Disorders of Sexual Desire
by Dr. Pamela Wang

Female sexuality is a complex process that is influenced by many factors, such as family background, religion and social situation. It can also change with age, health status and personal experiences.

It is estimated that up to 40 million American women may be affected by female sexual dysfunction. Female sexual dysfunction includes disorders of desire, arousal and orgasm and sexual pain conditions. Some women may experience one or several disorders at the same time. Decreased sexual desire or libido may be the most common sexual complaint. Despite the abundant publicity recently about sexuality issues, many women do not feel comfortable discussing this issue with their physicians. However, your primary care physician or gynecologist may be able to help you find ways to improve your sexual health.

There is no "normal" level of desire and a woman's feelings about sex can change, depending on what is happening in your life. Some women are not bothered by their low libido. Other women are concerned because they used to have a very active sex life and it has now become an issue for them or their partner.

A woman's low libido used to be considered a result of some emotional conflict. Now there is further support for the concept that female sexual dysfunction is a result of both psychological and biological influences.

CAUSES

Sexual desire is greatly affected by lifestyle factors such as caring for children and elderly parents and career stresses. Those who don't get enough sleep may be too tired to think about sex. A woman's partner brings another set of attitudes which can affect sexual function. Families often provide a basis for sexual response, such as values and expectations about virginity, marriage and fertility.

Sexual desire is greatly impacted by emotional stresses such as anxiety, depression, drug or alcohol abuse, body image and relationship problems. Current or past physical, verbal or sexual abuse can cause longstanding sexual dysfunction. Referral to a therapist or psychiatrist can be extremely helpful in these situations.

Chronic illness may dramatically affect sexual desire and function. For example, diabetes may inhibit arousal. Neurologic disease may affect sexuality on multiple levels.

Many medications are known to contribute to this problem (see Table 1).

TABLE 1. Medications that cause decreased sexual desire

	PsychoTherapeutic medications
		AntiPsychotics Tranquilizers (e.g. Valium, Ativan) Anti-Depressants (e.g. Prozac, Zoloft, Paxil, Elavil, Pamelor) Lithium
	Cardiovascular Medications
		Beta blockers (e.g. Tenormin, Lopressor) Clonidine Aldactone Digoxin
	Hormonal preparations
		Birth control pills Lupron
	Other
		Dilantin Anti-fungals (Nizoral) Indocin Anti- acid meds (Tagamet, Pepcid)

In the peri- or postmenopausal woman, hormonal changes may have significant effects on sexual satisfaction and therefore may affect desire. Symptoms such as vaginal dryness, depression, hot flashes and night sweats and a general decline in the sense of well-being all contribute to diminishing a woman's sexual desire. Often estrogen replacement may improve desire by treating these symptoms.

Testosterone may also play a role in determining a woman's level of sexual desire. Subnormal testosterone levels may be a result of oral estrogen therapy, such as with birth control pills or hormone replacement therapy, lactation, anorexia nervosa or low ovarian hormone production.

TREATMENT OPTIONS

If a medical cause for disordered sexual desire is identified, then targeting therapy towards the medical problem may bring improvement in desire. A review of medications may reveal a cause. For oral contraceptive users, switching to a preparation with stronger androgenic effects may be beneficial. Estrogen replacement via a patch may have a less negative effect on desire than oral estrogen. For those taking anti-depressants, bupropion (Wellbutrin) may cause fewer sexual side effects.

Alternative medicine may offer some benefits. Acupuncture and herbal medicines may affect libidio by improving overall well-being. The herbal supplement, Avlimil, has been promoted for treating female sexual dysfunction. The manufacturer funded a study involving 49 women aged 25 to 65 years which found an overall improvement in sexual dysfunction. However, this product is not FDA-approved and does not list the quantities of individual ingredients. Moreover, it is contraindicated in pregnancy and in women with hormone-sensitive conditions, such as endometriosis and breast, uterine and ovarian cancer. Avlimil contains the neurotoxin thujone which is found in sage leaf. In small amounts it is safe, but in higher doses can cause toxicity with nausea, headache and abdominal discomfort.

There exists no consensus about testosterone replacement in women with impaired sexual desire. There are currently no FDA-approved testosterone formulations for use in women. It is also not clear what the normal or therapeutic levels are for women. Carefully selecting women who may be appropriate candidates is the first step. A woman complaining of lowered libido should have their free and total testosterone levels checked. A baseline lipid profile and liver enzyme levels should also be included as testosterone replacement can have deleterious effects in these areas.

If testosterone levels are found to be low, then replacement can be considered. Testosterone can be supplemented through standard hormone replacement products which included estrogen replacement (Estratest) or natural alternatives such as micronized testosterone, testosterone proprionate 2 percent in petroleum applied to the skin or testosterone sublingual troches. Currently, there is a testosterone patch designed for women with female sexual dysfunction that is under investigation.

However, as a testament to the complexity of sexual desire, women who have low testosterone levels and lowered libido do not uniformly respond to testosterone supplementation. Reviewing one's stressors, relationships and sexual routines is recommended even if there seems to be a physiological reason for low sexual desire. Psychotherapy can be useful to address the emotional issues that may contribute to low desire.

A search for other types of sexual dysfunction is also warranted as several types of dysfunction can coexist. These include disorders of arousal and orgasm and sex pain disorders. As with disordered desire, you and your physician should consider medical and psychological contributing factors.

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