Sharon J. Parish1, 2 and Steven R. Hahn3
(1)
Weill Cornell Medical College, New York, NY, USA
(2)
Westchester Division, New York Presbyterian Hospital, 21 Bloomingdale Rd, White Plains, NY 10605, USA
(3)
Albert Einstein College of Medicine, Bronx, NY, USA
Sharon J. Parish
Email: shp9079@mail.cornell.edu
Keywords
Hypoactive sexual desire disorderDistressing low libidoAndrogen deficiencyHormonal insufficiencyMenopausal symptoms
20.1 Introduction and Definition
Diminished sexual desire that causes personal distress, the defining symptom of hypoactive sexual desire disorder (HSDD) , is a relatively common but commonly undiagnosed problem that significantly affects 8.9 % of US women between the ages of 18 and 44, 12.3 % of women ages 45–64, and 7.4 % of women over 65 [1]. In the past decade, substantial research has emerged on the epidemiology and natural history of HSDD, its impact on women and their partners, and approaches to detection and diagnosis, motivated partly in pursuit of effective treatment. This chapter will describe the epidemiology and impact of HSDD, discuss causes and factors, and present strategies for screening and diagnosis of this important condition.
20.1.1 Definition of HSDD: DSM-IV-TR vs. DSM-5
HSDD is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) , as persistent deficient sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty and is not better accounted for by another psychiatric disorder or due exclusively to the direct effect of a substance, medication, or general medical condition [2]. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, published in May 2013, desire and arousal disorders have been merged into a singular category entitled female sexual interest/arousal disorder (FSIAD) [3]. However, clinicians have utilized DSM-IV-TR criteria for several decades and have no research data or real clinical experience applying DSM-5 criteria to female sexual dysfunctions. Therefore, the discussion in this chapter is based on the long-standing DSM-IV-TR criteria.
The main differences between the DSM-IV-TR and DSM-5 are the merger of desire and arousal into the single female sexual interest/arousal disorder; the rating of disorders as mild, moderate, and severe; the requirement that the disorder be present for at least 6 months during the majority (>75 %) of encounters; and that it causes significant distress in the individual. Both schemas include the specifiers, indicating whether the disorder is lifelong (no prior history of normal functioning) or acquired (previous normal function) and whether it is generalized (all partners, activities, situations, forms of sexual expression) or situational (certain partners, situations, practices). When the disorder is situational, the woman may continue to masturbate or have partners outside the primary relationship but has decreased interest in her primary partner.
Women with HSDD usually do not initiate sexual activity and participate only reluctantly when their partners initiate sex. Sexual activity is often infrequent. Standards for frequency and degree of sexual desire do not exist; therefore, the diagnosis of this disorder is mainly based on clinical judgment, evaluating the individual’s characteristics, her interpersonal situation, the life stage and circumstances, and sociocultural factors.
20.1.1.1 Further Defining HSDD
In the DSM-IV-TR schema, HSDD is also subtyped as due to psychological or combined factors or “due to a medical condition” or a substance. HSDD is usually not diagnosed when the sexual dysfunction is due exclusively to another psychiatric disorder such as major depressive disorder, unless the decreased desire predated depression or is “a focus of independent clinical attention” [2].
The American Urological Association (AUA) has added an absence of sexual thoughts and a lack of desire in response to sexual stimulation (responsive desire) to the DSM-IV-TR definition. A further modification is the specification that the decrease in interest in sex must exceed that normally observed with increasing age and with the duration of sexual relationships [4]. Currently, the ICD-10 system used worldwide classifies sexual dysfunctions under behavioral syndromes associated with physiological disturbances and physical factors (F52 for female sexual dysfunction) and states that “Sexual dysfunction covers the various ways in which an individual is unable to participate in a sexual relationship as he or she would wish” [5]. HSDD is defined as a lack or loss of sexual desire that is the principal problem and is not secondary to other sexual difficulties, such as dyspareunia.
20.1.2 Models of Female Sexual Response
Female sexual dysfunction has been classified in the DSM based on the traditional human sexual response cycle which, when first described by Masters and Johnson [6], consisted of four phases: excitement, plateau, orgasm, and resolution. Kaplan [7] and Lief [8] modified this model by adding a desire phase and eliminating the plateau and resolution phases resulting in the linear three-phase model: desire, arousal, and orgasm. Basson and others argue that the three phases are more circular than linear [9]. Women may experience arousal, orgasm, and satisfying sexual experiences without initially, or ever, having desire for sex as a distinct experience. Women may be motivated to engage in sexual activity for many reasons besides desire for sexual activity per se including desire for intimacy or to communicate affection for a partner. Accordingly, sexually stimulating physical intimacy, initiated in response to one of these motives, may lead to arousal and only subsequently to what has been called “responsive desire” [4]. In a cross-sectional nonclinical cohort of 573 Danish women, approximately one-third of the study population endorsed each of the three models (Masters and Johnson, Kaplan, Basson) and 12.5 % none of the models; women who endorsed the cyclical Basson model or none of the models were more likely to have sexual dysfunction and distress (P = 0.01) [10].
20.2 Epidemiology
West et al. assessed 1944 nonpregnant women ages 30–70 in steady relationships for 3 months or longer. The prevalence of low sexual desire was 36.2 %, and the prevalence of distressing low sexual desire was 8.3 % [11]. The prevalence of low sexual desire increased with age and was higher in surgically menopausal women regardless of their current age or their age at the time of surgery. The highest rate of low sexual desire with distress was observed in young, surgically menopausal women (19.8 %).
Another study by Hayes et al. in women ages 20–70 also found that the proportion of women with low desire increased with age, but the increase was counterbalanced by a decrease in the proportion of women with distress about low sexual desire; as a result, the prevalence of distressing low sexual desire was relatively constant with age, ranging from 6 to 13 % in Europe and 12–19 % in the USA [12].
20.2.1 The PRESIDE Study and HSDD Registry
In the widely cited study, the Prevalence of Female Sexual Problems Associated with Distress and Determinants of Treatment Seeking (PRESIDE) , desire, arousal, and orgasm problems in a large population-based survey of adult US women (n = 31,581) were evaluated [1]. A response of “never” or “rarely” to the single question, “How often do you desire to engage in sexual activity?” was used to define a problem with desire, and the Female Sexual Distress Scale (FSDS) [13] was used to define distress (score of at least 15 out of a possible 48 points). The combination of low desire plus an FSDS score of 15 or higher was used as the self-report survey-based indicator of decreased sexual desire with distress. Low desire was reported in 37.7 % (age-adjusted estimate) of subjects and was the most common sexual problem reported, and distressing low desire affected 10 % of US women. Low sexual desire with distress occurred with a second distressing sexual problem in fewer than 5 %, and 2.3 % had all three distressing problems.
The HSDD Registry for Women is a multicenter, longitudinal study of women with HSDD which enrolled 1500 women with clinically diagnosed HSDD between 2008 and 2010. Half (50.2 %) of 426 premenopausal women also had arousal problems and 43.5 % reported lubrication problems, while 58 % of 174 sexually active postmenopausal women had arousal and 56.9 % had lubrication problems [14].
20.2.2 Impact of Low Desire on Quality of Life
Women with distressing low sexual desire have lower health-related quality of life. In the National Health and Social Life Survey (NHSLS), women with desire, arousal, and sexual pain problems had lower physical and emotional satisfaction with their partners and lower general happiness than women without sexual problems [15]. In the WISHeS study of postmenopausal US women, distressing low sexual desire was associated with lower health-related quality of life in seven out of eight domains of functioning including physical function, general health, vitality, social functioning, emotional role functioning, and mental health [16]. Women with low desire were more likely to be dissatisfied with their sex life, their partner, or their marriage and experienced more negative emotional states including frustrations, hopelessness, anger, poor self-esteem, and loss of femininity [16].
20.3 Factors Associated with Distressing Low Desire
20.3.1 Partners and Life Situation
In the PRESIDE study, life situation and social status had a significant relationship with the prevalence of distressing low sexual desire [17]. Caucasian women were more likely than African-American women to have HSDD. Working, midlife, married, and partnered women were more likely to have distressing low sexual desire. When marital status and availability of a sexual partner were considered together, single women with a sexual partner were at lowest risk for distressing sexual desire.
20.3.2 Menopause, General Health, and Psychiatric Disorders
In the WISHeS study, postmenopausal women, especially young women with surgical menopause, were more likely to have distressing low sexual desire than cycling premenopausal women [16]. In PRESIDE, while self-reported distressing low sexual desire was not associated with current hormone use in postmenopausal women, perceived overall health status, thyroid disease, and urinary incontinence showed significant associations with this sexual problem [17]. Depression, based on positive response to either of the two screening questions about depressed mood or anhedonia or the current use of antidepressants, and anxiety substantially increased the likelihood of distressing low sexual desire. In the HSDD Registry for Women study, one-third of premenopausal women met criteria for depression and also reported lower sexual function and relationship quality [18].
20.3.3 Antidepressant and Other Medications and Substances
Although the determination about whether the loss of desire is primarily due to depression alone may be challenging, treatment may clarify the importance of comorbid HSDD. Most antidepressants are associated with both orgasm and desire disorders, afflicting at least one-third of more users [19]. Therefore, treatment of depression with medication may substitute one cause of sexual dysfunction for another. However, in the HSDD Registry for Women study, women inadequately treated for depression had more severe sexual dysfunction as compared to women whose depression was in remission [18]. Bupropion appears to have significantly less sexual dysfunction compared to selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and norepinephrine uptake inhibitors (SNRIs) [20]. The use of antidepressants and other medications as well as drugs and alcohol should be included in the evaluation of all female sexual dysfunctions. Medications such as β-blockers, oral steroids, H2 blockers, and antidepressants have been reported to be associated with changes in sexual desire.
20.4 Psychophysiological Models of HSDD
The interrelationship between psychosocial and physiological factors and causes of HSDD is complex; Bancroft, Perelman, Pfaus, and others have offered the following elaborative concepts [21].
20.4.1 Dual Control of Sexual Interest and Response
Sexual response is the result of an interaction between sexual excitatory and inhibitory influences that may act independently. HSDD may be the result of insufficient excitatory processes or increased inhibition of sexual interest or response. Inhibition of sexual interest or responsiveness may be an adaptive response to relationship difficulties or life circumstances that serves to help avoid risky, distressing, or threatening sexual situations and behavior [22].
20.4.2 Central Nervous System and HSDD
Sexually excitatory processes include central pathways in the limbic system and hypothalamus utilizing neurotransmitters such as dopamine, oxytocin, melanocortin, and norepinephrine. Sexual inhibitory processes include neurotransmitter systems such as the opioid, endocannabinoid, and serotonergic systems [23] (Table 20.1). Studies using functional brain scanning have demonstrated distinguishable patterns of brain activity during erotic compared to non-erotic experiences in women, and patterns also differ between pre- and postmenopausal women [24]. Specific differences in processing arousing stimuli and/or retrieval of past erotic experiences were reported in women with HSDD, who appeared to pay more attention to monitoring their own responses when compared with women without sexual dysfunction.
Table 20.1
Decreased sexual desire screener (DSDS)
|
No |
Yes |
|
|
1. In the past, was your level of sexual desire or interest good and satisfying to you? |
||
|
2. Has there been a decrease in your level of sexual desire or interest? |
||
|
3. Are you bothered by your decreased level of sexual desire or interest? |
||
|
4. Would you like your level of sexual desire or interest to increase? |
||
|
5. Please circle all the factors that you feel may be contributing to your current decrease in sexual desire or interest: |
||
|
A. An operation, depression, injuries, or other medical condition |
||
|
B. Medications, drugs, or alcohol you are currently taking |
||
|
C. Pregnancy, recent childbirth, menopausal symptoms |
||
|
D. Other sexual issues you may be having (pain, decreased arousal or orgasm) |
||
|
E. Your partner’s sexual problems |
||
|
F. Dissatisfaction with your relationship or partner |
||
|
G. Stress or fatigue |
||
|
The patient qualifies for the diagnosis of generalized, acquired HSDD if • She answers “YES” to all of questions 1–4, and your review confirms “NO” to all of the factors in question 5. The patient MAY qualify for the diagnosis of generalized, acquired HSDD if • She answers “YES” to all of questions 1–4 and “YES” to any of the factors in question 5; clinical judgment is required to determine if the answers to question 5 indicate a primary diagnosis other than generalized, acquired HSDD. Co-morbid conditions such as arousal or orgasmic disorder do not rule out a concurrent diagnosis of HSDD. The patient does NOT qualify for the diagnosis of generalized, acquired HSDD if • She answers “NO” to any of the questions 1–4 |
Clayton et al. J Sex Med 2009;6:730–738
20.4.3 Intra- and Interpersonal Psychosocial and Cultural Influences
Understanding the intra- and interpersonal psychosocial and cultural components that contribute to a woman’s sexual dysfunction is a critical aspect of the diagnostic process [25]. Her beliefs and in particular her erotic thoughts and her inhibition of them (conscious and/or unconscious) will play a role in critical feedback in facilitating or inhibiting her desire in much the same dualistic manner as the biological factors discussed above. Furthermore, a woman’s sexual dysfunction may be due to or exacerbated by her partner’s sexual problems [26]. Decreased desire, erectile dysfunction, and premature or delayed ejaculation in male partners may produce frustration with sexual activity that leads to a decrease in sexual desire [27]. Assessment of HSDD should include the patient and partner’s sexual practices, frequency of sexual activity, and discrepancies in desire for sex, as well as communication between partners [28]. However, not all discrepancies in frequency preference reflect the presence of HSDD, as other relationship issues may be causing such disparity. In fact, sexual dissatisfaction with a partner or dissatisfaction about any other aspect of the relationship may contribute to sexual problems [29]. Women who only experience decreased desire regarding their partner, but have sexual fantasies or desire for other sexual activities, do not have generalized HSDD; they have a desire problem that is specific to their relationship. A common relationship difficulty that underlies HSDD is an unresolved conflict that leads to covert anger, buried resentment, and unconscious alienation [30]. A past history of sexual trauma is also associated with chronic and intermittent desire disorders [31] that are strongly influenced by the individual’s comfort with safety and intimacy in a relationship.
20.4.4 Hormonal Influences on HSDD
Hormonal abnormalities that can influence desire include hyperprolactinemia, thyroid dysfunction, and androgen deficiency caused by panhypopituitarism, oophorectomy, or adrenalectomy. Following bilateral oophorectomy, testosterone levels decrease by approximately 50 %, and many women report impaired sexual functioning [32]. The age-related decline in androgens parallels a midlife increase in HSDD, and naturally postmenopausal women have higher rates of low desire in comparison to premenopausal women [33, 34]. Overall, testosterone levels are variably associated with distressing low desire [35]. Several studies of postmenopausal women reported a positive correlation between free testosterone levels and self-reported desire [36, 37]. However, in two other population studies, testosterone levels were not correlated with sexual function, and no single testosterone level was predictive of sexual function [38, 39]. In a recent cross-sectional study of 560 pre- and postmenopausal women, free testosterone and androstenedione, measured by mass spectrometry, significantly correlated with sexual desire; but no correlations were observed between the primary androgen metabolite androsterone glucuronide (ADT-G) and sexual desire [40].
Testosterone’s variable association with desire disorders may be based in part on genetic differences in the responsiveness of androgen receptors to testosterone [41]. Also, assays for testosterone levels have not been designed to assess the lower levels found in women and measure testosterone produced in target cells [42].
Decreasing estrogen levels in postmenopausal women result in vulvovaginal mucosal changes, decreased lubrication, dyspareunia, and impaired arousal and may secondarily affect desire [43]. Oral hormonal contraceptives and oral menopausal hormone therapy decrease testosterone production and increases sex hormone-binding globulin (SHBG), thereby decreasing free testosterone and sometimes sexual interest [44]. Increases in SHBG due to hormonal contraception may persist for years, even after termination of oral contraceptive (OC) use [45]. The effect of OCs on sexual functioning is varied. In some studies, the use of OCs is associated with sexual problems including decreased interest in sexual activity and sexual arousal [46]. OC use has also been associated with vestibulodynia or vulvar vestibulitis and inflammation of the vulvar vestibule, as well as an increase in sexual pain [47, 48]. A recent study demonstrated that women who developed vulvar vestibulitis on combined hormonal contraceptives were more likely to have longer CAG repeat lengths in the androgen receptor (AR) gene on the X chromosome than women who did not develop vestibulodynia on the same OCs; the authors postulated that this difference in the impact of OC use on the occurrence of vestibular inflammation is due to decreased free testosterone combined with an “inefficient AR that predisposes women to vestibular pain” [49]. Overall, results regarding the effects of OCs on sexual functioning are mixed, with studies showing increased, decreased, and no change in sexual desire [50, 51]. OC use may improve sexual function by diminishing fear of pregnancy, improving personal appearance (e.g., acne), and decreasing menstrual irregularity and dysmenorrhea. However, in patients in whom OC use may be contributing to decreased interest, arousal, and vestibular pain, alternative forms of contraception (e.g., IUD) should be discussed.
20.5 Diagnosis of HSDD
The diagnosis of generalized HSDD requires establishing a history of few or absent sexual fantasies and/or spontaneous or responsive desire for sexual activity that is associated with personal distress and/or interpersonal difficulties and not limited to a specific situation or relationship and not better explained by a medical or nonsexual psychiatric disorder or the use of medications or substances. Distressing low desire may be characterized by low initiation and frequency or the lack of receptivity to sexual activity. The diagnosis of acquired HSDD requires establishing that the low desire was preceded by a period of normal sexual desire.
20.5.1 Decreased Sexual Desire Screener
Clinicians commonly face an array of barriers when engaging in sexual history taking and the clinical evaluation of sexual problems. Such barriers include discomfort with the topic, time constraints, lack of knowledge about evaluating and managing HSDD and other sexual problems, perceived lack of treatment options, and lack of training in communication skills. Self-administered questionnaires can assist in overcoming some of these roadblocks to effective sexual medicine care.
The Decreased Sexual Desire Screener (DSDS) is a validated, self-report questionnaire that can assist clinicians in making an accurate diagnosis of generalized, acquired HSDD [52] (Fig. 20.1). The first four yes/no questions establish the presence of an acquired decrease in sexual desire that is distressing and that the patient wishes to increase. The fifth question presents an array of causes or exacerbating factors related to lessened desire. Patients who endorse all four need a clinical assessment to confirm their responses and determine the extent to which any of the items reported in question 5 are contributing to decreased desire.
Fig. 20.1
Hormonal and nonhormonal central nervous system regulation of sexual function. Modified from Clayton, AH. Sexual function and dysfunction in women. Psychiatric Clinics of North America 2003;26:673–682. [53]
20.5.2 Other Questionnaires
While the DSDS is based on the diagnostic criteria for HSDD, other screening tools for female sexual dysfunction have been developed that are more dimensional and less specific to HSDD. The female sexual function index (FSFI)© is a 19-item, brief, multidimensional self-report instrument that assesses key dimensions of sexual function in women, including desire, subjective arousal, lubrication, orgasm, satisfaction, and pain. It has been validated in several patient samples, reliably discriminates between sexually disordered and healthy women, and is appropriate for clinical use [54]. The questionnaire, scoring appendix, and computation table for the domain sub-scores and the total score are available at www.fsfiquestionnaire.com. The maximum score is 36, with a cutoff of <26.5 indicating sexual dysfunction. The Female Sexual Distress Scale (FSDS)© and the revised version (FSDS-R)© are validated questionnaires that contain 12 and 13 items which assess distress about sexual problems; the FSDS-R has an additional question about the impact of low desire [55].
20.6 Conclusion
Distressing low sexual desire in women is a common complaint, affecting 7–12 % of women. While low desire increases with age, distress decreases; therefore, the prevalence of distressing low desire is relatively similar across age groups. Young, surgically menopausal (oophorectomized) women are more likely to be distressed about diminished desire than naturally menopausal women. HSDD has significant negative impacts on relationship satisfaction, quality of life, and overall happiness. HSDD should be classified as lifelong or acquired and generalized or situational, and it should be distinguished from sexual dysfunctions which can be better explained by a general medical condition, a nonsexual psychiatric disorder, or the use of a substance or medication. HSDD is described dynamically as an imbalance in the relationship of sexual excitatory and inhibitory processes which are independent of one another and determine sexual response. Inhibitory factors include life situation and relationship factors, personal sexual beliefs and related behaviors, and biological factors, including comorbid medical and mental disorders, medications, and substance use. Given the patient and clinician barriers related to addressing sexual problems, self-report questionnaires can help to facilitate the interview, detection, and identification process.
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