Unveiling Sexual Dysfunction: Clinicians Can Do More

AURORA, Colorado — Do you ask your patients about their sexual health? Many providers do not broach the topic — whether because they lack the time, feel awkward, or their patients have other, more pressing concerns to discuss.

Yet nearly half of women experience some form of sexual dysfunction, such as low sex drive, pain during sex (dyspareunia), or trouble reaching orgasm. When dysfunction is paired with significant distress, the condition is called hypoactive sexual desire disorder (HSDD).

At the 2023 annual meeting of the Society of General Internal Medicine, experts said patients want to talk about these problems, but they need their physicians to be ready for the conversation.

Hannah Abumusa, MD, clinical instructor of medicine at the University of Pittsburgh Medical Center, recommended implementing the "5As" framework.

Ask. Start by asking patients if they would be comfortable with you posing a few questions about their sexual health.
Advise. Make sure your patient knows many women struggle with the problem they have raised.
Assess. Ask a set of standardized assessment questions.
Assist. Tell your patient about treatment options.
Arrange. Arrange a follow-up visit to see if treatment has been effective.

Kathryn Leyens, MD, admitted she does not discuss sexual health enough with her patients, although she believes the topic is important.

"If it's brought up, I'm comfortable talking about it," said Leyens, a clinical assistant professor of medicine at the University of Pittsburgh. "But I think it's something that I could initiate more often."

The 5As framework offers a helpful way to initiate those conversations, she said.

Medications Might Be To Blame

Holly Thomas, MD, an assistant professor of medicine at the University of Pittsburgh, first conducts a medication review when discussing low sexual desire with her patients.

"There are definitely medications that we commonly use in primary care that can have negative effects on sexual function," Thomas said. "But we're not always the best at talking with patients about these things, and I think sometimes patients get the message that they should deprioritize their sex lives to their medication needs."

For example, sexual dysfunction is a common side effect of antidepressants, with paroxetine, fluvoxamine, sertraline, and fluoxetine carrying the highest frequency of this reported effect. Beta-blockers are also known to cause sexual dysfunction in women.

Pharmacologic Options

Once clinicians conduct a medication review, they can discuss treatment options with patients, which can range from prescription drugs to therapy.

Several medications have been shown in clinical trials to increase sexual desire in women. Flibanserin (Addyi), a once-daily pill, boosted libido in about half of women who used the drug in studies leading to its approval by the US Food and Drug Administration (FDA) in 2015.

The most common adverse effects reported in clinical trials included dizziness, syncope, and somnolence, which occurred in roughly 12% of users. The FDA recommends people avoid alcohol 2 hours before and after taking the drug.

Bremelanotide (Vyleesi) is an on-demand medication, like sildenafil for men, which in trials led to modest increases in desire among 25% of women who took the drug. About 40% of users reported experiencing nausea. Hyperpigmentation can also be a side effect, which in rare cases can be permanent, Thomas said. Patients can use a maximum of eight doses per month of the drug.

Testosterone serves as an off-label treatment, as the FDA has not approved the hormone for women. Adverse effects can include acne and weight gain. Data on the safety of its use past 2 years are scarce.

"But up until then, there's pretty strong evidence for the efficacy and safety of testosterone for treatment of hypoactive sexual desire disorder in women," Thomas said.

Hormone replacement therapy is another potential treatment option, which could include estrogen plus progesterone.

"It's not FDA-approved for HSDD, but if you're using it for other menopausal symptoms, it's likely to improve sexual function with small to moderate effect sizes," she said.

Bupropion (multiple brands) is a cost-effective option also prescribed for depression, Thomas said. A recently published systematic review provided further data to support the efficacy of the drug.

"That's something that a lot of us are very familiar with and maybe more comfortable prescribing if we're less familiar with some of the newer options," she said.

Nonpharmacologic Interventions

Thomas encouraged clinicians to consider nonpharmacologic approaches, too, such as referring patients to sex therapists.

"There's something called 'sensate focus,' which is a type of sex therapy that's been around for decades, but it's still very effective," Thomas said.

Cognitive behavioral therapy (CBT) is another option, she said. A systematic review published in 2022 showed CBT was an effective tool for treating HSDD, although Thomas noted the evidence is limited.

A newer treatment gaining traction is mindfulness meditation, often provided by therapists, which focuses on present moment and nonjudgmental bodily awareness. Thomas recommended referring patients to educational literature such as Better Sex Through Mindfulness: How Women Can Cultivate Desire by Lori Brotto (Greystone Books, 2018). The book also comes with a workbook.

"This has actually been shown in multiple trials to be effective for the treatment of low sexual desire with moderate to large effect sizes," she said.

Abumusa, Leyens, and Thomas report no relevant financial relationships.

2023 Society of General Internal Medicine Annual Meeting. Presented May 11, 2023.

Kelly Ragan is a journalist living in Colorado.

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