Balance between excitement, inhibition key to treat hypoactive sexual desire disorder

Key takeaways:

• Hypoactive sexual desire disorder is lack of motivation, desire, response or inability to keep interest in sex.
• Treatments include psychotherapy, cognitive behavioral therapy, mindfulness and pharmacotherapy.

CHICAGO — Many midlife women experience hypoactive sexual desire disorder, impacting both partner relationships and mental health, but FDA-approved treatments are available, according to a speaker.

In a study published in Annals of Family Medicine, researchers observed that nearly 40% of women aged 55 to 64 years have sex at least once weekly and nearly 40% at least once monthly. In addition, more than 30% of women aged 65 years and older have sex at least once weekly and 40% at least once monthly, according to Sheryl A. Kingsberg, PhD, chief of the division of behavioral medicine in the department of obstetrics and gynecology at University Hospitals Cleveland Medical Center and professor in the department of reproductive biology, psychiatry and urology at Case Western Reserve University School of Medicine.

Biological, psychological, sociocultural and interpersonal factors all impact whether a woman has sexual desire, Kingsberg said, and clinicians should consider these factors to identify how to approach treatment for low sexual desire.

Lack of ‘spontaneous drive’

Sexual response starts with excitement from psycho-erotic stimulation with body responses of increased heart rate, rising temperature, sweating and, for women, vaginal lubrication, Kingsberg said during a presentation at the Annual Meeting of The Menopause Society. With enough stimulation, the body reaches a peak level of excitement and, if orgasm is reached, sexual tension is released. However, not all midlife women feel intense desire at the beginning of a sexual encounter, especially aging women and those in long-term relationships, Kingsberg said.

“Some people will have spontaneous fantasy or desire, regardless of the age of their relationship,” Kingsberg said. “But many women will not, and they are not necessarily dysfunctional.”

Some women may cognitively choose to engage in sex due to various factors but can be distracted during the act and wonder why they are not interested in sex and why they are thinking of other things during encounters, Kingsberg said.

“If [women] can recognize that [distraction] is typical, and just allow mindful focus on the sensation as they engage in sexual activity, then their body becomes aroused and once aroused, then the desire kicks in,” Kingsberg said during the presentation. “But there are going to be women who miss that spontaneous drive. For them, if they had it and they lost it, that could be considered hypoactive sexual desire.”

Sexual dysfunction prevalence, impact

Hypoactive sexual desire disorder is defined as the lack of motivation for sexual activity as measured by decreased or absent spontaneous desire, decreased or absent response to erotic cues and stimulation or the inability to maintain desire or interest through sexual activity, Kingsberg said.

According to the American Sexual Health Association, one in 10 women have hypoactive sexual desire prevalence. In addition, both nonmenopausal and postmenopausal women experience hyperactive sexual desire.

A precipitating factor for sexual dysfunction can be one’s partner, Kingsberg said, as there is a “dynamic and reciprocal relationship” of one partner’s sexual function with the other. Lack of sexual desire also impacts women outside the bedroom, Kingsberg said, as women with hypoactive sexual desire disorder report negative body image, low self-confidence, feeling less connected to partners, interrupted communication and concern about infidelity.

Hypoactive sexual desire disorder is similar to depression biochemically and in symptomatology, Kingsberg said, as both involve the loss of interest in things that bring you pleasure and the loss of motivation to seek things out that are rewarding. For hypoactive sexual desire disorder, women lose interest in what brings sexual pleasure and lose the motivation to seek out a sexual encounter.

There are factors to create excitation or interest in sexual activity and there are factors to create inhibition in sexual activity, Kingsberg said. Dopamine, oxytocin, melanocortin, vasopressin and norepinephrine are all organic or physiological factors that excite interest in sex while serotonin, opioids and endocannabinoids all inhibit sexual arousal. Intimacy, shared values, romance and experience or behavior are psychosocial or interpersonal factors that excite interest in sex while relationship conflicts, negative stress, negative beliefs about sex and experience or behavior inhibit sex, Kingsberg said.

“The problem with hypoactive sexual desire disorder is that women either don’t have enough excitation or they have too much inhibition,” Kingsberg said. “So, we are working to see if we need to add to or help women increase their excitation or if we need to reduce their inhibition.”

Treating hypoactive sexual desire disorder

Hypoactive sexual desire disorder can be treated with psychotherapy, cognitive behavioral therapy, mindfulness, pharmacotherapy or any combination of treatments.

The goals of psychotherapy for women with hypoactive sexual desire disorder is to use cognitive behavioral therapy and utilize evidence-based approaches to treat sexual dysfunction to alter maladaptive behaviors, shift negative beliefs and values regarding sex, improve partner communication, reduce performance anxiety, regain confidence in sexual performance and surmount intimacy barriers, Kingsberg said.

Currently, two pharmacologic options are approved in the U.S. to treat hypoactive sexual desire disorder in premenopausal women. Approved in 2015, flibanserin (Addyi, Sprout Pharmaceuticals) is a 100 mg pill taken daily at bedtime for women who had sexual desire at some point with generalized loss. Bremelanotide (Vyleesi, Cosette Pharmaceuticals) is a cyclic heptapeptide lactam receptor agonist that is an on-demand, subcutaneous injection taken 45 minutes before sexual activity with a 16-hour window.

Testosterone is also an option to treat hypoactive sexual desire disorder, though there are no FDA-approved testosterone options for women. A testosterone position statement, supported by 12 international societies and published in The Journal of Clinical Endocrinology & Metabolism, states that evidence supports testosterone to treat only hypoactive sexual desire disorder in peri- and postmenopausal women. The International Society for the Study of Women’s Sexual Health also released a practice guideline on testosterone use, stating that one-tenth of a standard male dose of 1% transdermal testosterone, or 300 µg daily, should bring women back to premenopausal testosterone levels. Testosterone pellets are not recommended for use in women with hypoactive sexual desire disorder, according to the guidance.

According to Kingsberg, physicians and patients should be more open to discussing sexual issues to address concerns and improve overall well-being.

“Sex is still an uncomfortable topic. It still gets a little anxiety going,” Kingsberg said. “But, you can talk about smelly discharge. How can you discuss that but not talk about sex? There is [also] a fear of embarrassing patients and lack of training, not just in menopause, but in sexual medicine.”

References:

• Davis SR, et al. J Clin Endocrinol Metab. 2019;doi:10.1210/jc.2019-01603.
• Parish SJ, et al. J Sex Med. 2021;doi:10.1016/j.jsxm.2020.10.009.
• Shifren JL, et al. Obstet Gynecol. 2008;doi:10.1097/AOG.0b013e3181898cdb.
• Thomas HN, et al. Ann Fam Med. 2015;doi:10.1370/afm.1820.