What You Need to Know About 'Female Viagra'

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A clinician should also rule out the possibility that the dysfunction stems from a co-occurring medical or psychiatric condition, or substance abuse.
A clinician should also rule out the possibility that the dysfunction stems from a co-occurring medical or psychiatric condition, or substance abuse.

More than 16 years after the approval of sildenafil (Viagra), the first oral pill to treat impotence, the FDA approved the drug nicknamed “female Viagra” to treat hypoactive sexual desire disorder (HSDD) in premenopausal women. The August approval of flibanserin is “an incredible breakthrough for women because for years we've had a number of options for men to treat erectile dysfunction and desire problems,” but no such resources for women, Anita H. Clayton, MD, professor and chair of the department of psychiatry and neurobiological sciences at the University of Virginia, told Psychiatry Advisor.

Though the DSM-5 merged two DSM-IV diagnoses, HSDD and Female Sexual Arousal Disorder, to create a new diagnosis1 of female sexual interest/arousal disorder (FSIAD), flibanserin (Addyi) is indicated for women meeting the DSM-IV-TR criteria for HSDD.2 These include a persistent deficiency or absence of sexual desire and fantasies, as judged by the clinician, and this disturbance should cause distress or interpersonal difficulty for the patient.

A clinician should also rule out the possibility that the dysfunction stems from a co-occurring medical or psychiatric condition, relationship difficulty, or the use or abuse of medication or another substance.  The FDA further specifies that flibanserin is intended for acquired, generalized HSDD: “HSDD is acquired when it develops in a patient who previously had no problems with sexual desire. HSDD is generalized when it occurs regardless of the type of sexual activity, the situation or the sexual partner.”3

Clayton says the patients most likely to be helped by flibanserin are women like those involved in the trial that investigated the drug's efficacy and safety: They had a mean age of 36.6 years, were typically in long-term relationships and had children and jobs, were stressed out, and were in love with their partner but had no sexual desire.4

This lack of desire can negatively impact the patient, her partner and ultimately her family. “A lot of women start avoiding their partner–they might go to bed late, wake up early, or stay really busy” to avoid the partner's attempts to initiate sex, she noted.

An estimated 10% of women have decreased or absent desire and distress about it.5 Though some experts have expressed concern that HSDD is simply an attempt to make a non-issue into a medical diagnosis for the benefit of pharmaceutical companies,6 “these women feel like something is really missing–this is a real problem for them,” said Clayton. Some women have even felt dismissed when they complained to their healthcare provider about a lack of desire and were assured that it was normal, she added.

“This is basically a biologic phenomenon,” though it is important for clinicians to ascertain whether the lack of desire may be due to another issue before making a diagnosis of HSDD, as per the diagnostic criteria.

“Desire is best understood from a biopsychosocial perspective and thus the etiology of HSDD is also best understood from a biopsychosocial model,” said Sheryl A. Kingsberg, PhD, chief of the division of behavioral medicine in OB/GYN at University Hospitals Case Medical Center and professor of reproductive biology and psychiatry at Case Western Reserve University School of Medicine in Cleveland, Ohio. “That is, the etiology can be either neurobiologic, psychological or cultural or some combination.”

The Decreased Sexual Desire Screener is a simple tool that can help to guide diagnosis.7 It first asks four yes-or-no questions about past and current sexual desire and related levels of distress and satisfaction. If decreased sexual desire is reported, a fifth question asks patients to check possible reasons for the change, such as relationship dissatisfaction, depression, surgery or other medical conditions, and pregnancy, for example. If one or more of these are checked, they might indicate the need for a different treatment approach before medication is considered.  

“Essentially, question 5 rules out the psychological, situational and relationship factors, as well as identifying an etiology that may be better explained by a medication, substance or medical or psychiatric illness, leaving the neurobiologic etiology of HSDD as a diagnosis of exclusion,” Kingsberg told Psychiatry Advisor. If additional gynecologic or hormonal factors are uncovered as you take the patient's history, referral to a gynecologist should be made.

“It is also appropriate to refer to another clinician who specializes in sex therapy techniques if you think a pharmacologic option is not the best first line approach or if you think the combination of pharmacotherapy and psychotherapy is the best option,” she added.

Numerous studies have found a close association between female sexual dysfunction and psychological disorders such as depression or anxiety, including research co-authored by Kingsberg that was published in 2014 in the Journal of Sexual Medicine.8 The findings show that changes in severity of depression and anxiety corresponded to variations in sexual response, suggesting shared underlying mechanisms, such as an imbalance in dopamine, norepinephrine, oxytocin, melanocortins, serotonin, opioids and endocannabinoids, according to Kingsberg. When HSDD appears to be rooted in or worsened by psychological factors, cognitive behavioral therapy (CBT) is a recommended treatment approach.

“CBT is effective in altering negative schemas around sexual activity, anxiety about performance, poor body image, or CBT to address subclinical depression, anxiety or other subclinical psychological problems as well as CBT to help shift negative sociocultural beliefs or shame and guilt around having sexual desire,” Kingsberg said.  Sex therapy with the individual or couple may also be appropriate to more specifically address sexual activity and desire, and “couples therapy is often a useful treatment approach.”

Tori Rodriguez, MA, LPC, is a psychotherapist and freelance writer based in Atlanta.

References

  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 2013; 5th ed. Washington, DC.
  2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 2000; 4th ed. Washington, DC.
  3. U.S. Food and Drug Administration. FDA News Release: FDA approves first treatment for sexual desire disorder. Retrieved on December 11, 2015 from http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm458734.htm
  4. Katz M, DeRogatis LR; et al. Ackerman R, et al. Efficacy of flibanserin in women with hypoactive sexual desire disorder: results from the BEGONIA trial. Journal of Sexual Medicine; 2013; 10(7):1807-15.
  5. Shifren JL, Monz BU, Russo PA, et al. Sexual problems and distress in United States women: prevalence and correlates.Obstetrics and Gynecology. 2008; 112(5):970-8.
  6. >Meixel A and Yanchar E, Fugh-Berman A. Hypoactive sexual desire disorder: inventing a disease to sell low libido. Journal of Medical Ethics. 2015; doi:10.1136/medethics-2014-102596.
  7. Clayton AH, Goldfischer ER, Goldstein I, et al. Validation of the Decreased Sexual Desire Screener (DSDS): A Brief Diagnostic Instrument for Geeralized Acquired Female Hypoactive Sexual Desire Disorder (HSDD). Journal of Sexual Medicine; 2009; 6:;730–738.
  8. Kalmbach DA, Kingsberg SA, Ciesla JA. How changes in depression and anxiety symptoms correspond to variations in female sexual response in a nonclinical sample of young women: a daily diary study. Journal of Sexual Medicine. 2014; 11(12):2915-27.
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