Medical Devices

The Eros-Clitoral Therapy Device: This is the first treatment approved by the FDA for arousal and orgasmic disorders in women. This small handheld device applies a gentle vacuum to the clitoris, increasing blood flow to the clitoris and surrounding tissue. Clinical trials involving 52 patients showed improvement in postmenopausal and premenopausal women with sexual arousal disorder or orgasmic disorder.

Interstim: The InterStim (Medtronic) sacral nerve stimulating system is an implantable device designed to treat urge urinary incontinence. It uses mild electrical stimulation of the sacral nerves to modulate bladder contractility. Anecdotal reports suggest it may benefit sexual arousal and the ability to achieve orgasm in women. Multicenter studies are underway.

Pharmacotherapies

Sildenafil citrate (Viagra), a selective type 5 (cGMP specific) phosphodiesterase inhibitor, decreases the catabolism of cGMP, the second messenger in nitric oxide-mediated relaxation of clitoral and vaginal smooth muscle. In animal studies, sildenafil produced dose-dependent relaxation of clitoral and vaginal smooth muscle strips.

In a recent pilot study, sildenafil significantly increased physiologic and subjective parameters of sexual response in 48 women with arousal disorder. Some studies have failed to demonstrate any significant benefit of sildenafil on subjective sexual arousal, even when enhanced vaginal engorgement was verified.

Others, however, have shown improved sexual functioning in premenopausal women with sexual arousal disorder, postmenopausal women with various disorders, and women with spinal cord injury. Several others have found that sildenafil benefits antidepressant-induced sexual dysfunction in women. The most recent study found that sildenafil was effective and well tolerated in 202 postmenopausal women with FSAD without concomitant HSDD or contributory emotional, relationship or historical abuse issues. However, it is important to note that all positive changes in arousal disorders in women took place under regulated androgen and estrogen levels.

Until androgen is approved for general usage in women, the true efficacy of sildenafil cannot be demonstrated and prescribed for women. The usual dose of sildenafil in these trials was 50-100 mg before sexual activity.

L-Arginine and yohimbine Hcl: L-Arginine is an amino acid that functions as a precursor to the formation of nitric oxide, which mediates relaxation of vascular and nonvascular smooth muscle. Yohimbine (Aphrodyne, Dayto Himbin, Yocon, etc.) is an alkaloid agent that blocks presynaptic alpha-2 adrenoreceptors.

Effects on the peripheral autonomic nervous system include a relative decrease in andrenergic activity and enhanced parasympathetic tone. Reports on the ability of yohimbine to induce penile erections have shown mixed results, and a recent study of 24 postmenopausal women with sexual arousal disorderfound little difference in subjective reports of sexual arousal among those treated with yohimbine (5 mg), yohimbine (6 mg) plus L-arginine glutamate (6 g), or placebo.

Alprostadil (prostaglandin E1): In the form of an intraurethral pellet, it has been used to treat ED. In two small studies, topical alprostadil formulations were shown to enhance subjective and physiologic arousal in women. Phase II clinical studies are under way in postmenopausal women with sexual arousal disorder to assess the safety and efficacy of an alprostadil based formulation using a permeation enhancer to deliver the drug vaginally.

Phentolamine (Regitine): Phentolamine is a nonspecific alpha-adrenergic blocker that relaxes vascular smooth muscle. An experimental oral formulation (Vasomax) has been studiesin the treatment of ED and a pilot study in menopausal women with sexual dysfunction showed mildly improved vaginal blood flow and subjective arousal at a dose of 40 mg qd.

Bupropion HCl (Wellbutrin): This antidepressant is a weak blocker of the neuronal uptake of serotonin and norepinephrine; it also inhibits the neuronal reuptake of dopamine to some extent, although the exact mechanism of action is not clear. Unlike SSRIs, which may cuase decreased libido and exacerbate sexual dysfunction symptoms, bupropion is not only effective in treating SSRI-induced sexual dysfunction, but has also been shown to improve sexual function in women who are not depressed.

Apomorphine Hcl is a short-acting dopamine agonist that facilitates erectile responses. In addition to developing a nasally administered apomorphine for treatment of ED in men, a phase 2 clinical trial is being conducted in women with sexual dysfunction to assess the safety and efficacy of nasally administered apomorphine in increasing their sexual satisfaction.

Alpha-Melanocyte-stimulating hormone: This is an endogenous regulatory hormone with diverse physiologic functions, including the regulation of body weight, pigmentation, adrenal function, energy homeostasis, and immune and sexual function. Studies of a nasally administered synthetic peptide analogue of alpha-melanocyte-stimulating hormone (PT-141) for the treatment of female sexual dysfunction are underway.

Herbals: Several herbal remedies (such as Zestra, Avlimil and ArginMax) are currently available and recommended by some sexual health professionals for enhancement of sexual function . Like androgenic dietary supplements, they require no regulatory review.

Additional resources on female sexuality are available from MayoClinic.com:

http://www.mayoclinic.com/health/kegel-exercises/WO00119
http://www.mayoclinic.com/health/sexual-health/HA00035
http://www.mayoclinic.com/health/womens-health/WO00110
http://www.mayoclinic.com/health/sexual-health/HQ01363