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

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