Disorders of Sexual Desire

Hypoactive sexual desire disorder (HSDD) is the persistent or recurrent absence of sexual fantasy, thought, or desire for sexual activity which causes personal distress. Lowen reported an incidence of 22 percent, others as high as 55 percent, and appears to represent the most common form of FSD. All aspects of sexuality can cause HSDD. Psychosocial aspects of the relationship between partners appears to be a major cause. The couch potato, football watching, beer drinking husband is not uncommon. Demanding careers, raising children, motherhood, stressful life milestones, job loss, and the death of a loved one can all play a role. On the other hand, physical factors such as general health conditions, drug and alcohol abuse, aging, and many of the antidepressants may have a potential affect as well.

Diminution of sexual desire is a side effect of many medications, many of which are listed in our table one. SSRIs increase serotonin activity, inhibit the limbic system, and decrease sexual desire. Bupropion (Wellbutrin) has been demonstrated to increase sexual desire both alone as primary treatment or in combination with SSRIs and may have a beneficial effect both for depression and the associated sexual dysfunction. Patients who are on SSRIs can take "drug holidays" in which they discontinue their antidepressants during romantic getaways. Included in SSRIs would be St. John's Wort, a common herbal medication for depression. Yohimbe has been shown as promising treatment to reduce SSRI, and St. John's Wort induced sexual dysfunction in women.

Medications that suppress ovarian function will also suppress testosterone, which is primarily produced by the ovary. Without testosterone the central nervous system limbic systems cannot respond adequately to stimulation. GnRH agonists for endometriosis, Depo-Provera, and to a lesser extent oral contraceptives decrease ovarian production of testosterone and may also decrease libido.

Testosterone replacement has been documented to increase sexual interest and activity particularly after the ovaries have been removed, and testosterone has been proposed as a medical treatment for HSDD. It may also be helpful for women who are receiving hormone replacement therapy since estrogens increase serum-binging globulins, decreasing the non-bound free testosterone and the active form of the hormone testosterone. There also appears to be a female androgen deficiency syndrome (FADS) described by the Australian research, Dr. Susan Davis, in which women have low libido, poor motivation, fatigue, and lack of well being in the presence of normal estrogen and free testosterones in the lower third of the normal laboratory range. Dr. Davis recommends treating women with oral or transdermal testosterone under these circumstances.

Sexual Aversion Disorder

Sexual aversion disorder (SAD) is an exaggerated form of HSDD and represents the persistent or recurrent phobic aversion to genital contact with a sexual partner. Women with SAD have a history of sexual or physical abuse or serious problems in their relationship that usually requires extensive psychotherapy for these women who are apathetic towards sex and who have negative sexual experiences. Female sexual arousal disorder (FSAD) is the persistent or inability to attain or maintain sexual excitement, i.e. lubrication/swelling which causes personal distress. Arousal disorders may have a psychological aspect either primarily or secondary and are frequently tied to issues of HSDD. Sex therapy of arousal disorders usually involves teaching women how to appreciate their bodily responses and focusing on ways to enhance these responses with sexual thoughts of stimulation. On the other hand, arousal disorders can be physiologic in origin. SSRIs and other medications can interfere with arousal as well as desire. Hormonal preparations that decrease testosterone such as contraceptives decrease arousal and conversely testosterone may aide arousal. Blood flow in the hemodynamic basis of sexual arousal can be affected by antihypertensives, anticholinergics, and antihistamines. The hemodynamic aspects of arousal may, in fact, be a major area in which pharmacological therapy of FSD will be demonstrated.

In those patients who have never experienced an orgasm sex therapy and support groups to educate women about their bodies and learning to appreciate their bodily responses may be helpful.