• Information
  1. Classification of FSD
  2. Drug Classes for FSD
  3. Estrogens
  4. Androgens
  5. Other Agents

A. Classification of FSD

1. Hypoactive Sexual Desire Dirosder
2. Sexual Arousal Disorder
3. Dyspareunia (painful intercourse): Vaginal Dryness and others
4. FSD associated with psychiatric disorders, primarily anxiety and/or depression
5. FSD associated with various medications, particularly common antidepressants
6. FSD associated with nerve damage, such as multiple sclerosis, severe prolonged diabetes

B. Drug Classes for FSD

1. No drugs are currently approved by FDA for FSD
2. Estrogens
3. Androgens
4. Buproprion (Atypical Antidepressant)
5. Sildenafil (phosphodiesterase type 5 inhibitor)
6. Alprostadil (prostacyclin analog)
7. Apomorphine (dopamine agonist)
8. Vaginal Moisturizers and Lubricants
   1. Over the counter (OTC)
   2. KY Jelly®, Replens®

C. Estrogens

1. Can increase glandular secretions and thickness and elasticity of vagina
2. Reversing atrophic vaginitis and dryness associated with dyspareunia and sexual pain
3. Vaginal estrogens are more effective than oral estrogen for vaginal symptoms
4. Systemic Estrogens
   1. Clearly benefitical or FSD with hot flushes and night sweats (vasomotor symptoms)
   2. No evidence that estrogen enhances desire, arousal or sexual resonse
   3. In women with intact uterus who take an estrogen, progesterone must be added
   4. Complete review on use of systemic estrogens ± progesterone should be made with patient
   5. Note absolute and relative contraindications for systemic HRT
   6. Topical estrogens very effective for vaginal symptoms, generally well tolerated
5. Absolute Contraindications to Systemic HRT [2,3]
   1. Pregnancy
   2. Unexplained vaginal bleeding
   3. Active or chronic liver disease
   4. History of endometrial cancer (consider raloxifene; see below)
   5. History of breast cancer (SERM should be used; see below)
   6. Recent vascular thrombosis
   7. Informed patient refusal
6. Relative Contraindications to Systemic HRT
   1. Hypertriglyceridemia
   2. History of thromboembolic disease
   3. Gallbladder disease
   4. Migraine headaches
   5. Uterine leiomyoma
   6. Seizure disorder
7. Systemic Estrogens (incomplete listing) [2]
   1. Conjugated Estrogens (Premarin®) - 0.625mg x 28 days
   2. Plant-derived ("Phyto") Estrogen - estropipate (Ogen®) 0.625mg po qd
   3. Estradiol - usually 1mg
   4. Ethinyl estradiol - usually 5µg
8. Systemic Estrogen-Progesterone Combinations [4]
   1. Prempro® (28d each): 0.3mg conjugated equine strogen/1.5mg medroxyprogesterone; (also available as 0.45mg/1.5mg, 0.625/2.5 and 0.625/5)
   2. Activella®: 1mg estradiol/0.5mg norethindrone; 0.5mg estradiol/0.1mg norethindrone
   3. Angeliq®: 1mg estradiol/0.5mg drospirenone
   4. FemHRT: 5µg ethinyl estradiol/1mg norethindrone acetate; also available 2.5µg/0.5mg
   5. Prefest®: 1mg estradiol/0.09mg norgestimate
   6. Combi-Patch®: 0.05 estradiol/0.14mg norethindrone; also available 0.05mg/0.25mg patch
   7. Climara Pro®: 0.045 estradiol/0.015 levonorgestrel patch
9. Atrophic Vaginitis Treatment [5]
   1. Local application of vaginal estrogenic agents
   2. Vaginal tablets (Vagifem®)
   3. Vaginal cream (Vestine®, Synopause®)
   4. May improve sexual enjoyment as well [1,5]

D. Androgens [6]

1. Androgen Levels and Sexual Function [7]
   1. No single androgen level is predictive of low female sexual function
   2. Low serum DHEA-S levels are best correlated with reduced arousal, responsiveness, pleasure, and organism but not desire or self image
   3. Levels of testosterone and androstenedione do not correlate well with sexual function
2. Testosterone Replacement [6,8]
   1. May improve sexual arousal and libido
   2. Concern for undesirable effects of androgens are significant (see above)
   3. May be most appropriate in women undergoing bilateral oophorectomy
   4. Physiologic doses should be used, and levels may be monitored
   5. Low dose methyltestosterone (1.25-2.5mg/d) appears safe and may be effective
   6. High doses can cause liver dysfunction
   7. Liver function tests (LFTs) should be monitored
   8. Transdermal testosterone patch (150-300µg/d) improves sexual function, well being [8]
   9. Testosterone patch has no hepatic or lipid effects compared with placebo [8]
   10. The overall long-term risks are not well understood at this time
3. DHEA Therapy
   1. DHEA is an androgenic steroid normally made by the adrenals
   2. DHEA increases serum insulin-like growth fractor 1 (IGF-1) levels
   3. DHEA is converted to androstenedione and testosterone
   4. Low DHEA sulfate (DHEA-S) levels in blood correlate with reduced sexual function [7]
   5. May reduce HDL levels slightly when given to women with adrenal insufficiency
   6. Increases well being, sexual interest and thoughts in women with adrenal insufficiency
   7. Reduces feelings of anxiety and depression in women with adrenal insufficiency
   8. Dose is 50mg/day or 50mg qod po
   9. No benefit on body composition, physical performance, insulin sensitivity, or quality of life in elderly women (or in elderly men) [9]

E. Other Agents [1]

1. Buproprion (Wellbutrin®)
   1. Atypical antidepressant
   2. Mainly with norepinephrine reuptake inhibition (NERI) and dopamine agonist
   3. Unlike serotonin reuptake inhibitors (SSRI), not associated with FSD
   4. Switching patients from SSRI to buproprion may improve libido and anorgasmia
   5. Buproprion 300-400mg qd (split dosing) increases sexual arousal and orgasm completion
   6. Side effects include enrvousness, insomnia, rarely seizures
2. Sildenafil (Viagra®)
   1. PDE5 inhibitor approved for erectile dsyfunction in men
   2. Increases blood flow to female genitalia, but little benefit in FSD
   3. May be of some benefit in FSD associated with nerve damage, including multiple sclerosis
3. Alprostadil
   1. Intracavernous injection in men (Caverject®, Edex®)
   2. Urethral suppository in men (Muse®)
   3. Cream, not available in USA, has shown minimal benefit in women with FSD
4. Apomorphine (Apokyn®)
   1. Dopamine agonist given subcutaneously for Parkinson's Disease
   2. Oral formulation, not available in USA, minimal effects on arousal in women, causes nausea
5. Phentolamine
   1. alpha-adrenergic blocker
   2. Oral or vaginal solution, neither available in USA, reported to improve arousal in women

References

1. Drugs for Female Sexual Dysfunction. 2007. Med Let. 49(1259):33
2. Manson JE, Hsia J, Johnson KC, et al. 2003. NEJM. 349(6):523
3. Scuteri A, Bos AJG, Brant LJ, et al. 2001. Ann Intern Med. 135(4):229
4. 35. Angeliq. 2007. Med Let. 49(1254):15
5. 34. Potter JE. 2007. JAMA. 297(6):620
6. 12. Bhasin S, Enzlin P, Coviello A, Basson R. 2007. Lancet. 369(9561):597
7. 30. Davis SR, Davison SL, Donath S, Bell RJ. 2005. JAMA. 294(1):91
8. 15. Shifren JL, Braunstein GD, Simon JA, et al. 2000. NEJM. 343(10):682
9. 33. Nair KS, Rizza RA, O'Brien P, et al. 2006. NEJM. 355(16):1647