Patients often gloss over the topic when asked to talk about their sexual health. Almost always, providers have to initiate the conversation, as patients are either uncomfortable or unwilling to bring up the subject. I’m always amazed me when I hear the sad response, “It’s been years”, or the bitter “I could care less if it ever happens again”. These are not words of a widowed elderly person, someone way past menopause, or a man with brittle diabetes and erectile disorder. No, these remarks came from middle aged, healthy population of both men and women. I pondered about the reasons behind diminished libido in our cohort of patients. Luckily, the consensus report published last month in Mayo Clinic Proceedings sheds light on my query: Hypoactive Sexual Desire Disorder: International Society for the Study of Women’s Sexual Health (ISSWSH) Expert Consensus Panel Review. For the sake of time and simplicity, I will break this topic into two newsletters, with this month’s focus on women’s hypoactive sexual desire disorder (HSDD), and next month on men’s.
The female sexual disorder classification and nomenclature has gone through many changes over the past few years, and for good reason. As a health care provider, I’ve come to the conclusion that its time to call it like it is when it comes to sexual dysfunction; it is a highly complex issue that should not be classified under the umbrella of mental health disorders. Self-assessed poor health, thyroid disease, urinary incontinence, history of sexual abuse, lubrication problem and hormone dysregulation all correlate with low desire. Epidemiology studies approximate an overall prevalence of HSDD to be anywhere from 8% to 19%. Although the risk is higher with increasing age, the overall distress is lower among older individuals, explaining why our middle age patients seem to be more saddened about their lackluster sex life. Turns out, sexual desire entails a very complex neural pathway involving many regions of the brain composed of excitation and inhibition factors. Dopamine, melanocortin, oxytocin, and norepinephrine are excitatory, and opioid, serotonin, and endocannabinoids are inhibitory. For the science lovers in our audience, please see the chart below for a detailed report of how these systems weigh in on your sexual wellbeing.
The consensus report recommends providers using the table below to screen for HSDD, and to find underlying causes that prevent a fully functioning sexual desire. If the answer to first 4 questions is positive, then HSDD is diagnosed. Question 5 looks for concomitant causes, which I believe is very important to discover. For example, if a patient is currently taking a medication which lower dopamine level, then we have the option to discontinue the drug to revive sexual desire. Or if we detect hormonal deficiencies as a result of menopause, we can discuss natural hormone replacement therapy.