Improving prospects for treating hypoactive sexual desire disorder (HSDD): development status of flibanserin

Pharmacotherapy for female sexual dysfunctions (FSDs): what is on the market and where is this field heading?

INTRODUCTION

Female sexual dysfunctions (FSDs) are common in women of any age and have a huge impact on quality of life and relationships. They have a multifaceted etiology limiting the development of pharmacotherapies with a high rate of effectiveness. Safety issues are also a concern.

AREAS COVERED

The authors report the most recent advances in pharmacotherapy for premenopausal and postmenopausal women with a main focus on hypoactive sexual desire disorders (HSDD) and associated sexual symptoms. Good levels of evidence have emerged for psychoactive agents, such as flibanserin and bremelanotide, as well as hormonal compounds (transdermal testosterone). The authors also report briefly on intravaginal DHEA (prasterone), local estrogen therapy (LET), and ospemifene to manage effectively vulvovaginal atrophy/genitourinary syndrome of menopause (VVA/GSM). In addition, they discuss promising therapeutic options highlighting the main reasons that hamper the availability of new labeled products. Finally, they include the importance of the multimodal approach to address FSDs.

EXPERT OPINION

Approved pharmacotherapies for FSD are limited. Validated multidimensional instruments and adequate objective measures of physical and mental responses to sexual external and internal incentives are mandatory to identify women suitable to chronic or on-demand treatments and to assess their pattern of response in research and practice.

Female Sexual Dysfunction-Medical and Psychological Treatments, Committee 14

INTRODUCTION

Since the millennium we have witnessed significant strides in the science and treatment of female sexual dysfunction (FSD). This forward progress has included (i) the development of new theoretical models to describe healthy and dysfunctional sexual responses in women; (ii) alternative classification strategies of female sexual disorders; (iii) major advances in brain, hormonal, psychological, and interpersonal research focusing on etiologic factors and treatment approaches; (iv) strong and effective public advocacy for FSD; and (v) greater educational awareness of the impact of FSD on the woman and her partner.

AIMS

To review the literature and describe the best practices for assessing and treating women with hypoactive sexual desire disorder, female sexual arousal disorder, and female orgasmic disorders.

METHODS

The committee undertook a comprehensive review of the literature and discussion among themselves to determine the best assessment and treatment methods.

RESULTS

Using a biopsychosocial lens, the committee presents recommendations (with levels of evidence) for assessment and treatment of hypoactive sexual desire disorder, female sexual arousal disorder, and female orgasmic disorders.

CONCLUSION

The numerous significant strides in FSD that have occurred since the previous International Consultation of Sexual Medicine publications are reviewed in this article. Although evidence supports an integrated biopsychosocial approach to assessment and treatment of these disorders, the biological and psychological factors are artificially separated for review purposes. We recognize that best outcomes are achieved when all relevant factors are identified and addressed by the clinician and patient working together in concert (the sum is greater than the whole of its parts). Kingsberg SA, Althof S, Simon JA, et al. Female Sexual Dysfunction-Medical and Psychological Treatments, Committee 14. J Sex Med 2017;14:1463-1491.

Assessment and management of sexual dysfunction in the context of depression

Sexual dysfunction (SD) is pervasive and underreported, and its effects on quality of life are underestimated. Due in part to its bidirectional relationship with depression, SD can be difficult to diagnose; it is also a common side effect of many antidepressants, leading to treatment noncompliance. While physicians often count on patients to spontaneously report SD, treatment is optimized when the clinician instead performs a thorough assessment of sexual functioning before and during drug therapy using a standardized questionnaire such as the Arizona Sexual Experiences Scale (ASEX). Separating the effects of the disorder from those of medications is challenging; we present a concise, evidence-based schematic to assist physicians in minimizing treatment-emergent sexual dysfunction (TESD) while treating depression. Vascular, hormonal, neurogenic, and pharmacological factors should be considered when a patient presents with SD. We also recommend that physicians obtain patient information about baseline and historical sexual functioning before prescribing a drug that may lead to SD and follow up accordingly. When the goal is to treat depression while attenuating the risk of sexual symptoms, physicians may wish to consider agomelatine, bupropion, desvenlafaxine, moclobemide, trazodone, vilazodone, and vortioxetine.

Polypharmacology of dopamine receptor ligands

Most neurological diseases have a multifactorial nature and the number of molecular mechanisms discovered as underpinning these diseases is continuously evolving. The old concept of developing selective agents for a single target does not fit with the medical need of most neurological diseases. The development of designed multiple ligands holds great promises and appears as the next step in drug development for the treatment of these multifactorial diseases. Dopamine and its five receptor subtypes are intimately involved in numerous neurological disorders. Dopamine receptor ligands display a high degree of cross interactions with many other targets including G-protein coupled receptors, transporters, enzymes and ion channels. For brain disorders like Parkinsońs disease, schizophrenia and depression the dopaminergic system, being intertwined with many other signaling systems, plays a key role in pathogenesis and therapy. The concept of designed multiple ligands and polypharmacology, which perfectly meets the therapeutic needs for these brain disorders, is herein discussed as a general ligand-based concept while focusing on dopaminergic agents and receptor subtypes in particular.

Hypoactive Sexual Desire Disorder: A Review of Epidemiology, Biopsychology, Diagnosis, and Treatment

INTRODUCTION

Hypoactive Sexual Desire Disorder (HSDD) is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised (DSM-IV-TR) as persistent deficient sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), HSDD has been subsumed by Female Sexual Interest/Arousal Disorder. However, decades of research based on DSM-IV-TR HSDD criteria form the foundation of our understanding of the essential symptom of distressing low sexual desire, its epidemiology, clinical management, and treatment.

AIM

This publication reviews the state of knowledge about HSDD.

METHODS

A literature search was performed using terms HSDD and female sexual dysfunction (FSD).

MAIN OUTCOME MEASURES

Physicians acknowledge that FSD is common and distressing; however, they infrequently address it, citing low confidence, time constraints, and lack of treatment as barriers.

RESULTS

HSDD is present in 8.9% of women ages 18 to 44, 12.3% ages 45 to 64, and 7.4% over 65. Although low sexual desire increases with age, distress decreases; so prevalence of HSDD remains relatively constant across age. HSDD is associated with lower health-related quality of life; lower general happiness and satisfaction with partners; and more frequent negative emotional states. HSDD is underdetected and undertreated. Less than half of patients with sexual problems seek help from or initiate discussions with physicians. Patients are inhibited by fear of embarrassing physicians and believe that physicians should initiate discussions. The Decreased Sexual Desire Screener, a tool for detecting and diagnosing HSDD, is validated for use in general practice.

CONCLUSION

Women can benefit from intervention in primary care, behavioral health and sexual medicine settings. Psychotherapeutic and pharmacological interventions aim to enhance sexual excitatory process and decrease inhibitory processes. Flibanserin, the first centrally acting daily medication for HSDD, was recently approved in the US for premenopausal women.

Sex drive and sexual desire

PURPOSE OF REVIEW

Loss of sexual desire is increasingly recognized as a consequence of many disease processes, and one that can have a significant negative impact on quality of life. This review explores the biological and psychological aspects of desire, as well as the aetiology and therapeutic options for loss of desire.

RECENT FINDINGS

Discoveries have been made in terms of the physiology of desire in men, in that it is affected by estradiol as well as testosterone. It has also been shown that desire is less gender specific in androphilic women than in androphilic men and gynaephilic men and women. Fatigue has been described as the most common self-reported cause of loss of desire, with communication as the most common method for addressing this. In men, a clear distinction has been shown between disorders of arousal and disorders of desire, suggesting that they should remain as separate conditions in the Diagnostic and Statistical Manual of Mental Disorders criteria. Loss of desire has been proven to be a significant consequence of diabetes, multiple sclerosis and polycystic ovary syndrome and can occur as a side-effect of statins and 5α-reductase inhibitors. Testosterone therapy may be an effective treatment for loss of desire in both men and women, and is safe in the treatment of men who have been treated for prostate cancer. It also has a significant impact on desire when used in the treatment of individuals with gender dysphoria. Nonhormonal treatments including flibanserin and new methods of therapy may also be effective.

SUMMARY

Loss of desire is underrecognized as a symptom of disease or as a complaint in its own right. As further developments in treatment options, both therapies based and pharmacological, are made, it is increasingly important that clinicians enquire about sexual dysfunction, including loss of desire, at every consultation.

Flibanserin for the treatment of hypoactive sexual desire disorder in premenopausal women

INTRODUCTION

Hypoactive sexual desire disorder (HSDD) is the most common form of female sexual dysfunction (FSD). Some theories suggest that HSDD has a neurobiological component linked to neurotransmitter imbalances. Flibanserin is the only FDA-approved treatment of HSDD; before its approval, the disorder was often left untreated or interventions were made using evidence-based psychological methods or 'off-label' use of bupropion, testosterone and other dopaminergic agents.

AREAS COVERED

Flibanserin, a multifunctional serotonin agonist/antagonist, is approved as a nonhormonal option designed specifically for the treatment of HSDD. Flibanserin has been shown to cause statistically significant increases in the number of satisfying sexual events and in sexual desire scores on standardized/validated measures while reducing FSD-related distress of premenopausal women diagnosed with HSDD. Similar efficacy has been demonstrated in a smaller group of postmenopausal women also affected by HSDD. The side effects of flibanserin include dizziness, somnolence, nausea and (rarely) syncope, and are comparable to other CNS drugs.

EXPERT OPINION

While there has been debate over the approval of flibanserin for treatment of HSDD, it is evident that flibanserin provides meaningful relief to women suffering from a common sexual dysfunction and is an important addition to the field of women's health.