01/03/2024

AURORA, Colorado Do you ask your patients about their sexual health? Many providers don’t bring up the topic because they don’t have time, feel uncomfortable, or because their patients have other, more pressing concerns to discuss.

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Yet nearly half of women experience some form of sexual dysfunction, such as low sex drive, pain during sex (dyspareunia), or difficulty reaching orgasm. When the dysfunction is associated with significant distress, the condition is called hypoactive sexual desire disorder (HSDD).

At the Society of General Internal Medicine’s 2023 annual meeting, experts said patients want to talk about these issues, but need their doctors ready for the conversation.

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Hannah Abumusa, MD, clinical instructor of medicine at the University of Pittsburgh Medical Center, recommended implementing the “5As” framework.

  1. Ask. Start by asking patients if they would be comfortable with you asking a few questions about their sexual health.

  2. Recommend. Make sure your patient knows that many women struggle with the issue they have brought up.

  3. Evaluate. Ask a series of standardized assessment questions.

  4. Assist. Inform the patient about treatment options.

  5. Organize. Arrange a follow-up visit to see if the treatment has been effective.

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Kathryn Leyens, MD, admitted that she doesn’t discuss sexual health enough with her patients, although she thinks the topic is an important one.

“If it’s brought up, I feel comfortable talking about it,” said Leyens, an assistant professor of medicine at the University of Pittsburgh. “But I think it’s something I could start more often.”

The 5As framework offers a useful way to start these conversations, he said.

The drugs could be to blame

Holly Thomas, MD, an assistant professor of medicine at the University of Pittsburgh, first conducts a medication review when discussing low sex drive with her patients.

“There are definitely medications that we commonly use in primary care that can have adverse effects on sexual function,” Thomas said. “But we’re not always the best at talking to patients about these things, and I think sometimes patients get the message that they should deprioritize their sex life over their medication needs.”

For example, sexual dysfunction is a common side effect of antidepressants, with paroxetine, fluvoxamine, sertraline, and fluoxetine having the highest frequency of this reported effect. Beta blockers are also known to cause sexual dysfunction in women.

Pharmacological options

Once doctors conduct a medication review, they can discuss treatment options with patients, which can range from prescription drugs to therapy.

Several drugs have been shown in clinical trials to increase sex drive in women. Flibanserin (Addyi), a once-daily pill, increased libido in about half of women who used the drug in studies leading up to its U.S. Food and Drug Administration (FDA) approval in 2015 .

The most common adverse effects reported in clinical trials included dizziness, syncope, and drowsiness, which occurred in approximately 12% of users. The FDA recommends that people avoid alcohol 2 hours before and after taking the drug.

Bremelanotide (Vyleesi) is an on-demand drug, like sildenafil for men, that in studies led to modest increases in cravings in 25 percent of women who took the drug. About 40% of users reported feeling nauseous. Hyperpigmentation can also be a side effect, which in rare cases can be permanent, Thomas said. Patients can use up to eight doses of the drug per month.

Testosterone serves as an off-label treatment, as the FDA has not approved the hormone for women. Side effects can include acne and weight gain. Data on the safety of its use over the past 2 years is scarce.

“But until then, there’s pretty strong evidence for the efficacy and safety of testosterone for treating hypoactive sexual desire disorder in women,” Thomas said.

HRT is another potential treatment option, which could include estrogen plus progesterone.

“It’s not FDA-approved for HSDD, but if you’re using it for other menopausal symptoms, it’s likely to improve sexual function with small to moderate effect sizes,” she said.

Bupropion (from multiple brands) is an affordable option prescribed for depression as well, Thomas said. A recently published systematic review provided further data to support the drug’s efficacy.

“This is something many of us are very familiar with and perhaps more comfortable prescribing if we are less familiar with some of the new options,” she said.

Non-pharmacological interventions

Thomas encouraged doctors to consider non-drug approaches as well, such as referring patients to sex therapists.

“There’s something called ‘sensory focus,’ which is a type of sex therapy that’s been around for decades, but it’s still very effective,” Thomas said.

Cognitive behavioral therapy (CBT) is another option, she said. A systematic review published in 2022 showed that CBT was an effective tool for treating HSDD, although Thomas noted that the evidence is limited.

A newer treatment gaining traction is mindfulness meditation, often provided by therapists, which focuses on the present moment and non-judgmental body awareness. Thomas recommended referring patients to educational literature such as Better Sex Through Mindfulness: How Women Can Cultivate Desire by Lori Brotto (Greystone Books, 2018). The book also comes with a workbook.

“This has actually been shown in multiple studies to be effective for treating low sex drive with moderate to large effect sizes,” she said.

Abumusa, Leyens and Thomas report no relevant financial relationships.

Society of General Internal Medicine 2023 Annual Meeting. Presented May 11, 2023.

Kelly Ragan is a journalist living in Colorado.

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