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Sunday, September 19, 2010

Striving for Samantha? Limited Treatment Options for Women With Low Libido

Lack of sexual interest is the most common sexual complaint in women. The latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), which defines psychiatric disorders, defines Hypoactive Sexual Desire Disorder (HSDD) as ‘‘persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity’’ that causes ‘‘marked distress or interpersonal difficulty.’’ Epidemiologic surveys have suggested that from 25 to 50 percent of women report prolonged periods of reduced sexual interest. A lesser but still significant number, on the order of 7 to 15 percent, may meet criteria for HSDD, where loss of sexual interest results in significant distress, and cannot be explained by a co-morbid medical or psychiatric condition, medication side effect, or substance abuse. As a clinician who cares for women I can attest for the common nature of this complaint, and feel frustrated by the lack of therapeutic options.

In June 2010 an FDA advisory board recommended against approval of Filbanserin, the latest drug developed to treat women with decreased libido. Its reason for rejection was the perceived low efficacy of the drug paired with an unacceptably high rate of side effects including dizziness, nausea and fatigue in female users. Data from trials of Filbanserin given to women with HSDD had shown promise, with a reported increased number of “sexually satisfying events” experienced by women who took the drug. The advisory board’s recommendation against approval was disappointing news to women and the physicians who treat them.

Wouldn’t it be great if there were a female Viagra? In fact Pfizer did study the use of Viagra to treat sexual dysfunction in women. However, it was found to be ineffective. The testosterone patch is another option with demonstrated efficacy that has been rejected by the FDA because of safety concerns. These patches are widely available in Europe and have been found to be effective in surgically menopausal women with reduced libido. Unfortunately, their use has been associated with increased risk of breast cancer. Incidentally, testosterone use in men has also been found to have safety concerns and is associated with increased risk of cardiovascular events based on a recent trial published in the New England Journal of Medicine.

Topical estrogen therapy, which treats vaginal dryness and atrophy in post-menopausal women, can be useful for those who experience dysparunia (pain with intercourse). Making things more comfortable certainly can help with sexual desire. However, other than this, doctors are left recommending behavioral solutions and sexual therapy for our female patients to enhance sexual interest, as their eyes glaze over--light a candle, play some music, set aside time for romance and cuddling. Not to make light of relationship and lifestyle contributors, but I wonder what a man would say if I prescribed this for his erectile dysfunction?

Why are options for women so limited? Part of the reason may be because the diagnosis of Hypoactive Sexual Desire Disorder encompasses a multi-factorial array of variables that many are skeptical about addressing with a single drug, unlike male sexuality , I suppose, which is seen as a matter of simple mechanics. Experts in the field note problems with the way that HSDD is defined and revisions to the diagnostic criteria have been proposed for the next version of DSM.

Sexual complaints are common within our culture, however they present differently in men and women. Men complain more about function and women complain more about desire. Disinterest in sex that creates distress in one person may not create distress in another. Is the current paucity of options to treat sexual dysfunction in women related to our cultural notions of appropriate sexuality? Do we really believe that women who complain of decreased libido are hysterical or neurotic? Or, that their complex and ethereal nature can’t be helped by a single drug in the same way that men with a simple mechanical issue can? Or, are we over-medicalizing normal gender differences in sexuality, applying an artificial label “HSDD,” which further pressures women to feel as though they should fantasize and desire sex in the same way as men do. Or, in contrast, have we made a cultural determination that sexuality is not as important to a maturing woman’s well-being as it is to a man’s, and for this reason have we failed to push for solutions that might carry risks that we deem outweigh the less important benefit of promoting sexual desire in women? I don’t know the answers to these questions, but they are interesting to ponder. The discussion calls to mind the character of 50-something Samantha from Sex in The City. With her healthy libido, is Samantha the woman that women want to be? Or, is she the woman that men want us to be? Or, is she the woman that scares us? Or, is she simply a fantasy?

Monday, September 6, 2010

What I Learned from Asthma

As a kid I had allergies and asthma. Because of this, for several years, my mother wrote a note excusing me from the 600 meter run in elementary school. My father took me to weekly allergy shots. At times I had eczema on my forearms and eyes, and according to my allergist, whose notes I later read, I had moderate allergic shiners (also known as dark circles under my eyes). My allergies led to frequent nosebleeds, which got me sent to the nurse’s office in school. Some nose bleeds were bad enough so that I was sent home from school. For years I was in and out of doctors’ offices frequently, when my attacks were severe enough to require treatment with epinephrine injections to afford me some relief. Otherwise, I remained perpetually wired on a daily cocktail of theophylline, Dimetapp, and an occasional albuterol tablet. Despite all of this I tried hard not to be a complete dweeb.

I remember the doctors wanting to put me on oral steroids, which my parents refused. Maybe we were “difficult” patients. My parents were concerned about the long term toxicity of steroids, particularly the possibility of stunting my growth. Perhaps they thought I had a career ahead of me in professional basketball (I am now 5 foot 10 inches). We learned that I frequently would require a course of antibiotics after I became sick with a virus. As doctors became more cautious to avoid antibiotic overuse, our insight about this frequently met some resistance by those who were not familiar with me.

When I was thirteen I was admitted to Mott Children’s Hospital in Ann Arbor, Michigan. I shared a room with two other girls, one from the Upper Peninsula of Michigan, who had some sort of intestinal issue that had required her to have multiple surgeries and hospitalizations. The girl in the bed across from me had anorexia. I remember overhearing intense discussions with her parents and being perplexed about all the talk of food. My illness seemed pretty minor in comparison.

Asthma therapy has changed a lot since the 70s and early 80s, but some of the experiences of being a patient and having a long term health condition remain the same. It was my good fortune to have had an illness that, for the most part, has resolved. Although, it still seems that I am allergic to most living things with fur, much to my children’s dismay. After spending a year living in Brazil and going through a late puberty, in high school I stopped my allergy shots and discontinued most of my medication.

Asthma has played a minimal role in my adult life. Only occasionally do I use my albuterol inhaler before I run. However, having had this illness experience has taught me a few things about caring for patients, and likely contributed to my decision to become a doctor. As a child I remember feeling guilty about my allergies, as if somehow they were volitional, or that I was deliberately trying to get attention by inventing health issues that excused me from participating in various kids’ activities. In retrospect, I am glad that my parents were” difficult” at times, refusing steroids and insisting on the antibiotics that they learned from experience would help make me well.

Here are some of the lessons that I learned:

1. People with chronic illness may feel guilty about the social effects of their illness.

2. People with chronic illness may feel that they are to blame for their illness.

3. Our current culture of personal responsibility may not be helping those with chronic illness with these perceptions, and may lead to increased depression and social isolation in those who have chronic illness.

4. Difficult patients should be listened to and usually bring up valid points.

5. Allergies are not volitional.

6. Patients with chronic illness frequently understand their health conditions better than doctors do.

7. Chronic illness care is more effective in the context of a long term collaborative relationship with one’s personal physician.

8. Family pets are hard to get rid of.

Wednesday, September 1, 2010

Continuity of Care, Lost in the Shuffle

Guest post by Kreton Mavromatis, MD, FACC, Director of Cardiac Catheterization Laboratory, Atlanta VA Medical Center, Emory University

As I entered the clinic room I saw my patient for the first time, an elderly man, slumped in his wheelchair, thin, breathing rapidly, appearing tired both physically and mentally. I wished that I had seen him before. How long had he been this way? Had he been getting worse in the last week? The last day? The last few hours? What was his attitude towards his illness? At his advanced age, how hard did he want to fight to live, to feel better? How much medical and/or surgical treatment was he willing to endure?

It was not the first time I knew of my patient. I had spoken extensively with his referring physician about his heart failure, his other medical problems, and his attitudes. Yet, despite my in depth conversation with another experienced and caring physician, I still had so many questions. If only I had had a relationship with my patient before he became so threateningly ill.

Continuity of care is “the process by which the patient and the physician are cooperatively involved in ongoing health care management toward the goal of high quality, cost-effective medical care.” In today’s healthcare systems, physicians recognize it as a single physician caring for a single patient over time. Yet in today’s healthcare systems, this has been greatly lost. From part-time ambulatory care physicians only available certain days of the week, to groups of obstetricians who have a call system where one physician covers all the others on nights and weekends, to residents whose work-hour limits force them to turnover care to another resident, continuity of care is being destroyed. And it cannot be entirely replaced by careful “sign-outs” and EMRs.

Part of the practice of medicine is a “science.” Much can be communicated in the form of words and numbers describing symptoms, physical exam findings and test results. Yes, I knew my patient was short of breath a week ago when my referring physician had last seen him. But was he short of breath at rest and was he tachypnic? What was his respiratory rate? Was he using any of his accessory muscles to breath? Was he using inter-costal muscles, or just the diaphragm? For each symptom, each physical exam finding, each test result, multiple descriptors could be used to enhance the total clinical picture of a patient. As physicians, we note many of these consciously. But all the details are rarely documented in their entirety in our notes, as doing so would not be “time-efficient.” Furthermore, even with EMRs, these details cannot be conveyed in a practical and timely manner from physician to physician.

Part of the practice of medicine is an “art.” How stoic is a patient? How fearful? How much denial does the patient have? How much fatigue is the patient experiencing? What is the patient’s attitude toward his or her current illness and treatment in the context of his or her current life? Experienced physicians can recognize the answer to these questions through repeated encounters with patients and their families, encounters which involve conversation, the assessment of the body language and facial expressions. However, expressing it verbally to another physician in a detailed qualitatitive and quantitative way is rarely possible.

The evolution of our health care system has resulted in fantastic advances in health care delivery. The use of specialists, with their knowledge of large amounts of complex information and technology, has led to the better treatment of certain individual diseases. Work-hour restrictions have reduced physician fatigue as a source of medical errors, and led to a better quality-of-life for healthcare providers. Increased physician documentation requirements have resulted in data collection that can be analyzed for the purpose of quality improvement. Yet these same “advances” are destroying continuity-of-care, and the single doctor-patient relationship over time, which I believe is so essential to the highest quality of medical care. A new emphasis on preserving and revitalizing continuity of care must be made as our healthcare system continues to evolve.