Treatment Options for the Patient with Low Sexual Desire

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Distinguish between potential causes of Low Sexual Desire
2. Discuss different treatment options for Low Sexual Desire

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Genoox, Inc., and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2019, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

Ascertain if the patient’s primary concern is HSDD (Hypoactive Sexual Desire Disorder, i.e. low desire) and screen for arousal, orgasm or pain issues.

Determine if the problem is primarily desire and not secondary to arousal, orgasm or pain issues
Ascertain if the problem is universal rather than situational
- That is, determine that the lack of desire is persistent in every situation and does not appear to be a response to particular problematic relationship
Treatment with medication can be extremely effective but simultaneous consultation with a sex therapist can be encouraged

SYNOPSIS:

HSDD is the absence of fantasies and the absence of desire for sexual activity. In order for it to be considered a dysfunction, it must be causing distress or marked interpersonal difficulty. Since HSDD can be secondary to problems with pain, arousal or orgasm, those problems should be screened for as well and treated as appropriate. Treating HSDD successfully, often requires a complex combination of drugs, behavior modification and in some cases psychotherapy.

KEY POINTS:

Interview with patient should confirm that HSDD is a primary concern and not merely a result of other problems (e.g. problems with arousal, orgasms or pain)
If the HSDD seems most likely to be a result of other issues, those should be treated first before the low desire is addressed
- Sometimes when the primary issue is resolved, the lack of desire is resolved as well
Ascertain if the HSDD is a result of medications that can adversely affect levels of desire
While many medications can include adverse effects on sexual desire, some of the most common to do so include hormonal birth control and SSRIs
- If it is likely that HSDD is a result of medications, consider reducing or eliminating those under the guidance of the prescribing clinician
In the event that patient complains of low desire only within the context of current relationship, consider making a referral to a couple’s therapist
- This referral does not necessarily require a sex therapist, although a couple’s counselor with expertise in sex therapy would likely be the most effective
If circumstances lead to treatment for low desire, the following medications have been used:
- Testosterone (not FDA approved for this use)
  - Topical gel (1%)
  - Pellet – 75 mg pellet (1-2 pellets) administered every three months

- Flibanserin (FDA approved) – 100 mg tablet, nightly at bedtime
  - Note prescribers need to have completed an online exam in order to prescribe

- Estrogen therapy (with progesterone, if applicable) if concerns related to menopausal issues
- Bremelanotide (FDA approved) – injection under the skin of the abdomen or thigh at least 45 minutes before anticipated sexual activity
  - Optimal time to use bremelanotide is based on how they experience the duration of benefit and any side effects, such as nausea
  - Patients should not use more than one dose within 24 hours or more than eight doses per month

- The patient should be referred for sex therapy while they are being treated
- While medications can help the patient physiologically, sex therapy can help address and alleviate both bad habits, communication issues and insecurities can continue to affect the sexual relationship