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?