Distress and Sexual Health

Female Sexual Dysfunction includes disorders of desire; arousal; orgasm and sexual pain. Desire disorders include hypoactive sexual desire disorder and sexual aversion disorder. To make the diagnosis of Hypoactive Sexual Desire Disorder two key elements must be in place (hypoactive sexual desire and marked distress - personally or interpersonally as a result of the condition) Additionally, we exclude depressed desire that is due to medications, substances or general medical conditions or those due to another Axis I disorder.
How prevalent a problem is this? Research tells us that there is a range 9-26% and a mean of about 10% of women with HSDD.(Leiblum)- this include premenopausal and postmenopausal women.
Is this an isolated sexual health concern? No - data shows that women with HSDD are generally less healthy than their non-HSDD counterparts. They have less vitality, more bodily pain, poorer physical, social, emotional functioning. It is likely that women will come into the office with diffuse feelings of body aches and feeling unwell as part of their presentation. Sexual health affects both the physiology and psychology of women.

What's the physiology of sexual function in women? The physiology is that of central neuroendrocrine function matched with peripheral intact anatomic and vascular function. Centrally - Desire is augmented by excitation that is driven by dopamine, norepinephrine, testosterone, estrogen and inhibited by serotonin and prolactin. Arousal adds nitric oxide and acetycholine with the above factors and has the same inhibitory ones. Orgasm has oxytocin as an excitatory hormone. External genitalia needs estrogen, testosterone and progestin to function. Vasocongestion needs working and responsive vasculature- thus nitric oxide, norepinephrine, cholinergic fibers and prostaglandin E are excitatory with serotinin as inhibitory.
How do these factors play a role in diagnosis and interventions? Anything that decreases dopamine (or increases serotinin) will have adverse sexual side effects. Anything that lowers testosterone - like hyperprolactinemia, opiates or menopause - will also lower sexual functioning.
What diseases can decrease desire or arousal? Chronic diseases such as Diabetes, Thyroid disease, Cardiovascular Disease, Depression and Renal Failure. Other illnesses - adrenal disease, head injury, neurologic diseases including hyperprolactinemia, bilateral oophorectomy and incontinence can do so as well. (Basson)

What medication or substances adversely effect sexual health? Perhaps most well known are antidepressants that block reuptake of serotinin (SSRIs; SNRIs) Other psychiatric medicines such as benzodiazepines; antipsychotics; mood stabilizers and anti epileptics can do so. Less well known, perhaps, are H2 blockers, NSAIDs, oral contraceptive, thiazide diuretics, non-selective beta agonists. Additionally narcotics and other hormones (estrogen, progestins, anti androgens, GnRH agonists) are involved (Clayton, Kingsberg.) It is important, up front, when we prescribe these medications to make patients aware of the potential side effect!
How do I screen? If you wait for most women to ask about this, there are numerous reasons why they won't ("It is appropriate to talk to the doctor about this?" "How do I discuss this?""Maybe there isn't anything I can do?") The literature shows that docs have to ask and patients want us to. (Stengel) In the ideal, we should include sexual health screening at least on annual exams. There are  tools and surveys you can use: Brief Sexual Symptoms Checklist for Women (Hatzichristou); Decreased Sexual Desire Screener (Clayton); Female Sexual Distress Scale - Revised (DeRogatis)

What can we do about it? First off, sexual health tracks with physical health. So many of the same lifestyle issues we discuss (regular exercise, healthy nutrition, weight loss, smoking cessation, minimizing intake of alcohol) all help sexual health. There are some medications that are used - though none currently FDA approved (and there others in the pipeline to watch for) but most patients are likely to benefit from counseling (education, personal, couples, cognitive behavioral, mindfulness, etc.), lifestyle changes and medication.

The most commonly used medication is bupropion (which increases dopamine and NE)- which is used for non-depressed women with HSDD (it can also be used with depressed women, as well) Testosterone has been used - and a gel is in the pipeline. A melanocortin receptor agonist (this stimulates dopamine) is also in the pipeline.

It seems odd that few people would perceive erectile dysfunction (and associated distress) as 'not real' or not a significant health concern, yet there are those who feel that female sexual dysfunction is somehow different. Women may be more complex, physiologically and psychologically when it comes to sexual health. Remember, if a woman with diminished desire isn't bothered by it, then neither are we! But for many women, sexual health is part of overall health. Physicians need to learn about this health issue, develop skills in communication about sexual health and ask patients on a regular basis. By doing this, we can uncover health concerns that may appear to be 'playing in the background' - yet are the health burden at the heart of the problem.

RESOURCES
Leiblum SR, et al. Menopause. 2006;13:46-56.
Basson R, Schultz WW. Lancet. 2007;369:409-424.
Clayton A, Hamilton D. Psychiatr Clin N Am. 2010;33:323-338.
Kingsberg S, Janata J. Urol Clin N Am. 2007;34:497-506.
Stengel C. Martinez L. http://twshf.org/survey.html. Accessed August 2010.
Hatzichristou D, et al. J Sex Med. 2010;7:337-348
Clayton A, et al. J Sex Med. 2009;6:730-738
DeRogatis L, et al. J Sex Med. 2008;5:357-364