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Challenges in the identification and management of HSDD.

A 52-year-old woman, A.J., complains of mild vasomotor symptoms. She has had some sleep disturbance and an increase in daytime fatigue. She notes that she has been suffering from a depressed mood of increasing severity and frequency. On screening and then on direct questioning, she admits to a lack of sexual desire and a decrease in sexual arousal.


The patient's medical history reveals that she has been taking paroxetine for symptoms of depression for the past 4 years. Her depressive symptoms were well controlled; as noted, however, her depressive symptoms have recently recurred. Also, in the past few months her menstrual cycle has become increasingly irregular and has been characterized by bothersome heavy bleeding. Otherwise her medical history is unremarkable, without chronic or serious illness or surgical procedures. Her general physical examination is normal.

Regarding her sexual history, A.J. reports that she first noticed a decrease in sexual arousal 2 to 3 years previously, followed by a decrease in sexual desire. Intercourse has become uncomfortable for her. She appears to have pain due to a reduction in vaginal lubrication. It is not clear whether this is the underlying cause of her low desire. ]he patient's problems with decreased sexual desire and arousal are causing her extreme distress. She has been married for 26 years and has not experienced marked discord with her husband until recently, when her sexual difficulties began to create tension in the relationship.


This case illustrates some of the challenges involved in establishing a diagnosis of female sexual dysfunction and, specifically, hypoactive sexual desire disorder (HSDD). Problems with sexual desire and arousal may indicate a primary diagnosis of HSDD or may occur secondary to factors such as poorly controlled depressive symptoms, the manifestations of menopause, or the side effects of antidepressant medications. (1-3) Moreover, declining estrogen levels beginning during perimenopause may decrease vaginal lubrication and cause atrophy of vaginal tissue, which can result in discomfort during intercourse and can also reduce desire. (4) Because of the complex interplay among many factors, it is not always possible to clearly identify the "primary" disorder in a patient such as A.J. An important consideration is that personal distress must be present to establish a diagnosis of HSDD. (5,6)

The approach to management should address any factors that might be amenable to intervention, whether or not they constitute the primary cause of the complaint of loss of sexual desire. In A.J.'s case, a consultation with her psychiatrist is in order to discuss the possible strategies to lessen the potential impact of her depressive symptoms and antidepressant therapy on her sexual function. Her complaints of vasomotor symptoms and vaginal dryness suggest that she may benefit from systemic estrogen therapy to improve her sleep and reduce daytime fatigue and/or local estrogen therapy to decrease pain on intercourse by increasing vaginal lubrication. However, estrogen therapy does not directly affect sexual desire, so the patient's complaints of low desire may well persist. If so, a trial (off-label) of testosterone therapy may be appropriate, as testosterone treatment may be effective in significantly increasing sexual desire and decreasing distress in naturally menopausal women with HSDD when used concomitantly with estrogen replacement therapy. (7) Testosterone therapy, in combination with estrogen, has also been shown to improve arousability, fantasy, orgasm, and overall sexual satisfaction in women with HSDD. (8) A recent trial investigating the use of testosterone alone in naturally menopausal women with low desire has demonstrated modest dose-dependent improvements in sexual satisfaction with this therapy. (9)


(1.) Basson R, Berman J, Burnett A, et al. Report of the International Consensus Development Conference on Female Sexual Dysfunction: definitions and classifications. J Urol. 2000;163:888-893.

(2.) Bonierbale M, Lancon C, Tignol J. The ELIXIR study: evaluation of sexual dysfunction in 4,557 depressed patients in France. Curr Med Res Opin. 2003;19:1114-11224.

(3.) Kennedy SH, Dickens SC, Eisfeld BS, et al. Sexual dysfunction before antidepressant therapy in major depression. J Affect Disord. 1999;56:2001-2008.

(4.) Meston CM, Bradford A. Sexual dysfunctions in women. Annu Rev Clin Psychol. 2007;3:233-256.

(5.) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revision. Washington, DC: American Psychiatric Press; 2000.

(6.) Basson R, Schultz WW. Sexual sequelae of general medical disorders. Lancet. 2007;369:409-424.

(7.) Simon J, Braunstein G, Nachtigall L, et al. Testosterone patch increases sexual activity and desire in surgically menopausal women with hypoactive sexual desire disorder. J Clin Endocrinol Metab. 2005;90:5226-5233.

(8.) Abdullah RT, Simon JA. Testosterone therapy in women: its role in the management of hypoactive sexual desire disorder. Int J Impotence Res. 2007;19:458-463.

(9.) Davis SR, Moreau M, Kroll R, et al. Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med. 2008;359: 2005-2017.

Sharon J. Parish, MD

Associate Professor of Clinical


Department of Medicine

Albert Einstein College of Medicine

Director of Psychosocial Training

Department of Medicine

Montefiore Medical Center

Bronx, New York
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Title Annotation:hypoactive sexual desire disorder
Author:Parish, Sharon J.
Publication:Journal of Family Practice
Article Type:Case study
Geographic Code:1USA
Date:Jul 1, 2009
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