Urology time® celebrates its 50th anniversary in 2022. To mark the occasion, we highlight 50 of the key innovations and developments that have transformed the field of urology over the past 50 years. In this episode, Rachel S. Rubin, MD, discusses the evolution of treatment for female hypoactive sexual desire disorder (HSDD). Rubin is a board-certified urologist with postgraduate training in sexual medicine. She is an Assistant Clinical Professor of Urology at Georgetown University and recently opened a private practice in the Washington DC area.
Could you provide an overview of the historical view and approach to female HSDD and discuss some of the misconceptions that surround this condition?
Even in 2022, there are a lot of misconceptions about HSDD, mostly because we’re not trained to consider it a medical condition. Many people believe that libido is a psychosocial construct and cannot be improved with medication. But this goes against our understanding that antidepressants and other hormonal drugs have a clear impact on libido. As urologists, we are constantly discussing and treating issues related to male libido. It’s very easy for us to talk about libido and testosterone and different ways to boost dopamine in the brains of men. Unfortunately, we have not been equal in our treatment strategies regarding female libido and HSDD.
HSDD was first described decades ago by Helen Singer Kaplan[, PhD]. What makes it different from just low libido is that the patient has to be bothered by its symptoms. About 40% of all women will say they have a low libido, but only about 10% would be bothered by it. Consider BPH. When a man has symptoms of BPH but is not bothered by them, it is not really a medical problem. He should say, “Doctor, I want to do something about my BPH symptoms, it bothers me.” That’s why we ask a “boring” question. Now, in 2022, we have several solutions that can help us address HSDD in women and treat our patients in a biopsychosocial construct, very similar to how we treat our male patients.
What treatments currently exist for female HSDD?
When we treat HSDD in women, we take a biopsychosocial approach. What’s really important, just like with our male patients, is to take a history and physical exam and really try to figure out what’s going on. In addition to sex therapy, which is wonderful but often expensive and not covered by insurance, we now have biological treatment options.
Sex education and therapy will always be important when managing any sexual health issue. We know sex therapy works for all of our patients. I always say: No one is so good at sex that they can’t get better, right? Improve sex education, improve communication with our partners. How many sex lives can we fix if we just explain how our body parts work? Getting our patients to really understand the biomechanics of this can be wonderful for improving HSDD in a relationship.
There is also a lot of data on mindfulness and some cognitive behavioral therapy approaches to help people with low libido.
The novelty that has occurred in this space is drugs. Now we have been using certain off-label medications for years in our male and female patients. Drugs like testosterone, bupropion, and buspirone have long been used to help improve libido.
As of 2022, we have 2 FDA approved drugs for HSDD specifically in premenopausal women. The first one that hit the market in 2015 is called flibanserin [Addyi]. It is a night medicine. It takes about 2-3 months to find out if you are a responder, and it helps improve desire. Studies have also shown that it also improves arousal, orgasm, lubrication, and satisfaction. It is a night medicine; it makes you drowsy and can often replace any other sleeping pills.
The second on the market is called bremelanotide [Vyleesi], which is an auto-injector that you take an hour before you “want to” so it’s more of an on-demand drug. It is a subcutaneous auto-injector; you put it in your belly or your thigh. It acts on melanocortin receptors and gives the brain a boost of dopamine. The biggest side effect is nausea, and you don’t want to give that to someone with uncontrolled high blood pressure.
These are the 2 biggest things that have come to market in the last decade. Of course, testosterone is a great conversation starter. We know that testosterone works for libido in women the same way it does for men. But we have many FDA approved products for men and no FDA approved products for women. In 2019, a global position statement on the use of testosterone in women was released by a number of companies which stated that testosterone works, is safe and should be considered in women. postmenopausal patients with HSDD. It is approved in Australia for use in postmenopausal women. But due to some FDA challenges and costs, it could not be marketed in the United States. But it works pretty well.
What makes the evolution of the treatment of female HSDD an innovation in urology?
Urologists are amazing at separating reproduction from sexual health. We train our doctors to know that male reproduction and male sexual health are two different things and that quality of life is so important. We love to teach and talk about erectile dysfunction, ejaculatory dysfunction, hormones, libido and orgasm as it relates to male sexual health. And now, for the female side of the population, we have the tools to say it’s no different – women aren’t just reproductive beings, are they? They deserve a quality of life when it comes to sexual health. And it’s not just within the purview of an OB/GYN to do these things. As urologists, we are certified to care for all genders. We are very good doctors of sexual medicine, and we must apply what we know about sexual medicine, not only for our male patients, but for all our patients. And what’s interesting here is that caring about female sexual medicine will improve the quality of life for many of our male patients. We always complain about having all these tools for men, and we don’t have any tools for our female patients. But we have so many more tools than we think when it comes to medications for HSDD.