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Treatment[edit]

Below is a look at what is currently known about treatment options for the DSM-IV diagnoses of sexual and arousal disorders as well as recommendations for future investigations should SIAD be the new diagnosis. It should be noted that this is what is known when looking at arousal, desire, and orgasm separately however there is a lot of overlap within treatment options. When SIAD is entered into the DSM-V the treatment research will likely transfer over to treatment options specific to that diagnosis criteria, until then, however, below is a review of the current understanding.

General Treatments Relevant to All Sexual Problems in Women[edit]

Also see sexual dysfunction. There are some general changes to lifestyle that can impact all sexual function and disorders. Improved well being including diet, exercise, possible alcohol and chemical substance abuse, and sleep should be addressed in all women [1]. Prescription and nonprescription medications, vitamins and herbal supplements and recreational drugs can also impact sexual function [1]. Finally, education about basic genital anatomy and physiology, and a discussion of sexual stimulation and sexual activities other than intercourse should be part of early stage treatment as well as learning to use techniques that enhance arousal [1].

Treatment Issues Specific to Low Desire[edit]

For more information specific to desire disorders, see hypoactive sexual desire disorder

Psychosexual Treatments for Low Desire[edit]

There are only a few studies looking at treatments that focus specifically on low desire [1]. However, in treatment, when low desire is accounted for by depression, poor body image, sexual assault, or other factors, these factors must be addressed first [1]. Some psychosexual treatments that have shown to impact desire have been group cognitive behavioral therapy treatments [2], a modified Masters and Johnson sex therapy [3], and sensate focus and traditional sex therapy techniques [4]. In one non-controlled trial, mindfulness-based cognitive therapy administered in a group format to women with mixed HSDD and FSAD resulted in significant improvements in sexual desire and other domains or sexual response and mood [5].

Recommendation[edit]

Psychological approaches have a long history of being effective immediately after treatment and sustained, as well as not having any adverse side effects. [1] . Newer cognitive-behavioural treatments which integrate mindfulness meditation show excellent promise but require controlled testing [1] so this may be worth investing in. In general more randomized, controlled testing is required in order to make more conclusive inferences about these treatments. [1]

Hormonal Treatments for Low Desire[edit]

Testosterone (T) has been used for hormonal treatment since the 1930s [1]. In more recent controlled studies 300μg/day patch increased sexual desire [6], [7], [8], [9]. However, in one study 30% of T group experienced androgenic side effects and there were four new cases of breast cancer in the T but not the placebo group [10]. In Europe, Tibolone (an androgenic, progestogenic, and estrogenic synthetic hormone) is available and has shown a significant increase in Female Sexual Function Index (FSFI) after 24 weeks of use [11]. It has also been shown to significantly increase sexual desire, arousability, vaginal lubrication, and the frequency of sexual fantasies compared to a placebo condition [12].

Recommendation[edit]

T therapy is effective for estrogen-replete, naturally menopausal women and marginally effective for pre-menopausal women however there is conflicting data showing no effect among cancer survivors with HSDD. The long-term risks are unknown for breast cancer, insulin resistance, and metabolic syndromes so careful discussion of risks is necessary before using this treatment method [1] .

Nonhormonal Medications for Low Desire[edit]

In non-depressed women with HSDD, the anti-depressant Bupropion was found to significantly improve sexual arousal and orgasm but not sexual desire. [13]. As well it is seen to benefit both males and females [14]. Flibanserin is a centrally acting agent for HSDD however the method of action is not fully understood. It is suggested to act on a 5-HT2A serotonin receptor agonist and 5-HT1A serotonin receptor antagonist. [15] A pooled analysis of 1378 premenopausal US women showed a statistically significant increase in the frequency of sexually satisfying events in women taking Flibanserin [15]. However, in 2010 the FDA did not approve of the drug stating that the results were not robust enough to justify the risks [16].

Recommendation[edit]

These medications do show promise but randomized controlled trials are required [1].

Treatment Issues Specific to Low Arousal[edit]

For more information specific to arousal disorders, see female sexual arousal disorder

Psychological Treatments[edit]

Generally sensate focus and masturbation training are used as psychological treatment for low arousal, and tends to emphasize self-focus and assertiveness [17]. However, there have not been any randomized control trial studies for psychological treatment of FSAD.

Recommendation[edit]

Psychological treatment should be recommended for FSAD because the majority of sexual arousal problems in healthy women are not due to impaired genital responsiveness [1].

Hormonal Pharmacotherapy for FSAD[edit]

In a placebo controlled study with hypogonadotropic hypogonadal women or those suffering from hypogonadism, treatment with [[testosterone undecanoate enhanced genital arousal [18]. Local and systemic estrogen treatment benefits vulvo-vagnial atrophy and relieves vaginal dryness and dyspareunia [19]. [20]. As well Tibolone has been used as treatment in postmenopausal women in a randomized, double-blind, cross-over study and showed a significant increase in vaginal blood flow in response to erotic fantasy [21]. This is associated with a significant increase in sexual desire, frequency of arousability and of sexual fantasies compared with those taking a placebo [21]. Vaginal lubrication was significantly improved as well [21].

A randomized controlled trial studying the effect of vaginal application of dehydroepiandrosterone (DHEA) on vaginal atrophy in postmenopausal women showed rapid beneficial change to vaginal epithelial cell maturation and vaginal pH as well as increase sexual desire/interest, sexual arousal, orgasm, and pain [22].

Nonhormonal Pharmacotherapy for FSAD[edit]

For men, there has been the development of many pharmacological treatments in order to treat arousal disorders and many pharmacological treatments have been tested in women, however none have been approved for use for women [1] .

Treatment Issues Specific to Difficulties with Orgasm[edit]

For more information specific to orgasmic disorders, see female orgasmic disorder. There is some evidence that shows significant heritability in orgasmic function both alone or with a partner [23]. Directed masturbation, sex education, anxiety reduction techniques, and CBT remain the main therapeutic tools for anorgasmia [1]. However, sildenafil used for women with SSRI-induced FOD showed to have significantly fewer negative sexual side effects [24].

The Placebo Response[edit]

For more information specific to placebo response, see placebo. With all of these treatments, there is significant placebo response among women randomized to the placebo group of a drug trial [25], [26], [27], [28]. Bradford and Meston reviewed 16 placebo-controlled pharmacological trials in women’s sexual dysfunction and found that placebo response is stronger in retrospective studies, those studies using postmenopausal women, and those focusing on sexual desire. [29].

Overall Recommendations For SIAD Treatment[edit]

Some of the issues with the current research on treatment for female desire and arousal disorders are that few studies have looked at arousal and sexuality from a cultural perspective and thus these disorders are observed through an ethnocentric lens, sexual stimulation must be assessed, studies with better methodological trials on psychological treatments are needed, and subjective excitement, pleasure, and relationship satisfaction should be targeted end points in all future randomized control trials [1].

==References==

  1. ^ a b c d e f g h i j k l m n o Brotto, L., Bitzer, J., Leiblum, S., & Luria, M. (2010) Women’s Sexual Desire and Arousal Disorders. ‘’International Society for Sexual Medicine 7’’: 586-614.
  2. ^ Trudel, G., Marchand, A., Ravart, M., Aubin, S., Turgeon, L., Fortier, P. (2001). The effect of a cognitive behavioral treatment program on hypoactive sexual desire in women. Sex Relat Ther 16:145–64.
  3. ^ Hawton, K., Catalan, J., Fagg, J. (1991) Low sexual desire: Sex therapy results and prognostic factors. Behav Res Ther 29:217–24.
  4. ^ Sarwer, D.B., Durlak, J.A. (1997) A field trial of the effectiveness of behavioral treatment for sexual dysfunctions. J Sex Marital Ther 23:87–97.
  5. ^ Brotto, L.A., Basson, R., Luria, M. (2008) A mindfulness-based group psychoeducational intervention targeting sexual arousal disorder in women. J Sex Med 5:1646–59.
  6. ^ Shifren, J.L., Braunstein, G.D., Simon, J.A., Casson, P.R., Buster, J.E., Redmond, G.P., Burki, R.E., Ginsburg, E.S., Rosen, R, Leiblum, S.R., Caramelli, K.E., Mazer, N.A. (2000) Transdermal testosterone treatment in women with impaired sexual function after oopherectomy. N Engl J Med 343:682–688.
  7. ^ Braunstein, G.D., Sundwall, D.A., Katz, M., Shifren, J.L., Buster, J.E., Simon, J.A., Bachmann, G., Aguirre, O.A., Lucas, J.D., Rodenberg, C., Buch, A., Watts, N.B. (2005). Safety and efficacy of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: A randomized, placebo-controlled trial. Arch Intern Med 165:1582–9.
  8. ^ Lobo, R.A., Belisle, S., Creasman, W.T., Frankel, N.R., Goodman, N.F., Hall, J.E., Ivey, S.L., Kingsberg, S., Langer, R., Lehman, R., McArthur, D.B., Montgomery-Rice, V., Notelovitz, M., Packin, G.S., Rebar, R.W., Rousseau, M., Schenken, R.S., Schneider, D.L., Sherif, K., Wysocki, S. (2006) Should symptomatic menopausal women be offered hormone therapy? Med Gen Med 8:40.
  9. ^ Shifren, J.L., Davis, S.R., Moreau, M., Waldbaum, A., Bouchard, C., DeRogatis, L., Derzko, C., Bearnson, P., Kakos, N., O’Neill, S., Levine, S., Wekselman, K., Buch, A., Rodenberg, C., Kroll, R. (2006) Testosterone patch for the treatment of hypoactive sexual desire disorder in naturally menopausal women: Results from the INTIMATE NM1 Study. Menopause 13: 770–779.
  10. ^ Davis, S.R., Moreau, M., Kroll, R., Bouchard, C., Panay, N., Gass, M., Braunstein, G.D., Hirschberg, A.L., Rodenberg, C., Pack, S., Koch, H., Moufarege, A., Studd, J., The APHRODITE Study Team. (2008) Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med 359:2005– 2017.
  11. ^ Nijland, E.A., Schultz, W.C.M.W., Nathorst-Boös, J., Helmond, F.A., Van Lunsen, R.H., Palacios. S., Norman, R.J., Mulder, R.J., Davis, S.R. (2008) Tibolone and transdermal E2/NETA for the treatment of female sexual dysfunction in naturally menopausal women: Results of a randomized active-controlled trial. J Sex Med 5:646–656.
  12. ^ Laan, E., van Lunsen, R.H.W., Everaerd, W. (2001) The effects of tibolone on vaginal blood flow, sexual desire and arousability in postmenopausal women. Climacteric 4:28–41.
  13. ^ Segraves, R.T., Clayton, A., Croft, H., Wolf, A., Warnock, J. (2004) Bupropion sustained release for the treatment of hypoactive sexual desire disorder in premenopausal women. J Clin Psychopharmacol 24:339–42.
  14. ^ Crenshaw, T., Goldberg, J., Stern, W. (1987). "Pharmacologic modification of psychosexual dysfunction". Journal of Sex & Marital Therapy 13: 239–252.
  15. ^ a b Boehringer-Ingelheim news release. Available at: http://www.boehringer-ingelheim.com/corporate/news/press_releases/detail.asp?ID=7095 (retrieved November 16, 2009).
  16. ^ "Drug for sexual desire disorder opposed by panel". New York Times. 18 June 2010
  17. ^ Both, S., Laan, E. (2003) Directed masturbation. In: O’Donohue, W., Fisher, J.E., Hayes, S.C., eds. Cognitive behavior therapy: Applying empirically supported techniques in your practice. New York: John Wiley & Sons 144–151.
  18. ^ Tuiten, A., Laan, E., Panhuysen, G., Everaerd, W., de Haan, E., Koppeschaar, H., Vroon, P. (1996) Discrepancies between genital responses and subjective sexual function during testosterone substitution in women with hypothalamic amenorrhea. Psychosom Med 58:234–241.
  19. ^ The North American Menopause Society. The role of local vaginal estrogen for treatment of vaginal atrophy: 2007 position statement of the North American Menopause Society. (2007) NAMS 14:355–356.
  20. ^ Suckling, J., Lethaby, A., Kennedy, R. (2006). Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev 4:CD001500.
  21. ^ a b c Laan, E., van Lunsen, R.H.W., Everaerd, W. (2001). The effects of tibolone on vaginal blood flow, sexual desire and arousability in postmenopausal women. Climacteric 4:28–41.
  22. ^ Labrie, F., Archer, D., Bouchard, C., Fortier, M., Cusan, L., Gomez, J., Girard, G., Baron, M., Normand, A., Moreau, M., Dube, R., Cote, I., Labrie, C., Lavoie, L., Berger, L., Gilbert, L., Martel, C., Baker, J. (2009). Intravaginal dehydroepiandrosterone (Prasterone), a physiological and a highly efficient treatment of vaginal atrophy. Menopause 16:907–22.
  23. ^ Dunn, K.M., Cherkas, L.F., Spector, T.D. (2005) Genetic influences on variation in female orgasmic function: a twin study. Biol Lett 1:260–263.
  24. ^ Nurnberg, H.G., Hensley, P.L., Heiman, J.R., Croft, H.A., Debattista, C., Paine, S. (2008) Sildenafil treatment of women with antidepressant-associated sexual dysfunction: A randomized controlled trial. JAMA 300:395–404.
  25. ^ Davis, S.R., Moreau, M., Kroll, R., Bouchard, C., Panay, N., Gass, M., Braunstein, G.D., Hirschberg, A.L., Rodenberg, C., Pack, S., Koch, H., Moufarege, A., Studd, J., the APHRODITE Study Team. (2008) Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med 359:2005–2017.
  26. ^ Basson, R., McInnes, R., Smith, M.D., Hodgson, G., 
Koppiker, N. (2002). Efficacy and safety of sildenafil citrate in women with sexual dysfunction associated with female sexual arousal disorder. J Womens Health Gend Based Med 11:339–349.
  27. ^ Buckler, H.M., Robertson, W.R., Wu, F.C. (1998). Which androgen replacement therapy for women? J Clin Endocrinol Metab 83:3920–3924.
  28. ^ Davis, S., Papalia, M., Norman, R.J., O’Neill, S., Redelman, M., Williamson, M., Stuckey, B.G.A., Wlodarczyk, J., Gard’ner, K., Humberstone, A. (2008). Safety and efficacy of a testosterone metered-dose transdermal spray for treating decreased sexual satisfaction in premenopausal women: A randomized trial. Ann Intern Med 148:569–577.
  29. ^ Bradford, A., Meston, C.M. (2009). Placebo response in the treatment of women’s sexual dysfunctions: A review and commentary. J Sex Marital Ther 35:164–81.
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