Sheryl A. Kingsberg, PhD
Professor of Reproductive Biology, Case Western Reserve University School of Medicine, Cleveland, OH

Dr KINGSBERG: Good afternoon everybody. We're hoping that you will enjoy this symposium. This is an exciting time in the field of women's sexual health. ASRM is the perfect place to be talking about this topic, since health care professionals really need to get up to speed and become more comfortable addressing the sexual health needs of their female patients.

Today, we're hoping to accomplish this with regard to the assessment and treatment of hypoactive sexual desire disorder in pre- and postmenopausal women. I would like to introduce our speakers today. First, we have Dr Sharon Parish, who is a general internist. She is a clinical educator in the field of behavioral medicine. She is an associate professor of clinical medicine at Albert Einstein College of Medicine. She obtained her MD at Albany Medical College and completed her residency in internal medicine at the George Washington University Medical Center. She also did a fellowship in psychosocial and behavioral medicine at NYU. As an academic general internist, Dr Parish's mission is to bring cutting edge interventions in the interface of medicine and the behavioral sciences to primary care training and practices. So she's going to bring that to our symposium today.

She has authored numerous book chapters and review articles on the primary care approach to female sexual dysfunction and sexual health curriculum. She has created several web-based programs on hypoactive sexual desire disorder, including interactive learning modules using simulated patients. She's on the board of directors of the International Society of the Study of Women's Sexual Health and is the Chairman of the ISWSH Education Committee.

Dr Alan Altman is Assistant Clinical Professor of Obstetrics and Gynecology at Harvard Medical School and a practicing gynecologist specializing in peri- and postmenopausal care and issues of midlife sexuality. He is now a resident of Aspen, Colorado. And he's the author of the book Making Love the Way We Used to or Better and has a new book in press called The Betrayal of American Women: Don't Throw Away Those Hormones so Quickly.

He's the president-elect of the International Society of Women's Sexual Health, and Dr Altman will speak on the assessment and treatment of hypoactive sexual desire disorder and vaginal atrophy and hormones in the postmenopausal woman.

I am a clinical psychologist and professor of reproductive biology at Case Western Reserve University School of Medicine and the Chief of Internal Medicine in the Department of ObGyn at University Hospital's Case Medical Center. I am currently the President of the International Society for Women's Sexual Health; and it is my pleasure again to be here talking about assessment and treatment of hypoactive sexual desire disorder.

My talk is going to be on female sexual dysfunction and hypoactive sexual desire disorder giving the clinician a primer on the approach to this. Dr. Altman and Dr. Parish will follow up with some interesting, innovative work.

Let's start with talking about female sexual health and what is normal. In order for you to really understand how to assess and treat sexual dysfunction in your female patients, you really need to know what normal is in order to know what abnormal is.

Normal really has been culturally determined. Who defines normal anyway? We could use objective standards. We could use statistical approaches, which means that if half the people are normal, half of women are abnormal. There are many ways that we look at what is normal female sexual health.

Now I think it's helpful to look at it historically to think about how culture has affected how health care professionals look at women's sexual health. Historically, women's sexual health has been given very little attention. It's only in the last few years, at best, that we've started to gain a little bit of research, and a bit of grant funding for studying female sexual health.

One of the reasons is, again, culturally determined, that historically, women were considered nymphomaniacs if they enjoyed sex. And really, we can trace this back to the Victorian era. The point at which physicians discovered that orgasm for women was not important for conception, women’s sexual health became demonized. Once that happened, it took Sex and the City for women's sexual health to reach primetime. Even still, it is culturally determined.

Our culture says what's healthy sexuality, what's not healthy sexuality. That puts women in a very uncomfortable double bind. They're considered frigid if they don't really like sex, and they're considered promiscuous if they do. They really don't know how to find that balance. They may be looking to you as healthcare professionals to guide them as what's normal, what should be what's going on in her sexual life.

If we think about, therefore, a sexual response and what would be normal— because they're going to come into your office and they're going to say, "Well, is my sexual response OK? Is it normal?" We think, "Well, what model are we going to use to understand this?”

There are several models that have attempted to improve our understanding of women's sexual function, and the first one—ironically—is probably the only one, for those of you who went to medical school, that you have been exposed to. In fact, very few people get sexual health education in medical school, or in nursing school. So if you did get your 1 required hour in 4 years of medical school and residency, what you probably learned is Masters and Johnson sexual response cycle.

They were two of the first to pioneer research in understanding sexual health in both men and women. They studied the physiology of the sexual response in the lab in both men and women. Based on their research in the mid- 1960s, Masters and Johnson developed a model of the sexual response that posits that the sexual response is linear. It begins with the stage they labeled “excitement” which reflects the period of psychological interest, your body becomes aroused, you then reach a peak level of stimulation called the plateau phase, then you have an orgasm, which is simply a reflex, and then after orgasm the body moves to an unstimulated state called resolution. For men, there is a refractory period and for women there is not. Masters and Johnson further described their model by stating that although the model is linear—excitement, plateau, orgasm, resolution—there is an infinite variety of ways in which women will experience their sexual response cycle. So for one woman, say woman A in the figure shown, she moves from excitement to plateau to orgasm. She has another orgasm and then she moves off to resolution.

Now woman B, or perhaps the same woman on a different occasion, moves from excitement to plateau, but she doesn't orgasm. If this was the same woman on two different occasions, we would say that's completely normal. Women are not really expecting to have an orgasm 100% of the time. Men, in contrast, sort of expect that and are very disturbed if they do not reach orgasm. They think there is a problem. But for women, there tends to be sort of an acceptance that orgasm may not occur every time.

But if woman had this plateau and no orgasm on every occasion, we would consider her to have an orgasmic dysfunction.

Then woman C has just a different variation of how she experiences the sexual response where she moves from excitement to plateau to orgasm very quickly. Now this is a lovely model, but still linear.

A decade later, in the 1970s, Helen Singer Kaplan and Harold Lief both independently came up with a slight variation of this model. They posit a 3-part cycle that includes desire, arousal, and orgasm with a greater emphasis on the psychological aspects of desire. But again, it’s a very linear model.

More recently, Rosemary Basson created yet a third model of the sexual response that is not linear. This is particularly important for you in your clinical practice thinking about women coming in and asking you what is normal. "My sister said this is how it works for her. Is that how it's supposed to work for me?"

Now this particular model fits all women—and many men as well—and is particularly useful to understand potential changes in response that peri- and postmenopausal women experience. That is, desire may not be the first phase of the sexual response. That would be normal, that for some women desire is more responsive and many women begin their sexual response from a position of sexual neutrality. As you can see, the spontaneous sexual drive or that sort of urge to be sexual is in the center of the cycle, reflecting that it may or may not be present and if it is, it is not always present at the beginning of a sexual encounter. For many women, the desire for emotional intimacy is really what gets us going. That is what would set a woman up to either be receptive to somebody's initiation or for her to consciously initiate with her partner.

She may not be particularly hungry for sex, but she thinks about being intimate and close and chooses to initiate or be receptive to satisfy her desire for emotional intimacy.

And if she gets stimulated and biologically everything is OK— that means no pain. Psychologically everything is OK— that means she's still feeling close with her partner. They don't get in an argument. There isn't a knock on the door, "Mommy, Mommy are you there?" Assuming all of that is OK, then her body gets aroused.

It's only at the point that her body is aroused that the thought of, "Oh, sex. This feels great" enters her mind: That's the desire piece. It kicks in after arousal. So for many women, the order of things has changed. That is, although at some point in time they used to perhaps have drive initially, now it's really a responsive desire, and arousal actually precedes desire.

Normalizing this alternate response model for women is really very helpful, so that as long as once they get started they're fine; we wouldn't necessarily call that hypoactive sexual desire disorder but rather responsive desire. So your patients need to figure, is there no desire or is it responsive desire?

Last year, Michael Sands and Bill Fisher did a study looking at these models of sexual response. They said, "Which one really fits women the best?" So they took 133 nurses and they showed them the three models. One-third chose Masters and Johnson, one-third chose the Helen Singer-Kaplan model and one-third chose Rosemary Basson’s model as best fitting their sexual response.

Ultimately what the result of this study suggests is that women are smart enough to know what model of sexual response fits them. If you point out that there is a variation and that not one size fits all, it's very normalizing for them, and then you can help them determine what's normal for them so that they can figure out what is abnormal when they do have problems.

Speaking of abnormal, what are the female sexual disorders? According to the DSM-IV-TR, there are six female sexual disorders. Hypoactive sexual desire disorder is definitely the most prevalent. That is the one we're spending the most time on today, but I will review the others for you because if you're going to be able to make a differential diagnosis, you really need to know what they all are.

Here is a Venn diagram showing an overlap. And most health care professionals think about sexual disorders in women and they see this overlap and wonder: "How am I ever going to disentangle all of this overlap of sexual disorders for women?"

This is really complicated. Women are complicated. Well, the Venn diagram is here to show you that there is huge overlap, but it doesn't take much, a minute or two, to do a simple assessment to figure out which disorder— that may be overlapping— but which disorder is the primary one that brought her into your office with distress and needs to be treated.

For example, a woman might come in and she may say her chief complaint is pain. “It hurts when I have intercourse.” With a little bit of an assessment,“Tell me about your sexual response? Do have you any desire? Do you have orgasm?” She says, "Well, you know what? No, I don't have any desire." The fact that she doesn’t have desire results in her inability to get aroused and without adequate lubrication that results from arousal she now experiences pain with intercourse. Dyspareunia would not be the chief complaint, it would be hypoactive sexual desire disorder. On the other hand, another woman walks in and says, "I don't have any desire." You might initially consider the diagnosis of HSDD but, in fact, if you assess her sexual response, she reports that it hurts every time she has intercourse and now she doesn't like sex anymore. She has no interest in engaging in an activity that causes her physical pain. So simply teasing that out and figuring out the primary disorder will help guide diagnosis and treatment.

When we think about the prevalence of sexual disorders for our patients, we tend to underestimate them. The results of the National Health and Social Life Survey, 43% of approximately 1800 women between 18 and 59 years of age responded in the affirmative to the question of whether they had any sexual problems or concerns in the last 12 months.

Now if we look at a more recent study which included an assessment of distress, which is the key diagnostic criteria in the DSM to determine whether somebody has a disorder. For example, you can have low desire, but if you're not distressed, then we wouldn't necessarily diagnose you with that.

The PRESIDE study, which was published last year, surveyed over 31,000 women. This survey evaluated the prevalence of problems with desire arousal and orgasm also evaluated distress. The results suggest that over 40% of women reported having a sexual problem. Stratified by age shows that problems with sexual desire that also caused distress in the younger women was 9%. In the midlife women, it was 12.3% and the 65 and older it was 7.4%.

It may surprise you that the midlife women have the highest rates of the disorder, or low desire with distress, but it makes sense. Women who are 65 and older have the expectation that at 65 things may not be working the way that they used to, and so they're not quite as distressed by it. But the midlife women are very distressed because they want what they had in their 30s or 20s and now that they're experiencing these changes, they're more distressed.

Another study published in 2008 looked at hypoactive sexual desire disorder in the surgically menopausal patient. When you think about whether or not to have a surgical menopause or even an older woman who loses her ovaries, who has already been postmenopausal, rates of hypoactive sexual desire disorder are going to be higher. So when you're thinking, "Well, what does it matter? She's postmenopausal." By taking away her ovaries—and Dr Altman will talk more about later—I just want to point out that surgically menopausal women have the highest prevalence of hypoactive sexual desire disorder.

What is the definition of HSDD? It is persistent or recurrent deficiency or absence of sexual thoughts, fantasies and receptivity to sexual activity causing personal or interpersonal distress? But here is, I think, probably the key concept. The idea of desire is a bit tricky. Desire is a very simple word, and so most of us think, "Well, I know the definition of desire, and my patients are going to know what I'm talking about when I say desire." But in fact, desire is deceptively simple, and it's actually complex. In order to really understand hypoactive sexual desire disorder in your patients and to understand how to think about assessing and figuring out a treatment approach, I think it's best to define desire as having 3 components.

If you can review this with your patients, then you and your patients will have a much clearer sense of the components when they come in and say, "I have no interest in sex." Oftentimes, patients will say, "I have no interest in sex," and you think, "Well, where do I go with that? That is so overwhelming a concept, I wouldn't even know where to begin to address that."

Here is how you begin. You say, "Well, let's look at desire as having three components.” Drive is the biologic piece. That is what your patients know of as spontaneous sexual interest. When your body signals to you through sexual thoughts, dreams, fantasies that it has an interest in being sexual, what your patients know of as feeling horny, that is drive.

Drive is based on neuroendocrine mechanisms including hormones and neurotransmitters, such as dopamine and norepinephrine. There are many components to the biology of desire. Many illnesses can impact drive and many medications can impact drive.

We're all born with a certain level of drive. For some of us, every day could be barely enough. For others, twice a year is more than enough, and there is a range. The second component of desire is a patient's beliefs, expectations, and values that contribute to their being interested or not in sex. For a 65-year-old, happily married, postmenopausal woman whose belief is that sex is good and healthy and appropriate, her interests will be fine, particularly because now she's an empty nester. Her kids have finally moved out. She and her husband don't have to worry about pregnancy or menstrual bleeding or anything.

But her next door neighbor and best friend is 65 and a grandmother and a widow. Her beliefs are that grandmothers aren't supposed to be sexual and that being sexual would be a little disrespectful to her husband’s memory. So her desire, based on those values, has gone down.

The third component of desire is motivation. This reflects all of the psychological and interpersonal factors creating a willingness to bring your body to a sexual experience. You can have all the biologic urge that you want, but if you're not motivated because you've just had an argument with your lover or you're worried about taking an exam the next day, then drive goes out the window.

It's very important to understand which components have been compromised, because if a woman comes in and says, "Hey, don't you have something for me to treat low desire?" and it's not a biologic issue but it's a motivation issue and you think about offering her a pharmacologic treatment, it won't work. Had you assessed the fact that it was a relationship issue and had referred her on to counseling, then we would have a better sort of approach than had you moved into a pharmacologic treatment.

On the other hand, there may be times when the best treatment approach is a combination of counseling and a pharmacologic agent. Once again, you want to think about making sure that a patient understands that, yes, there is a drive piece, but she also needs to think about the concepts of what's going in her relationship as well, or the consequences of having lived with low desire for a long time.

It's important to consider the components of desire before you think about a treatment. Are you going to work with psychotherapy, refer the patient to a sex therapist or a psychotherapist with no medication involved, or are we going to do pharmacotherapy with no psychotherapy—not a great idea I think, but that certainly is possible. There are some women who really know it's a drive issue and that's all they need.

There are currently no FDA-approved pharmacologic treatments for hypoactive sexual desire disorder. There are off-label uses that Dr Altman will talk about, oftentimes in postmenopausal women.

I wanted to spend a couple of minutes talking about sex therapy. The reason I bring this up is because now that you're going to ask about sexual disorders in your patients, many of you are going to refer them. One common stumbling block is that a clinician who doesn't do therapy knows little about what happens in sex therapy. And so it's kind of disconcerting to send somebody out into this big black hole of sex therapy when you don't really know. What is going to happen?

I thought it would be very helpful to spend just a couple of minutes and talk about what sex therapy is so that you can feel more comfortable making that referral. Sex therapy really is just psychotherapy, but obviously the chief complaint will be a sexual problem. When we think about the empiric data on the best treatments, it tends to be more cognitive/behavioral, so it would be based on principals of learning and cognitive processing. Sexual desire resides primarily in your head. Sex therapy tends not to focus solely on sexual function, since we know that desire has so many components.

If you just worked on function—can you get aroused? can you orgasm? And you missed the context in terms of the brain, which is really important for sex, you often miss a huge component of what's important. I happen to think that sex therapy really can best be understood by looking at it as a biopsychosocial approach. You've got the biologic issues factoring into sexual problems and the psychological, and they interact.

When we think about approaches to sex therapy, it tends to be very short-term, which is very nice when you think about sending off a patient. Are you sending them for years and years of psychoanalysis? No you're not. It tends to be brief generally 5 to 20 sessions.

Cognitive behavioral therapy really is about altering dysfunctional thoughts. Once a problem gets started, if you can't alter the belief systems that develop, you can try all the pharmacologic and biologic treatments that are available but the psychosocial components must also be addressed. If beliefs, attitudes and behaviors are not also considered, then you've done your patient a disservice.

And finally, I just wanted to mention the concept of sensate focus. Sensate focus therapy was developed by Masters and Johnson in the 1960s. It is essentially a behavior therapy that really is about cognitive desensitization and developing increasing comfort with being sexual using homework assignments that allow for systematic desensitization and graduated exposure to increasingly more explicit sexual activity.

The other thing that I wanted to mention with regard to sex therapy is the idea of success. I need you to think about this in your own practices. When a patient comes in and says she's got a sexual disorder and you think, "What would a successful treatment look like?" You need to think about what it would look like for her, not just for what you think success is. Success is not simply just adequate genital functioning. It is so much more than that.

And for some women, it doesn't even require that it be "adequate" based on your standards. It may just need to be better and more satisfying. So you have to pay attention to the fact that she may not be asking for much. For example, with desire disorders, you think, "Well, I don't know if I can restore her desire to want to have sex twice a week." That may not be what she's looking for. Maybe she wants to regain just a little bit of that interest that she used to have and she now misses.

I promised I would review the other sexual disorders, just so that you know what they are. Sexual aversion disorder really is a phobia. It is revulsion and avoidance of sexual activity. Desire disorder is about no interest. This is about fear and phobic avoidance.

Female sexual arousal disorder, often considered the equivalent of erectile dysfunction in men, is about the inability to obtain or maintain, or subjectively be aware of, adequate genital lubrication and swelling and increased heart rate. We now consider this to have subtypes: Generalized, which means no subjective awareness of being aroused and physiologically no arousal. But there is also a group of women that have “missed” arousal. If you ask, "Are you aroused?" they would say that they're not. But in fact, if you measured them with vaginal plethysmography, in fact, yes they are.

A third subtype includes women who report subjective arousal but the genital arousal is not there. That often may be the case with postmenopausal women.

Orgasmic disorder is the inability to reach orgasm despite adequate desire and arousal has a higher prevalence than one might think. Twenty one percent of women will report difficulty based on the PRESIDE study. Anywhere from 3.4% to 5.8% have associated distress.

About 40% of women are what we call situationally orgasmic. So again, it’s important not to over-pathologize. If a women asks if she has a sexual disorder because she does not have orgasm with intercourse, the answer would be no. In fact, intercourse is not a reliable way for women to achieve orgasm. Only about 15% to 30% of women are reliably orgasmic with intercourse alone. So helping women to know that if they can find a few ways in which they are reliably orgasmic would both treat her difficulty and simultaneously be very reassuring to her.

Cognitive behavior therapy is often the most effective treatment, but simple permission-giving by the health care professional is really going to be key. If you can tell women it is appropriate to figure out how their bodies work and they get permission from their physician or nurse practitioner to masturbate in order to determine what stimulation works for orgasm, it is hugely helpful in reinforcing to them that sexuality is appropriate and they're entitled to know how their bodies work. Also, pay attention to medication side effects.

The next sexual disorder is dyspareunia. When we think about dyspareunia as a sexual disorder, it doesn't really make intuitive sense. Really, the question is, "Is pain sexual here?" It's not. It's usually that the sex is painful and we need to treat it as a symptom and know that it's very common.

Vaginismus is really an anxiety disorder. It is the inability to allow wanted penetration because the muscles tighten up in anticipation of pain. This can be with penetration in a sexual encounter, but it can also be in a pelvic exam--your patients tighten their vaginal muscle because they expect a pelvic exam will hurt. The prevalence is actually fairly high, ranging from 1% to 6%.

Cognitive behavior therapy is a very effective treatment using dilators of increasing diameter. In addition, pelvic floor physical therapists are very useful in treating vaginismus.

Prevention and treatment of sexual problems cannot exist if you don't ask. You can't treat a problem if you don't know it exists. Unfortunately, you have not been given the tools or the permission or the expectation that you need to be asking about sexual problems. If you don't ask, your patients are going to be too afraid to ask you. It's up to you.