME www.jfponline.comSupplement to The Journal of Family Practice / Vol 58, No 7 / July 2009 S23

Identifying HSDD in the family medicine settingTable 3Medical and psychosocial effects of diseaseon female sexual functionModality/Screening tool administration time DomainsFemale Sexual Self-report; Desire, arousal, lubrication, orgasm,Function Index 19 10-15 minutes satisfaction, painBrief Index of Self-report; Thoughts/desires, arousal, frequency of sexualSexual Functioning 15-20 minutes activity, receptivity, pleasure/orgasm, relationshipfor Women 21satisfaction, problems affecting sexualityBrief Profile of Female Self-report DesireSexual Function 20Decreased Sexual Self-report/ interview; DesireDesire Screener 17 15 minutesBrief HSDD Screener 18Self-report; 3-8 minutes DesireFemale Sexual Distress Self-report; DistressScale/Female Sexual 10-15 minutesDistress Scale–Revised 15,16Table 4Decreased Sexual Desire Screener 17Dear Patient,Please answer each of the following questions:1. In the past was your level of sexual desire or interest good and satisfying to you? Yes/No2. Has there been a decrease in your level of sexual desire or interest? Yes/No3. Are you bothered by your decreased level of sexual desire or interest? Yes/No4. Would you like your level of sexual desire or interest to increase? Yes/No5. Please check all the factors that you feel may be contributing to your current decrease in sexualdesire or interest:A. An operation, depression, injuries, or other medical condition qB. Medication, drugs, or alcohol you are currently taking qC. Pregnancy, recent childbirth, menopausal symptoms qD. Other sexual issues you may be having (pain, decreased arousal or orgasm) qE. Your partner’s sexual problems qF. Dissatisfaction with your relationship or partner qG. Stress or fatigue qClinicianVerify with the patient each of the answers she has given.The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision, characterizesHypoactive Sexual Desire Disorder (HSDD) as a deficiency or absence of sexual fantasies and desirefor sexual activity, which causes marked distress or interpersonal difficulty, and which is not betteraccounted for by a medical, substance-related, psychiatric, or other sexual condition. HSDD canbe either generalized (not limited to certain stimulation, situations, or partners) or situational, andcan be either acquired (develops only after a period of normal functioning) or lifelong.If the patient answers “NO” to any of the questions 1 through 4, then she does not qualify for thediagnosis of generalized acquired HSDD.If the patient answers “YES” to all of the questions 1 through 4, and your review confirms “NO” answersto all of the factors in question 5, then she does qualify for the diagnosis of generalized acquired HSDD.If the patient answers “YES” to all of the questions 1 through 4 and “YES” to any of the factorsin question 5, then decide if the answers to question 5 indicate a primary diagnosis other thangeneralized acquired HSDD. Co-morbid conditions such as arousal or orgasmic disorder do notrule out a concurrent diagnosis of HSDD.Based on the above, does the patient have generalized acquired HSDD?Yes/NoClayton AH, Goldfischer ER, Goldstein I, et al. Validation of the Decreased Sexual Desire Screener (DSDS): a brief diagnostic instrumentfor generalized acquired female hypoactive sexual desire disorder (HSDD). J Sex Med. 2009;6:730-738. Copyright © 2009 BlackwellPublishing Ltd. Reproduced with permission of Blackwell Publishing Ltd.Establishing a diagnosisIf screening tools suggest the presenceof FSD, a diagnosis can be establishedby evaluating the patient’spast medical history, undertaking acomprehensive sexual assessment,performing a physical examination,and conducting selected laboratorytests. 9,22 The medical history shouldinclude reproductive history andcurrent status; presence of any endocrine,neurologic, cardiovascular,or psychiatric disorders; and currentuse of prescription and over-thecountermedications. 9 The comprehensivesexual assessment shouldencompass inquiries aimed at identifyingthe components of the complaint.Essential questions to includein the sexual assessment are listed inTable 5. 23 The physical examinationshould include inspection of the externalgenitalia as well as mono- andbimanual examinations to check forconditions that may impair sexualfunction (such as vaginismus, vulvarvestibulitis, rectal disease, urinarytract infection, fibroids, endometriosis,and cysts, among others). 22,24Appropriate laboratory tests shouldbe ordered to check the patient’sthyroid function, liver function, lipidprofile, and fasting glucose level. 25 Ifa hormonal problem is suspected, assessmentof prolactin, total and freetestosterone, sex hormone–bindingglobulin, dihydroepiandrosterone,and estrogens may be warranted. 26Androgen levels in premenopausalwomen should be measured at thetime they peak (on days 8 through 10of the menstrual cycle).ConclusionLack of physician-patient communicationis a major contributor tothe underdiagnosis of sexual dysfunctionin women. Without properrecognition of these problems, women affectedby FSD remain untreated and experience adverseconsequences that undermine their relationshipsand quality of life. As primary careproviders, family physicians have numerous opportunitiesto screen women for various typesof FSD, including HSDD, and to implement appropriatestrategies for establishing a diagnosis.Candidates for FSD screening can be identifiedby overcoming obstacles to discussing sexual issuesand by maintaining an awareness of medicalfactors that can contribute to sexual dysfunction.Simple screening tools can determinewhich women should be further evaluated withmedical and sexual histories, physical examination,and laboratory tests to establish a diagnosis.Greater involvement of family physiciansin the detection of sexual dysfunctions such asHSDD will undoubtedly improve the lives of themany women who continue to experience theseproblems. nDisclosureDr. Kingsberg receives research grants from BioSante Pharmaceuticals,Boehringer Ingelheim Pharmaceuticals, Inc., and Procter& Gamble Pharmaceuticals; is a consultant for Boehringer IngelheimPharmaceuticals, Inc., and Wyeth; and is a speaker for EliLilly and Company and Johnson & Johnson.References1. Bachmann G. Female sexuality and sexual dysfunction:are we stuck on the learning curve? J SexMed. 2006;3:639-645.2. Laumann EO, Paik A, Rosen RC. Sexual dysfunctionin the United States: prevalence and predictors.JAMA. 1999;281:537-544.3. Marwick C. Survey says patients expect little physicianhelp on sex. JAMA. 1999;291:2173-2174.4. Kingsberg S. Just ask! Talking to patients aboutsexual function. Sexuality Reprod Menopause.2004;2:199-203.5. Nusbaum MR, Gamble G, Skinner B, et al. Thehigh prevalence of sexual concerns amongwomen seeking routine gynecological care. J FamPract. 2000;49:229-232.6. American Association of Retired Persons. Sexualityat Midlife and Beyond. 2004 Update of Attitudesand Behaviors. Washington, DC: AmericanAssociation of Retired Persons; 2005. http://assets.aarp/org/rgcenter/general/2004-sexuality.pdf. Accessed March 26. 2009.7. Goldstein I, Lines C, Pyke R, et al. National differencesin patient-clinician communication regardinghypoactive sexual desire disorder. J SexMed. 2009;6:1349-1357.8. Tsimtsiou Z, Hatzimouratidis K, NakopoulouE, et al. Predictors of physicians’ involvementin addressing sexual health issues. J Sex Med.2006;3:583-588.9. Kingsberg SA. Taking a sexual history. Obstet GynecolClin N Am. 2006;33:535-547.Table 5Essential questions to include in a sexual assessment 23• How does the patient understand or describe the problem?• How long has the problem been present?• Is the problem lifelong or acquired after a period of normal function?• Was the onset sudden or gradual?• Is the problem specific to a situation or partner or is it generalized?• Were there likely precipitating events (biological or situational)?• Are there problems in the patient’s primary sexual relationship(or any relationship in which the sexual problem is occurring)?• Are there current life stressors that might be contributing to sexual problems;and, if so, how is stress perceived and managed?• Is there some underlying guilt, depression, or anger that is notbeing directly acknowledged?• Are there physical problems, such as pain?• Are there problems with desire, arousal, or orgasm, and can the patient determinethe primary problem?• Is there a history of physical, emotional, or sexual abuse that maybe contributing?• Does the partner have any sexual problems?10. Risen CB. A guide to taking a sexual history. PsychiatrClin N Am. 1995;18:39-53.11. Basson R. Sexuality and sexual disorders. ClinUpdates Women’s Health Care. 2003;11:1-94.12. Nusbaum MR, Hamilton CD. The proactivesexual health history. Am Fam Physician.2002;66:1705-1712.13. Basson R, Shultz WW. Sexual sequelae of generalmedical disorders. Lancet. 2007;369:409-424.14. Dennerstein L, Randolph J, Taffe J, et al. Hormones,mood, sexuality, and the menopausaltransition. Fertil Steril. 2002;77(suppl 4):S42-S48.15. Derogatis LR, Rosen R, Leblum S, et al. The FemaleSexual Distress Scale (FSDS): initial validationof a standardized scale for assessment ofsexually related personal distress in women. JSex Martial Ther. 2002;28:317-320.16. Derogatis LR, Clayton A, Lewis-D’Agostino D,et al. Validation of the Female Sexual DistressScale–Revised for assessing distress in womenwith hypoactive sexual desire disorder. J SexMed. 2008;5:327-364.17. Clayton AH, Goldfischer ER, Goldstein I, etal. Validation of the Decreased Sexual DesireScreener (DSDS): a brief diagnostic instrumentfor generalized acquired female hypoactivesexual desire disorder (HSDD). J Sex Med.2009;6:730-738.18. Leiblum S, Symonds T, Moore J, et al. A methodologystudy to develop and validate a screenerfor hypoactive sexual desire disorder in postmenopausalwomen. J Sex Med. 2006;3:455-454.19. Rosen R, Brown C, Heiman J, et al. The FemaleSexual Function Index (FSFI): a multidimensionalself-report instrument for the assessmentof female sexual function. J Sex Marital Ther.2000;26:191-208.20. Rust J, Derogatis L, Rodenberg C, et al. Developmentand validation of a new screening tool forhypoactive sexual desire disorder: the Brief Profileof Female Sexual Function (B-PFSF). GynecolEndocrinol. 2007;23:638-644.21. Taylor JF, Rosen RC, Leiblum SR. Self-reportassessment of female sexual function: psychometricevaluation of the Brief Index of SexualFunctioning for Women. Arch Sex Behav.1994;23:627-643.22. Kingsberg SA, Janata JW. Female sexual disorders:assessment, diagnosis, and treatment. UrolClin N Am. 2007;34:497-506.23. Basson R. Eliciting the sexual concerns of yourpatient in primary care. Med Asp Human Sex.2000;1:11-18.24. Phillips NA. The clinical evaluation of dyspareunia.Int J Impot Res. 1998;10(suppl 2):S117-S120.25. Hatzichristou D, Rosen RC, Broderick G, et al.Clinical evaluation and management strategyfor sexual dysfunction in men and women. J SexMed. 2004;1:49-57.26. Meston CM, Bradford A. Sexual dysfunctions inwomen. Annu Rev Clin Psychol. 2007;3:233-256.S24 July 2009 / Vol 58, No 7 / Supplement to The Journal of Family Practice Copyright © 2009 Dowden Health Media and DIME www.jfponline.comSupplement to The Journal of Family Practice / Vol 58, No 7 / July 2009 S25

Supplement toOpportunities for interventionin HSDDJames A. Simon, MD,CCD, NCMP, FACOGClinical Professor of Obstetricsand GynecologyDivision of ReproductiveEndocrinology and InfertilityGeorge Washington UniversitySchool of MedicinePresident and Medical DirectorWomen’s Health & ResearchConsultantsGeorge Washington UniversityHospitalWashington, DCHypoactive sexual desire disorder (HSDD) is relatively common amongwomen and causes considerable distress as well as interpersonal difficulties.1,2 Nevertheless, many women with HSDD remain untreated becausethey are reluctant to discuss sexual issues with their physicians and have low expectationsconcerning the prospects for help. 3,4 Compounding this situation is thefact that clinicians frequently do not inquire about patients’ sexual health. 5 As primarycare providers, family physicians are in an excellent position to improve thecare of women with HSDD by adopting a proactive approach to identifying sexualconcerns and determining the best available courses of treatment. 6Deciding whether to treat or referOnce a patient has voiced concerns regarding sexual function, whether spontaneouslyor in response to direct questioning, the physician can make a decisionas to whether the problem should be addressed during the same visit, during afollow-up visit, or through referral to a specialist in sexual disorders. 7 The choiceof whether to treat the patient or refer her to a specialist will depend on the familyphysician’s level of comfort and experience in establishing a diagnosis andtreating the disorder. 7,8 Other factors that come into play are the complexity of theproblem and the availability of appropriate resources. 7,8 A recent survey of primarycare physicians found that the vast majority had little confidence in their abilitiesto diagnose HSDD, had not screened patients for HSDD, and had not prescribedmedication for HSDD. 5 The findings from this survey and similar studies indicatethat family physicians interested in pursuing additional medical education andtraining will have a vital opportunity to improve the care of women with HSDD. 5,9Indeed, family physicians who are prepared to discuss sexual dysfunction can domuch to advance the quality of life for these patients. In addition to providingmedical treatment, physicians can avail themselves of important opportunities toeducate patients concerning their problem.If the physician decides to refer the patient, a determination must be made asto the best types of experts to involve in the case. Options include medical professionalswho are experienced in the treatment of HSDD (such as some gynecologistsand other primary care practitioners) and mental health professionals whocan address the psychosocial aspects of the disorder (such as psychologists, psychiatrists,marriage or relationship counselors, and sex therapists). 7 The choicewill depend on the nature of the individual’s dysfunction as well as her interestand willingness in exploring specific forms of more focused treatment. 7 Even ifthe family physician chooses to assume responsibility for the patient’s medicalmanagement, consideration should be given to referralsfor nonpharmacologic interventions such as cognitivebehavioraltherapy. 7Nonpharmacologic interventionsRelatively few systematic trials of psychotherapy for HSDDhave been conducted, and varying levels of efficacy havebeen reported with both traditional sex therapy and cognitive-behavioraltherapy. 10 At least in part, these divergentresults likely stem from the heterogeneity of treatmentmethods and study designs, which has limited the comparabilityof results across studies. 11 Overall, the data gatheredthus far would seem to support the efficacy of cognitivebehavioraltreatment for HSDD. 12 Sex therapy typically involvescognitive-behavioral approaches, the goals of whichare to alter negative thoughts, attitudes, and behaviors.Often, modified sensate focus exercises are used wherebycouples initially engage in nonsexual touching and caressingand gradually transition to sexual touching and activity.However, sensate focus techniques appear to be lesseffective in treating HSDD than in treating sexual aversionand arousal disorders. 13 Whereas HSDD is characterizedby persistently or recurrently deficient (or absent) sexualfantasies and desire for sexual activity, female sexual aversiondisorder (FSAD) consists of persistent or recurrentextreme aversion to, and avoidance of, all (or almost all)genital sexual contact with a sexual partner. 1 Female sexualarousal disorder is defined as a persistent or recurrentinability to attain, or to maintain until completion of thesexual activity, an adequate lubrication-swelling responseof sexual excitement. 1Pharmacologic, hormonal,and alternative therapiesPharmacologic therapiesA wide range of pharmacologic agents have been evaluatedfor their efficacy in the treatment of HSDD. Some ofthese drugs have shown little potential for clinical use,whereas others have exhibited promise.Numerous investigations have examined whethervasoactive drugs used to treat erectile dysfunction in menmight also improve sexual function in women. 14 In general,studies of such agents (including phosphodiesterase inhibitorsand alprostadil) have produced negative results. Oneexception was a placebo-controlled trial in which sildenafilwas associated with significant benefits in postmenopausalwomen with FSAD who had normal (protocol-specified)levels of estradiol and free testosterone (or were receivingestrogen and/or androgen replacement therapy). 15However, sildenafil had no significantly positive effects onsexual function in a subgroup of women who had HSDD inaddition to FSAD. Another placebo-controlled study foundthat sildenafil significantly improved sexual function (particularlythe ability to achieve orgasm) in postmenopausalwomen with depression who had sexual dysfunctionrelated to therapy with selective serotonin reuptake inhibitors.16 Assessments of sustained-release bupropion inwomen with HSDD have revealed significant, albeit small,effects on some measures of sexual function but not others.14,17 Research focusing on dopaminergic drugs (such aslevodopa, pergolide, and apomorphine) has yielded mixedresults in women with HSDD. 18Flibanserin is another agent under investigation forHSDD. This agent is known to work on the central nervoussystem, acting as both a 5-HY1A serotonin receptoragonist and a 5-HY2A serotonin receptor antagonist.However, its specific mechanism of action remains understudy. A number of clinical trials are under way in premenopausalwomen with HSDD. 19Melanocortin receptor agonists have generated interestin the wake of studies demonstrating increased sexual responsivenessin both men and women. 14,20-22 One such agent,bremelanotide, had shown significant benefits with respectto desire and arousal success rates in postmenopausalwomen, although its effects in premenopausal women werecomparable to those of placebo. 23 The clinical developmentof bremelanotide for the treatment of sexual dysfunctionwas discontinued in 2007-2008 due to concerns about increasedblood pressure. 23 The clinical development programhas now been redirected toward potential use of the drug totreat hemorrhagic shock and prevent postsurgical organdysfunction. 23,24 However, the manufacturer is also initiatingstudies of a new melanocortin receptor agonist, PL-6983, foruse in sexual dysfunction. 23 Effects on blood pressure are believedto be less pronounced with this compound than withbremelanotide. 23 Other melanocortin receptor agonists arelikewise continuing to undergo evaluation.Hormonal therapiesEstrogen therapy improves vaginal dryness and pain,which may contribute to sexual problems in women withsurgical or natural menopause but does not directly affectsexual desire. 25 In contrast, a growing body of datahas demonstrated that exogenous testosterone improvesmany facets of sexual function, including arousability,S26 July 2009 / Vol 58, No 7 / Supplement to The Journal of Family Practice Copyright © 2009 Dowden Health Media www.jfponline.comSupplement to The Journal of Family Practice / Vol 58, No 7 / July 2009 S27

Opportunities for intervention in HSDDTable 1Current options for testosterone therapy in women with HSDDType of therapyCombination of oral esterified estrogensand methyltestosterone*Testosterone products approved forthe treatment of low testosteronedisorders in men (used off-label inwomen)Custom compounded products(eg, buccal therapy with testosteronelozenge)Comments*Manufacturer discontinued supplying product to US market in March 2009.HSDD, hypoactive sexual desire disorder.Table 2• Only for use in postmenopausal women• Available in various formulations (oral, intramuscularinjection, transdermal)• Doses must be adjusted downward for use in women,then titrated according to clinical responseNote: Appropriate doses have not been clearlyestablished for women with low sexual desire.• Requires availability of skilled compoundingpharmacist• Clinician must be knowledgeable andexperienced in this approachHerbal therapies and proposed mechanisms of action in femalesexual dysfunction 33TherapyGinkgo bilobaL-arginineDamiana leafGinsengProposed mechanism of actionIncreases blood flow by inhibiting platelet-activating factorRequired to produce nitric oxide; increases blood flowStimulates sexual desire; may have progestin-like actionPhytoestrogenic activity; increases blood flowdesire, fantasy, orgasm, and overall satisfaction. 26 Currently,no testosterone products are specifically approved bythe US Food and Drug Administration (FDA) for the treatmentof low sexual desire in women. However, some optionsare available, as listed in Table 1. At present, only oraltherapy is FDA approved for use in women (albeit not forthe treatment of sexual dysfunction). Transdermal testosteroneis being evaluated in clinical trials of women withsexual dysfunction. Some practitioners are treating suchwomen with transdermal testosterone products that areapproved by the FDA for various disorders in men; thesetherapies are being prescribed off label in women, withdoses adjusted as needed. Family physicians should familiarizethemselves with the treatments listed in Table 1 so asto evaluate potential advantages in specific patients.The beneficial effects of testosterone therapy haveprompted research into treatments designed specificallyfor HSDD or other forms of female sexual dysfunction(FSD). A wide range of formulations, including injections,implants, and tablets, have been studied, with varying results.27 In recent years, the most active area of developmentin the United States has involved transdermalformulations. A controlled trialof surgically menopausal women withHSDD who were receiving estrogen replacementtherapy found that the additionof a testosterone patch (delivering300 mcg/d) for 24 weeks significantlyincreased the frequency of episodes ofsexually satisfying activity (Figure). 28Furthermore, the testosterone groupexhibited a significant increase in sexualdesire and a significant decreasein distress. The risk of a patient experiencingat least one type of androgen–related adverse effect (eg, acne, alopecia,unwanted hair growth, or voicedeepening) was lower in the testosteronegroup than in the placebo group(12.7% vs 15.8%, respectively). Lipidprofiles were similar in the 2 groups.Other studies likewise documentedsignificant increases in the frequencyof satisfying sexual episodes, as wellas significant increases in desire anddecreases in distress, during 24 weeksof treatment with a testosterone patch(300 mcg) vs placebo in postmenopausalwomen with HSDD who werenot taking estrogen. 29 The overall incidence of androgenicadverse events was higher with the 300 mcg testosteronepatch than with placebo (30.0% vs 23.1%, respectively).Most of this difference was attributable to a significantlyhigher incidence of increased hair growth with testosterone300 mcg/d, compared with placebo (19.9 vs 10.5%, respectively).The frequency and severity of acne, alopecia,and voice deepening were similar between groups, andmost of these events were considered to be mild. However,various studies have produced conflicting data concerningthe safety of exogenous testosterone in women, and thelonger-term effects (including the potential impact on therisk of breast cancer) remain unknown. 27 Large-scale studiesof sufficient duration are needed to shed more light onthese issues.Studies have also documented benefits with transdermaltestosterone creams or gels. In a crossover trial ofpremenopausal women with diminished libido, a ≥50%increase in total sexual self-rating score was reported by46% of women with testosterone cream, compared with19% with placebo, after 12 weeks of treatment with eachstudy drug. 30 A testosterone gel for use in HSDD is currentlyin late stages of clinical development. 31,32Complementary and alternative therapiesSeveral forms of complementary and alternative medicine(CAM) have been used to treat FSD, including symptomsassociated with HSDD. Many herbal derivativesare based on traditional Chinese and Native Americanmedicine. 33 The mechanisms of action of these therapiesare largely unknown, although hypotheses have been advancedto explain their effects (Table 2). 33Only limited data are available concerning the effectivenessand long-term safety of most of these products inHSDD or other forms of FSD. In one of the few publishedreports (a randomized, placebo-controlled, double-blindtrial of women with sexual dysfunction secondary to antidepressanttherapy) improvements were observed withboth ginkgo biloba and placebo, but there were no significantdifferences between treatments. 34 A randomized,double-blind, crossover study of 24 women with sexualarousal disorder found significant improvements frombaseline with yohimbine (with or without L-arginine glutamate),but the effects were not significantly differentfrom those achieved with placebo. 35Other work has produced conflicting results concerningsupplementation with dehydroepiandrosterone(DHEA), which is produced in the adrenal gland and convertedto testosterone. In a 4-month, randomized study ofwomen with adrenal insufficiency, DHEA was associatedwith significant improvements in the frequency of sexualthoughts or fantasies, sexual interest, and sexual satisfaction.36 However, DHEA failed to produce significant improvementsin sexuality measures. 37-39 Commercial DHEAsupplements are sold over the counter.In addition, a variety of nonprescription oral andtopical commercial products are being marketed with theassertion that they can improve female sexual function.These products contain proprietary blends of herbal andother botanical ingredients as well as vitamins and minerals.33 A handful of studies have reported significant increasesin sexual desire and arousal with these treatments. Forinstance, a randomized, double-blind, placebo-controlledtrial found significant improvements in sexual arousal, desire,and pleasure with the use of an herbal topical cream. 40Another controlled study identified improvements in sexualdesire and other measures of sexual function with a nutritionalsupplement that supposedly enhances a woman’ssexual response by increasing blood flow and promotingrelaxation. 41 In the case of most commercial products, how-FigureChanges in 4-week frequency of scoresassociated with transdermal testosteronevs placeboA4 wk mean changefrom baselineBMean change frombaseline (SEM)CMean change from baseline3Total satisfying sexual activity2.521.510.500 4 8 12 16 20 24WeeksSexual desire141210864200 4 8 12 24WeeksPersonal distress0-5-10-15-20-25-300 4 8 12 24WeeksTestosteronePlaceboP≤.05 vs placeboChanges in 4-week frequency of total satisfying sexual activity, sexual desire score,and personal distress with transdermal testosterone vs placebo over 24 weeks.*P≤.05, transdermal testosterone vs placebo.Reprinted with permission from Simon JA, et al. Testosterone patch increases sexualactivity and desire in surgically menopausal women with hypoactive sexual desiredisorder. J Clin Endocrinol Metab. 2005;90:5226-5233.ever, few or no studies have been conducted, and existingdata have been neither peer reviewed nor published, leavingquestions regarding efficacy and safety unanswered. 33Physicians should be aware that an increasing numberof women are using alternative medicines, including productsthat claim to improve sexual response. 33,42 Notably,large-scale surveys have found that approximately 70% ofadults do not disclose the use of CAM to their physicians. 42S28 July 2009 / Vol 58, No 7 / Supplement to The Journal of Family Practice Copyright © 2009 Dowden Health Media and DIME www.jfponline.comSupplement to The Journal of Family Practice / Vol 58, No 7 / July 2009 S29

Opportunities for intervention in HSDDSupplement toIn light of the potential for adverse events or drug-druginteractions, physicians should specifically ask patientswhether they are taking herbal or other remedies.of HSDD through increased recognition of this disorderin women, application of existing forms of hormonal andnonpharmacologic therapies, and referrals to specialists. nConclusionNo therapies have yet been approved by the FDA for patientswith HSDD specifically, although many types of treatmentare currently under study and some (such as testosteronepatches and gels) are in advanced stages of development.Until such treatment becomes available, family physicianscan make strides toward improving the managementReferences1. American Psychiatric Association. Diagnosticand Statistical Manual of Mental Disorders. 4thedition, text revision. Washington, DC: AmericanPsychiatric Press; 2000.2. Lindau ST, Schumm LP, Laumann EO, et al. Astudy of sexuality and health among older adultsin the United States. N Engl J Med. 2007;357:762-774.3. Laumann EO, Paik A, Rosen RC. Sexual dysfunctionin the United States: prevalence and predictors.JAMA. 1999;281:537-544.4. Marwick C. Survey says patients expect little physicianhelp on sex. JAMA. 1999;291:2173-2174.5. Harsh V, McGarvey EL, Clayton AH. Physicianattitudes regarding hypoactive sexual desire disorderin a primary care clinic: a pilot study. J SexMed. 2008;5:640-645.6. Nusbaum MR, Gamble G, Skinner B, et al. Thehigh prevalence of sexual concerns amongwomen seeking routine gynecological care. J FamPract. 2000;49:229-232.7. Kingsberg S. Just ask! Talking to patients aboutsexual function. Sexuality Reprod Menopause.2004;2:199-203.8. Basson R. Sexuality and sexual disorders. ClinicalUpdates in Women’s Health Care. 2003;11:1-94.9. Bachmann G. Female sexuality and sexual dysfunction:are we stuck on the learning curve? J SexMed. 2006;3:639-645.10. Brotto LA. Psychologic-based desire and arousaldisorders: treatment strategies and outcome results.In: Goldstein I, Meston CM, Davis SR, et al,eds. Women’s Sexual Function and Dysfunction:Study, Diagnosis, and Treatment. New York: Taylor& Francis; 2006.11. Meston CM, Bradford A. Sexual dysfunctions inwomen. Annu Rev Clin Psychol. 2007;3:233-256.12. McCabe M. Evaluation of a cognitive behavioralprogram for people with sexual dysfunction. J SexMarital Ther. 2001;27:259-271.13. Carey JC. Disorders of sexual desire and arousal.Obstet Gynecol Clin N Am. 2006;33:549-564.14. Segraves RT. Management of hypoactive sexualdesire disorder. Adv Psychosom Med. 2008;29:23-32.15. Berman JR, Berman LA, Toler SM, et al. Safetyand efficacy of sildenafil citrate for the treatmentof female sexual arousal disorder: a double-blind,placebo-controlled study. J Urol. 2003;170:2333-2338.16. Nurnberg HG, Hensley PL, Heiman JR, et al.Sildenafil treatment of women with antidepressant-associatedsexual dysfunction. JAMA.2008;300:395-404.17. Segraves RT, Clayton A, Croft H, et al. Bupropionsustained release for the treatment of hypoactivesexual desire disorder in premenopausal women.J Clin Psychopharmacol. 2004;24:339-342.18. Segraves R, Woodard T. Female hypoactive sexualdesire disorder: history and current status. J SexMed. 2006;3:408-418.19. Goldfischer E, Pyke R, Miki J. The Rose study:placebo-controlled randomized withdrawal trialof flibanserin for hypoactive sexual desire disorderin premenopausal women. Sexologies.2008;17(suppl 1):S121.20. Diamond L. Co-administration of low dose intranasalPT-141, a melanocortin receptor agonist,and sildenafil to men with erectile dysfunctionresults in an enhanced erectile response. Urology.2005;65:755-759.21. Safarinejad MR. Evaluation of the safety and efficacyof bremelanotide, a melanocortin receptoragonist, in female subjects with arousal disorder:a double-blind placebo-controlled, fixed doserandomizedstudy. J Sex Med. 2008;5:887-897.22. Shadiack AM, Sharma SD, Earle DC, et al. Melanocortinsin the treatment of male and female sexualdysfunction. Curr Top Med Chem. 2007;7:1137-1144.23. PL-6983 is the new bremelanotide. BremelanotideBull. 2008;May 20:1-10. http://www.bremolanotide.com/bremelanotide-bulletin/index.php.Accessed April 2, 2009.24. Palatin Technologies, Inc. Bremelanotide fororgan protection and related indications. http://www.palatin.com/pdfs/bremelanotide.pdf.Accessed March 18, 2009.25. Simon JA. The role of testosterone in the treatmentof hypoactive sexual desire disorder inpostmenopausal women. Menopause Manage.2005;Nov/Dec:6-11, 32.26. Abdullah RT, Simon JA. Testosterone therapy inwomen: its role in the management of hypoactivesexual desire disorder. Int J Impotence Res.2007;19:458-463.27. Hubayter Z, Simon JA. Testosterone therapy forsexual dysfunction in postmenopausal women.Climacteric. 2008;11:181-191.28. Simon J, Braunstein G, Nachtigall L, et al. Testosteronepatch increases sexual activity and desirein surgically menopausal women with hypoactivesexual desire disorder. J Clin Endocrinol Metab.2005;90:5226-5233.29. Davis SR, Moreau M, Kroll R, et al. Testosteronefor low libido in postmenopausal women not takingestrogen. N Engl J Med. 2008;359:2005-2017.30. Goldstat R, Briganti E, Tran J, et al. Transdermaltestosterone therapy improves well-being, mood,and sexual function in premenopausal women.Menopause. 2003;10:390-398.31. Simon J. Testosterone gel (LibiGel) significantlyDisclosureDr. Simon receives research grants and/or is a consultant and/or speakerfor Allergan, Inc., Amgen, Inc., Ascend Therapeutics, Inc., Barr Pharmaceuticals,Inc., Bayer HealthCare Pharmaceuticals, BioSante Pharmaceuticals,Boehringer Ingelheim Pharmaceuticals, Inc., Concert Pharmaceuticals,Inc., Corcept Therapeutics, Inc., Depomed, Inc., FemmePharma GlobalHealthcare, Inc., GlaxoSmithKline, KV Pharmaceutical Co., Meditrina Pharmaceuticals,Inc., Merck & Co., Inc., Merrion Pharmaceuticals, Inc., Nanma/Tripharma/Trinity, Novartis Pharmaceuticals Corp., Novogyne Pharmaceuticals,Novo Nordisk A/S, Pear Tree Pharmaceuticals, Procter & Gamble Pharmaceuticals,QuatRx Pharmaceuticals Co., Roche, Schering-Plough Corp.,Sciele Pharma, Inc., Solvay Pharmaceuticals, Inc., Ther-Rx Corp., WarnerChilcott, and Wyeth.improves sexual function in surgically menopausalwomen in phase II study. Presented at:Annual Meeting of the International Society forthe Study of Women’s Sexual Health. Atlanta, GA;October 30, 2004.32. Simon JA. Efficacy and safety of testosterone therapy.Presented at: Annual Meeting of the InternationalSociety for the Study of Women’s SexualHealth. San Diego, CA; February 21, 2008.33. Jayne C. An evidence-based review of herbal therapiesfor the treatment of female sexual dysfunction.2005. http://www.femalesexualdysfunctiononline.org.Accessed March 10, 2009.34. Kang BJ, Lee SJ, Kim MD, et al. A placebocontrolled,double-blind trial of ginkgo biloba forantidepressant-induced sexual dysfunction. HumPsychopharmacol. 2002;17:279-284.35. Meston CM, Worcel M. The effects of yohimbineplus L-arginine glutamate on sexual arousal inpostmenopausal women with sexual arousal disorder.Arch Sex Behav. 2002;31323-332.36. Arlt W, Callies F, van Vlijmen JC, et al. Dehydroepiandrosteronereplacement in women with adrenalinsufficiency. N Engl J Med. 1999;341:1013-1020.37. Lovas K, Gebre-Medhin G, Trovik TS, et al. Replacementof dehydroepiandrosterone in adrenalfailure: no benefit for subjective health statusand sexuality in a 9-month, randomized, parallelgroup clinical trial. J Clin Endocrinol Metab.2003;88:1112-1128.38. Barnhart KT, Freeman E, Grisso JA, et al. The effectof dehydroepiandrosterone supplementationto symptomatic perimenopausal women onserum endocrine profiles, lipid parameters, andhealth-related quality of life. J Clin EndocrinolMetab. 999;84:3896-3902.39. Morales AJ, Haubrich RH, Hwang JY, et al. Theeffect of six months’ treatment with 100 mg dailydose of dehydroepiandrosterone (DHEA) on circulatingsex steroids, body composition and musclestrength in age advanced men and women.Clin Endocrinol. 1998;49:421-423.40. Ferguson DRM, Steidle CP, Singh GS, et al.Randomized, placebo-controlled, double-blind,cross-over design trial of the efficacy and safetyof Zestra for Women in women with and withoutfemale sexual arousal disorder. J Sex Marital Ther.2003;29(suppl 1):33-44.41. Ito TY, Trant AS, Polan ML. A double-blind placebo-controlledstudy of ArginMax, a nutritionalsupplement for enhancement of female sexualfunction. J Sex Martial Ther. 2001;27:541-549.42. Eisenberg DM. Advising patients who seek alternativemedical therapies. Ann Intern Med.1997;127:61-69.Case StudyChallenges in the identification andmanagement of HSDDSharon J. Parish, MDAssociate Professor of ClinicalMedicineDepartment of MedicineAlbert Einstein College ofMedicineDirector of PsychosocialTrainingDepartment of MedicineMontefiore Medical CenterBronx, New YorkA52-year-old woman, A.J., complains of mild vasomotor symptoms. She hashad some sleep disturbance and an increase in daytime fatigue. She notesthat she has been suffering from a depressed mood of increasing severityand frequency. On screening and then on direct questioning, she admits to a lackof sexual desire and a decrease in sexual arousal.EvaluationThe patient’s medical history reveals that she has been taking paroxetine for symptomsof depression for the past 4 years. Her depressive symptoms were well controlled;as noted, however, her depressive symptoms have recently recurred. Also,in the past few months her menstrual cycle has become increasingly irregular andhas been characterized by bothersome heavy bleeding. Otherwise her medicalhistory is unremarkable, without chronic or serious illness or surgical procedures.Her general physical examination is normal.Regarding her sexual history, A.J. reports that she first noticed a decrease insexual arousal 2 to 3 years previously, followed by a decrease in sexual desire. Intercoursehas become uncomfortable for her. She appears to have pain due toa reduction in vaginal lubrication. It is not clear whether this is the underlyingcause of her low desire. The patient’s problems with decreased sexual desire andarousal are causing her extreme distress. She has been married for 26 years andhas not experienced marked discord with her husband until recently, when hersexual difficulties began to create tension in the relationship.DiscussionThis case illustrates some of the challenges involved in establishing a diagnosisof female sexual dysfunction and, specifically, hypoactive sexual desire disorder(HSDD). Problems with sexual desire and arousal may indicate a primary diagnosisof HSDD or may occur secondary to factors such as poorly controlled depressivesymptoms, the manifestations of menopause, or the side effects of antidepressantmedications. 1-3 Moreover, declining estrogen levels beginning duringperimenopause may decrease vaginal lubrication and cause atrophy of vaginaltissue, which can result in discomfort during intercourse and can also reduce desire.4 Because of the complex interplay among many factors, it is not always possibleto clearly identify the “primary” disorder in a patient such as A.J. An importantS30 July 2009 / Vol 58, No 7 / Supplement to The Journal of Family Practice Copyright © 2009 Dowden Health Media and DIME www.jfponline.comSupplement to The Journal of Family Practice / Vol 58, No 7 / July 2009 S31

Case studyconsideration is that personal distress must be present toestablish a diagnosis of HSDD. 5,6The approach to management should address anyfactors that might be amenable to intervention, whetheror not they constitute the primary cause of the complaintof loss of sexual desire. In A.J.’s case, a consultation withher psychiatrist is in order to discuss the possible strategiesto lessen the potential impact of her depressive symptomsand antidepressant therapy on her sexual function.Her complaints of vasomotor symptoms and vaginaldryness suggest that she may benefit from systemic estrogentherapy to improve her sleep and reduce daytimefatigue and/or local estrogen therapy to decrease pain onintercourse by increasing vaginal lubrication. However,estrogen therapy does not directly affect sexual desire, sothe patient’s complaints of low desire may well persist. IfReferences1. Basson R, Berman J, Burnett A, et al. Report of theInternational Consensus Development Conferenceon Female Sexual Dysfunction: definitionsand classifications. J Urol. 2000;163:888-893.2. Bonierbale M, Lancon C, Tignol J. The ELIXIRstudy: evaluation of sexual dysfunction in 4,557depressed patients in France. Curr Med Res Opin.2003;19:1114-11224.3. Kennedy SH, Dickens SC, Eisfeld BS, et al.Sexual dysfunction before antidepressanttherapy in major depression. J Affect Disord.1999;56:2001-2008.4. Meston CM, Bradford A. Sexual dysfunctions inwomen. Annu Rev Clin Psychol. 2007;3:233-256.5. American Psychiatric Association. Diagnosticand Statistical Manual of Mental Disorders. 4thedition, text revision. Washington, DC: AmericanPsychiatric Press; 2000.6. Basson R, Schultz WW. Sexual sequelae of generalmedical disorders. Lancet. 2007;369:409-424.7. Simon J, Braunstein G, Nachtigall L, et al. Testosteronepatch increases sexual activity and desireso, a trial (off-label) of testosterone therapy may be appropriate,as testosterone treatment may be effective insignificantly increasing sexual desire and decreasing distressin naturally menopausal women with HSDD whenused concomitantly with estrogen replacement therapy. 7Testosterone therapy, in combination with estrogen, hasalso been shown to improve arousability, fantasy, orgasm,and overall sexual satisfaction in women with HSDD. 8 Arecent trial investigating the use of testosterone alone innaturally menopausal women with low desire has demonstratedmodest dose-dependent improvements in sexualsatisfaction with this therapy. 9 nDisclosureDr. Parish is a consultant for Boehringer Ingelheim Pharmaceuticals, Inc.,and Wyeth.in surgically menopausal women with hypoactivesexual desire disorder. J Clin Endocrinol Metab.2005;90:5226-5233.8. Abdullah RT, Simon JA. Testosterone therapy inwomen: its role in the management of hypoactivesexual desire disorder. Int J Impotence Res.2007;19:458-463.9. Davis SR, Moreau M, Kroll R, et al. Testosteronefor low libido in postmenopausal women nottaking estrogen. N Engl J Med. 2008;359:2005-2017.instructions forreceiving creditContinuing Education CreditThere are 2 optionsfor receiving credit:1. A diagnosis of hypoactivesexual desire disorder (HSDD)in women involves:a. Overlap with another femalesexual dysfunctionb. Personal distressc. Decreased androgen levelsd. Transition through menopause2. Unlike HSDD, female sexualaversion disorder involves:a. Avoidance of all or almost allgenital sexual contactb. Inability to attain an adequatelubrication responsec. Personal distressd. Absence of sexual fantasies3. The prevalence of HSDD:a. Has been decreasing in recent years,according to epidemiologic studiesb. Has generally been reportedas 50 years old4. The PRESIDE study showed that themost common sexual complaintamong US women is:a. Low sexual desireb. Lack of sexual arousalc. Failure to achieve orgasmd. Erectile dysfunction in partnerOption 1:The DIME online enrollment systema. Please visit the url:www.DIMedEd.org/updates/HSDDFamilyPractice.htmlb. Complete the enrollment form,posttest, and evaluation.c. Successful completion of the selfassessmentis required to earnCategory 1 CME credit. SuccessfulPlease Circle or check the correct answer to each question.Release date: July 15, 2009Expiration date: July 15, 2010CME Posttest5. Survey data have revealed thatthe identification of female sexualdysfunction is hampered by:a. The rarity of these conditionsb. A lack of simple screening toolsc. Patient concerns that the physicianwill be embarrassedd. The reluctance of physicians torefer patients to specialists6. Which of the followingphysician characteristics was citedas increasing patient comfort indiscussing sexual issues,according to 90% of womensurveyed?a. Number of years in clinical practiceb. Solo vs group practicec. Having seen the patient befored. Never having seen the patient before7. Which of the following medicalsituations should prompt screeningfor female sexual problems?a. Diagnosis of diabetesb. Early postnatal periodc. Presence of adrenal diseased. All of the above8. A recent survey found that thevast majority of family physiciansscreen their female patientsfor HSDD.a. Trueb. Falsecompletion is defined as a cumulativescore of at least 70% correct. If youreceive a passing score, your certificateof credit will be made available to youimmediately.If you have difficulty accessing thelink, please contact the DIME officeat (312) 553-8000 or dimeservices@DIMedEd.orgOption 2:Complete this enrollment form,posttest, and evaluation form andmail them to:DIME 17771222 Merchandise Mart PlazaSuite 4-160Chicago, IL 60654A certificate of credit will be e-mailedor mailed to you within 6 weeks.Estimated time to complete activity: 1.25 hours9. Studies of pharmacologictherapies for HSDD haveshown that:a. Drugs used to treat erectiledysfunction in men are consistentlyeffective in womenb. Bupropion improves all measuresof sexual functionc. Dopaminergic agents providethe greatest efficacyd. None of the above10. Which of the followingstatements is not true?a. Data have confirmed thattransdermal testosterone improvessymptoms of HSDDb. Estrogens have a greater impacton female sexual function thando androgensc. Studies of dehydroepiandrosteronein women with HSDD have yieldedconflicting resultsd. More data are needed todetermine whether flibanserin iseffective in women with HSDDS32 July 2009 / Vol 58, No 7 / Supplement to The Journal of Family Practice Copyright © 2009 Dowden Health Media and DIME www.jfponline.comSupplement to The Journal of Family Practice / Vol 58, No 7 / July 2009 S33

Supplement toinstructions forreceiving creditContinuing Education CreditThere are 2 optionsfor receiving credit:Option 1:The DIME online enrollment systema. Please visit the url:www.DIMedEd.org/updates/HSDDFamilyPractice.htmlb. Complete the enrollment form,posttest, and evaluation.c. Successful completion of the selfassessmentis required to earnCategory 1 CME credit. Successfulcompletion is defined as a cumulativescore of at least 70% correct. If youreceive a passing score, your certificateof credit will be made available to youimmediately.If you have difficulty accessing thelink, please contact the DIME officeat (312) 553-8000 or dimeservices@DIMedEd.orgOption 2:Complete this enrollment form,posttest, and evaluation form andmail them to:DIME 17771222 Merchandise Mart PlazaSuite 4-160Chicago, IL 60654A certificate of credit will be e-mailedor mailed to you within 6 weeks.EDUCATIONAL OUTCOMESQUESTIONSRelease date: July 15, 2009Expiration date: July 15, 2010Estimated time to complete activity: 1.25 hoursEvaluation questionsPlease answer to the best of your ability. These questions are not graded and your answers will NOT affect your CME credit.1. In prevalence studies of sexual dysfunction, whichof the following is the most common sexual complaintreported by women?a. Orgasm difficulties c. Low sexual desireb. Low sexual arousal d. Pain with intercourse2. A 57-year-old woman presents for a new patient visitand examination. She stopped menstruating at age 51and received combination estrogen/progestin therapyfor several years to alleviate vasomotor symptoms butdiscontinued use. She reports no significant medicalhistory. On the patient intake checklist she notedpain during intercourse and, upon questioning,reports a progressive decrease in sexual desire sincethe menopause transition. Her husband complainsabout her lack of desire; however, she is satisfied withher current sexual activity and does not feel that itnegatively affects her relationship. What would beyour diagnosis for this patient?a. Dyspareunia c. Sexual aversion disorderb. Situational hypoactive d. Generalized HSDDsexual desire disorder(HSDD)3. What treatment strategy would you select for thispatient?a. Administer compounded testosterone to increase sexualdesireb. Administer local estrogen to relieve pain during intercoursec. Administer systemic estrogen to relieve pain duringintercourse and increase desired. Refer to a sex therapist4. A wide range of pharmacologic agents have beenevaluated for their efficacy in the treatment of HSDD.Which of the following mechanisms of action has notbeen investigated for the treatment of HSDD?a. Testosterone formulationsb. 5-HY1A serotonin receptor agonist/5-HT2A serotoninreceptor antagonistc. Melanocortin receptor agonistd. Serotonin-noradrenaline reuptake inhibitorLast nameFirst name, InitialAcademic TitleAffiliationSpecialtyStreet or PO BoxCityStatEPhoneFaxe-mailENROLLMENT FORMREQUEST FOR CREDIT (PLEASE PRINT)degree(s)Zip CodeTo receive the information you are requesting, please make certain your contactinformation is legible.Overall Enduring MaterialEvaluation5=Excellent, 4=Good, 3=Satisfactory,2=Fair, 1=PoorUsing the above scale, please evaluatethis activity by marking the appropriateresponse.1. Objectivity and balance5 4 3 2 12. Did you perceive any bias orcommercialism in this activity towardany product or drug?n Yes3. Scientific rigorn No If Yes, please explain5 4 3 2 14. Amount of information presented5 4 3 2 15. Level of instruction5 4 3 2 1Learning Objectives5=Strongly agree, 4=Agree, 3=Neutral,2=Disagree, 1=Strongly disagreeUsing the above scale, indicate whether aftercompleting this activity you are better able to:6. Define HSDD and identify thefactors associated with it or thatmay contribute to it.5 4 3 2 17. Describe the steps required fortaking a thorough and clinicallypertinent sexual history.5 4 3 2 18. Explain how to screen patients forHSDD, how to identify and diagnosepatients at risk for HSDD, and how torefer them to appropriate resources.5 4 3 2 19. Identify interventions andpharmacologic treatments forHSDD and provide evidence of theireffectiveness.5 4 3 2 110. Discuss patient and providerobstacles to the recognition andmanagement of HSDD and identifystrategies for overcoming thesebarriers.5 4 3 2 1Reason for Participation5=Extremely, 4=Very, 3=Somewhat,2=Not very, 1=Not at allUsing the above scale, indicate how importantthe following reasons are for your participationin educational activities.11. Topics5 4 3 2 112. Faculty/editor’s reputation5 4 3 2 113. CME credit5 4 3 2 114. As a result of participating in thisactivity, did you learn anything thatwould cause you to make a changein your clinical practice (chooseonly one)?■ Yes, I am going to try toincorporate some of the informationpresented into my clinical practice■ No, I am not going toincorporate any of the informationinto my clinical practice15. If yes, how soon do you intend toincorporate changes in your practice asa result of this CME activity?■ Immediately■ In 1 month■ In 3 months■ In 6 months■ I do not know16. If no, why not?■ I learned some new information,but the information presented is notapplicable to my clinical practice■ The information presented confirmedmy current clinical practice■ I did not find the informationuseful and I will not change mycurrent clinical practice■ I do not know17. Please indicate whether you wouldrecommend this activity to others.■ Yes■ No18. Please rate your interest in the followingeducational topics for HSDD from 5(highest interest) to 1 (lowest interest):___ Definitions of FSD___ Emerging treatment strategiesfor HSDD___ Psychosocial aspects of FSD___ Diagnosing HSDD___ Referral strategies for FSD___ Screening tools for FSD___ Available treatments for HSDD___ Etiology of FSD/HSDD___ Approaches to taking a sexual history19. Additional comments:S34 July 2009 / Vol 58, No 7 / Supplement to The Journal of Family Practice Copyright © 2009 Dowden Health Media and DIME www.jfponline.comSupplement to The Journal of Family Practice / Vol 58, No 7 / July 2009 S35

Supplement toAvailable at www.jfponline.com Vol 58, No 7 / July 2009