Treatment for low sexual desire includes office-based counseling, psychological therapy, and medications. Office-based counseling can be facilitated using an approach based on the PLISSIT model employed in sex therapy. (The letters of the model's name refer to the four different levels of intervention that a sex therapist can use: permission [P], limited information [LI], specific suggestions [SS], and intensive therapy [IT].) In addition to sex therapy, intensive psychological therapy may include cognitive-behavioral training and mindfulness-based stress reduction training (see Chapter e4-06).
Based on the understanding of sexual excitatory and inhibitory pathways, medications that increase dopamine or decrease serotonin release or binding may be effective in increasing sexual desire. Flibanserin, which is a full agonist of the 5-HT1A receptor and, with lower affinity, an antagonist of the 5-HT2A receptor, was the first FDA-approved medication for the treatment of low sexual desire in premenopausal women. A 2016 systematic review evaluated the efficacy of flibanserin in 5914 premenopausal and postmenopausal women. Compared to women taking placebo, women who were taking flibanserin had a small increase in the number of satisfying sexual events and sexual desire intensity but were four times more likely to experience the side effects of dizziness and somnolence.
Flibanserin is prescribed in a single daily oral dose of 100 mg, to be administered at bedtime. Consumption of alcohol with this medication is contraindicated due to the potential for adverse effects, including syncope and hypotension. Additionally, prescribing clinicians are required to complete a knowledge certification and enrollment process before prescribing this medication.
Bremelanotide, a melanocortin receptor agonist, is also FDA-approved for the treatment of HSDD in premenopausal women; the mechanism by which it improves sexual desire is unknown. In two randomized controlled trials, including 1247 women, patients had modest improvements in sexual function scales when compared with placebo (25% vs 17%). The medication is a subcutaneous injection (1.75 mg) dosed as-needed, 45 minutes prior to sexual activity and it may be taken no more than once a day or 8 times per month; pricing in the United States is approximately $100–250 per autoinjector. Side effects include nausea (in 40% of patients, including some requiring antiemetics), vomiting, and skin darkening (1%); transient blood pressure elevations may also occur, so it should not be used in women with uncontrolled hypertension. Patients taking naltrexone for the treatment of drug or alcohol use disorders should not take bremelanotide as it may decrease naltrexone levels to the subtherapeutic range.
Several studies have investigated the efficacy of testosterone for the management of hypoactive sexual desire disorder. The results of a systematic review of seven randomized trials involving more than 3000 menopausal women showed that the testosterone patch, compared to placebo, resulted in a significant increase in the number of sexually satisfying encounters and sexual activity as well as sexual desire and orgasms. Side effects included increased acne and hair growth, although there was no significant difference in serious adverse events. However, the lack of FDA-approved testosterone formulations for women with sexual dysfunction (because of insufficient long-term safety data) limits off-label use of this medication for treatment.
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