Balon and Segraves17 recently surveyed approximately 30 psychiatrists in the field of antidepressant-induced sexual dysfunction regarding their treatment practices. These experts most frequently preferred a change in either the drug or the dosage of the antidepressant, adding other drugs (eg, bupropion, a phosphodiesterase type 5 inhibitor), or adding testosterone to treat patients with desire disorders.
Patients and doctors: a conspiracy of silence
Many patients are reluctant to discuss details of their sexual functioning, and a similar number of health care professionals are also uncomfortable with the topic. Most patients take their cues from the clinician. Thus, if the physician does not ask about sexual dysfunction, the patient will rarely raise the issue. These tendencies lead to a complex series of misperceptions, rationalizations, and denials that result in FSD going completely undetected and untreated in many cases.
Data show that simple direct questions about the quality of a woman’s sexual functioning do not usually make a patient uncomfortable.
Montejo-González and colleagues18 reported a 4-fold increase of positive reports (14% vs 58%) concerning SSRI-induced sexual dysfunction when direct questions replaced spontaneous reports. Landén and coworkers19 reported an even greater distinction (6% vs 41%). Most patients reported being embarrassed to raise the issue and feared embarrassing their physician by doing so. They also rationalized that nothing could be done, that the problem would pass, or that the problem would persist as just another sign of aging.
Often, the clinician can ease the discussion by asking 2 simple questions: “How are things going for you sexually—is everything okay?” and “Is your partner having any sexual problems?” These questions do not have to be asked literally, as long as they elicit answers. The conspiracy of silence about sexual problems must end if we are going to make progress with treatment of these conditions, and as professionals, we must take the lead.
Treatments for FSD
The predominant psychological interventions are psychotherapy (in myriad formats), sex therapy, and couples or relationship therapy. An important consideration for the psychological approaches is the nature of the condition and its suspected etiology(ies). If the problem appears to arise from intrapsychic conflict, a problematic relationship, or poor sexual learning, then one or some combination of these treatment methods may prove effective. If the cause appears to be biologically based, then psychological approaches may be helpful, but they are not likely to provide lasting benefit. There are no FDA-approved drug treatments for FSDs, despite substantial research activity during the past decade.20-23 Of the many drugs evaluated in phase 2 and, in several instances, phase 3 trials, only 3 agents have emerged that appear to have a realistic opportunity to become marketed drugs in the near future.
The first of these, a testosterone patch (Intrinsa) that has been developed to treat HSDD in postmeno-pausal women, is currently marketed in Europe. The patch has shown efficacy in surgically and naturally meno-pausal women as well as in postmenopausal women not taking estrogen.24 However, the testosterone patch has failed to gain FDA approval in this country because of concerns about its long-term safety. It is unclear when and if the patch will become available in the United States. A second transdermal testosterone preparation (Libigel) is currently in phase 3 clinical trials.25 It must also pass long-term safety hurdles.
There is also a centrally acting agent, flibanserin (a 5HT1A agonist/5HT2A antagonist), that has shown considerable promise in the treatment of HSDD in premenopausal women.26 Flibanserin is fairly far along in phase 3 trials, and if it continues to perform well, could conceivably be available sometime in 2010. Currently, there are several off-label agents available to treat FSD. Bupropion has been demonstrated to have some efficacy in treating HSDD in premenopausal women.27 Although it is clear that bupropion has the lowest incidence of sexual adverse effects when used as an antidepressant, its overall record as a prosexual therapeutic agent is less consistent.
Another popular off-label pharmacological approach is the use of transdermal testosterone gel prepared by local compounding pharmacists. Typically, a 2% percutaneous gel is applied to the clitoris, labia, and vulva, beginning daily for approximately 2 weeks and then according to a protocol that best accommodates patient needs. Response is often positive, but several months of treatment may be required to restore the patient’s sexual desire.