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

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