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Disorders of Desire

TABLE 6 Basic Treatment Strategies for Female Sexual Dysfunction

Provide education Provide information and education Enhance stimulation and eliminate routine Encourage use of erotic materials (videos, books); suggest masturbation to maximize familiarity with pleasurable sensations; encourage communication during sexual activity; recommend use of vibrators*; discuss varying positions, times of day or places; Provide distraction techniques** Encourage erotic or nonerotic fantasy; recommend pelvic muscle contraction and relaxation (similar to Kegel exercise) exercises with intercourse; recommend use of background music, videos or television. Encourage noncoital behaviors*** Recommend sensual massage, sensate-focus exercises (sensual massage with no involvement of sexual areas, where one partner provides the massage and the receiving partner provides feedback as to what feels good; aimed to promote comfort and communication between partners); oral or noncoital stimulation, with or without orgasm. Minimize dyspareunia Superficial: female astride for control of penetration, topical lidocaine, warm baths before intercourse, biofeedback. Vaginal: same as for superficial dyspareunia but with the addition of lubricants. Deep: position changes so that force is away from pain and deep thrusts are minimized, nonsteroidal anti-inflammatory drugs before intercourse.

Disorders of Desire
Women with disorders of desire are difficult to treat. Occasionally, decreased desire in patients is secondary to boredom with sexual routines. Suggesting changes in positions or venues, or the addition of erotic materials is helpful.

Disorders of desire in premenopausal patients may be secondary to lifestyle factors (e.g., careers, children), medications or another sexual dysfunction (e.g., pain or orgasmic disorder). No medical treatment is available specific to patients with disorders of desire. If no underlying medical or hormonal etiology is discovered, individual or couple counseling may be helpful.

Estrogen replacement therapy has been shown to correlate positively with sexual activity, enjoyment and desire, although the findings are not universal.

In peri- and postmenopausal women, the relationship between hormones and sexuality is unclear.^18-21 Nonetheless, estrogen replacement therapy has been shown to correlate positively with sexual activity, enjoyment and fantasies--the latter thought to represent desire.^23,24 The mechanism of estrogen's effect on desire is indirect and occurs through improvement in urogenital atrophy, vasomotor symptoms and menopausal mood disorders (i.e., depression). This relationship helps predict which patients are likely to respond to estrogen replacement therapy (i.e., those with symptoms of hypoestrogenism) and may explain why some studies do not show estrogen-mediated improvement in sexual functioning.²⁵

The role of progesterone therapy, which is necessary in estrogen-treated patients with an intact uterus, has not been widely studied in terms of sexuality, but one study²⁴ suggests that it exhibits a negative impact by dampening mood and decreasing available androgens. The addition of estrogen for several weeks before progesterone therapy is initiated, or taking into account monthly symptom calendars, will help determine each hormone's influence and guide dosage and schedule adjustments.

Testosterone appears to have a direct role in sexual desire.²⁰ However, because studies evaluate mostly testosterone-deficient, oophorectomized women or women who develop supraphysiologic levels secondary to testosterone treatment, clinical applications are limited. No guidelines for testosterone replacement therapy for women with disorders of desire and no consensus of "normal" or "therapeutic" levels of testosterone therapy exist. Many physicians are concerned about the lack of safety data on the role of testosterone in breast cancer and on hepatic side effects; however, hepatocellular damage or carcinoma is rare at prescribed dosages,²⁶ and the development of breast cancer has not been reported clinically.²⁷

The side effects of testosterone, which occur in 5 to 35 percent of patients, include lower levels of high-density lipoprotein, acne, hirsutism, clitorimegaly and voice deepening.²⁷ However, these side effects on lipoprotein levels are rarely significant if estrogen and testosterone are coadministered; moreover, most other side effects are reversible with discontinuation of testosterone or a dosage adjustment.²⁶

A role for testosterone treatment exists in selected patients (Table 7). Coadministration with estrogen therapy should be provided to prevent deleterious effects on lipoprotein levels. Before initiating testosterone treatment, physicians should discuss the potential and theoretic risks, and individual risk and benefit assessments with the patient. In general, patients with current or previous breast cancer, uncontrolled hyperlipidemia, liver disease, acne or hirsutism should not receive testosterone therapy.

Arousal Disorders
Current treatment of patients with arousal disorders is limited to the use of commercial lubricants, although vitamin E and mineral oils are also options. Arousal disorders may be secondary to inadequate stimulation, especially in older women who require more stimulation to reach a level of arousal that was more easily attained at a younger age. Encouraging adequate foreplay or the use of vibrators to increase stimulation may be helpful. Taking a warm bath before intercourse may also increase arousal. Anxiety may inhibit arousal, and strategies to alleviate anxiety by employing distraction techniques are helpful.

Urogenital atrophy is the most common cause of arousal disorders in postmenopausal women, and estrogen replacement, when appropriate, is usually effective therapy. However, women taking systemic estrogens occasionally require supplementation with local therapy. Long-term use of estrogen-containing vaginal creams is considered an unopposed-estrogen treatment in women with an intact uterus, requiring progesterone opposition. An oral progesterone such as medroxyprogesterone 5 mg daily for 10 days every one to three months (or equivalent) may be used initially, with frequency or dosage increased if withdrawal bleeding occurs. Estring (an estradiol-containing vaginal ring) has little systemic absorption and does not require the addition of progesterone. Patients who are uncomfortable wearing the ring during the day often achieve relief with night use only.

TABLE 7 Testosterone Therapy for Treatment of Disorders of Desire*

Screening Baseline testosterone levels** (free and total), baseline lipid profile, baseline liver enzyme levels, mammography, Papanicolaou smear Initiate therapy*** Combination product (Estratest or Estratest hs) Methyltestosterone (Android), 1.25 to 2.5 mg daily Micronized oral testosterone, 5 mg twice daily Testosterone proprionate 2 percent in petroleum applied daily to every other day Testosterone injectables/pellets Reevaluation at three to four months Repeat testosterone levels, lipid profile, liver enzyme levels Monitor symptoms, side effects Continued therapy Taper to lowest effective dosage Monitor lipid levels, liver enzyme levels once or twice yearly Routine Papanicolaou smear and mammography schedules

*--These are recommendations; no evidence-based protocols are available on testosterone therapy for the treatment of women with desire disorders. **--Many authors recommend that total levels remain in "normal" range for premenopausal women. ***--None of these medications are labeled by the U.S. Food and Drug Administration for treatment of desire disorders. --Alternate daily combined with estrogen-only pill, take testosterone pill every other day, 5 days a week, etc. (not shown in studies to be safer or have fewer side effects).

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