It has been about a year since the release of Addyi (Flibanserin), a drug created for pre-menopausal women who suffer from Hypoactive Sexual Desire Disorder (HSDD). Amid much controversy and FDA regulation, it was finally approved and made available for patients. The significance of this medication is that it takes steps to help correct a condition that many women suffer from but few talk about or acknowledge. This has made the treatment and research on newer treatments difficult. When Viagra was released for male erectile dysfunction, it lead to a plethora of medications being developed for the condition. For women, the research has been slow and limited. In this article, I will discuss HSDD, treatment options and surrounding issues.
Hypoactive Sexual desire disorder or HSDD is described as a woman’s lack of sexual desire, on a chronic basis, which also causes personal or emotional issues as well as relationship problems. If a woman does not have a desire for sexual activity but is not bothered by it or does not have any relationship issues as a result of it, then it is not a disorder. Estimates place it as common as 1 in 10 women being affected during their life and as many as 15% have it as an ongoing problem. It is not a disorder to have a lack of interest in sexual activity but it is a disorder if it causes emotional distress or relationship problems. Some have argued that the problem is really on the part of the partner but that is not usually the case and it also downplays the importance of sexual intimacy in a relationship. The diagnosis is based on a clinical evaluation. No blood test exists to diagnosis HSDD, but it is made by a good history of the patient’s complaints. Furthermore, other conditions need to be evaluated such as infection, painful intercourse, vaginismus and many others. Physical problems need to be checked for first before diagnosing HSDD.
Once the diagnosis is made and the woman wants to have treatment, options needs to be considered. In the past, the most common form of treatment was psychological with counseling and therapy. This had limited success. Research has shown that it is as much of a physical problem as well as psychological. The brain has several neurotransmitters which are involved in our thoughts, moods, emotions and desires. An imbalance of certain neurotransmitters can lead to loss of desire, addiction, emotional problems, depression, anxiety and others. The mechanism of Flibanserin is not fully understood but is suspected to interplay with the serotonin system. In normal sexual desire, norepinephrine and dopamine increase sexual excitement while serotonin increases sexual satiety or inhibition. The drug is believed to increase dopamine and norepinephrine while decreasing serotonin. The combined effect is to increase a woman’s desire for sexual activity. It is only indicated for pre-menopausal woman who do not have any other physical causes of sexual dysfunction. It is not the “female Viagra” as it has a completely different mechanism. Viagra, and similar medications, work by making nitroglycerin work better in the body to improve blood flow, which is what allows an erection to happen. Of interest, Viagra (sildenafil) was first thought to be a medication for heart disease and it would help to improve blood flow to the heart but it was later discovered to improve penile blood flow as well. Consequently, taking nitroglycerin while using these mediations is dangerous because it will cause all the blood vessels to dilate and lead to an unsafe and possibly fatal drop in blood pressure. Addyi does not work on the mechanics of sexual activity as it does not affect blood flow or work in the genitalia. It works in the brain, on brain chemistries, where sexual desire is thought to start.
I have treated several patients with HSDD and have had some promising results. The medication is not a cure for everyone and does have some specific requirements. Aside from having to accurately diagnosis HSDD, it is important to know the risk and benefits of the medication. It does cause sedation and it is advised to take at night. Patients can become extremely lethargic if taking the medication. In addition, it is advised that no alcohol should be consumed while taking Addyi. One study showed that taking excessive amounts of alcohol then immediately taking the medication can lead to patients passing out. Another study, which did not isolate alcohol use, did not necessarily show this effect. That is to say that when patients were taking the medication in the study and had a routine that may or may not have involved alcohol, they did not necessarily have increased risk of passing out. Regardless, the FDA has mandated that any patient on Addyi must sign a consent showing they understand they cannot drink alcohol while undergoing treatment and the prescriber must take a course to show they are certified to prescribe the mediation.
The medication has met with moderate success but for some woman has been life changing. Many patients have complained that their relationship was not doing well and they were not happy with how their sexual life was going. The medication did help them with sexual desire and did increase the number of satisfying sexual encounters. That being said, the medication needs to be taken every day and women will tend to feel a slow increase in desire over the next 4-8 weeks. It does not wok instantaneously and will not cause immediate sexual desire or hyper sexuality. It can slowly increase the desire for sexual activity and will be fairly sustained throughout the course of treatment. If the drug is discontinued, it takes about 4-8 weeks to return to baseline. Some women maintain sexual desire even after stopping the medication. While it does not work for all women, it is an important step in the treatment of HSDD and further research should be conducted. If you think you may have this condition, you should seek medical advice and discuss your options.
