Richard Grunert, MD, is a urologist at The University of Vermont Medical Center and an assistant professor at the Larner College of Medicine at UVM.

Richard Grunert, MD, is a urologist at The University of Vermont Medical Center and an assistant professor at the Larner College of Medicine at UVM.

There has been a lot of recent press about the new drug, Addyi, or flibanserin, which was just FDA-approved for the treatment of hypoactive sexual desire in premenopausal women. This has been called in the Media “the female Viagra.” There has great interest in and passionate debate about this drug.

Why has it taken 17 years since the FDA approved Viagra, the drug that increases male sexual performance by increasing blood flow to the penis, to come up with a female drug equivalent? Has there been gender bias by the medical community, the FDA, and industry? In this case, the answer is no. For women, the most common type of sexual dysfunction is not related to blood flow or age, but to desire. This is much more complicated to treat.

Erectile dysfunction, the common sexual dysfunction seen in men is a specific organ-based issue: just increase the blood flow and the problem improves. Sexual dysfunction in women, however, is more commonly related to a lack of desire, or what is called “hypoactive sexual desire” (HSD). While HSD also occurs in men, flibanserin is only approved for use in women.

WHAT’S THE DIFFERENCE BETWEEN LIBIDO AND HSD?

HSD is different than simply a low sex drive or low libido. A lot of people experience a low libido, and it causes no problem at all in their lives. Libido is thought to be influenced by a triad of factors, specifically one’s personals health and wellness, their relationship health, and what is thought to be normal for their given social environment. Therefore, a normal libido is usually considered to reflect a healthy person in a good supportive relationship with appropriate intimacy.

HSD is properly defined as low sexual desire, which is causing personal distress, but which is not related to relationship issues, medical problems, or drug side effects. Any patient being evaluated for HSD requires a thoughtful and targeted evaluation by their doctor, with emphasis on both the physical and social issues that affect a person’s life. This evaluation will require sexual, medical, and psychosocial histories. If any treatable issues known to cause low libido are identified, these are addressed. HSD is more common in pre-menopausal women and is thought that HSD affects about 10 percent of women.

HOW DO WE TREAT HSD?

Until now the mainstay of therapy for HSD has been behavioral, and it is easy to understand why there have been many objections raised to the medicalization of this disorder. The focus on the medical issues may reduce the relationship context of sexuality despite the fact that this is often the cause of sexual problems; however, many patients do not respond to behavioral therapy alone and, therefore, there was a push to develop flibanserin and have it approved by the FDA.

WHAT IS FLIBANSERIN AND HOW DOES IT WORK?

Flibanserin is thought to influence the neurohormones in the desire part of the brain: the prefrontal cortex by influencing the brains motivational reward structures to enable sexual desire. It was approved by the FDA after it was shown in clinical trials to favorably increase sexually satisfying events, increase self reported sexual desire, and reduce distress. The improvement was modest; 41-55 percent of patients taking flibanserin saw improvement, but when compared to the placebo this was only a 12-15 percent improvement.

Flibanserin must be taken daily and the effects may not been seen until 4 to 8 weeks. There are also very common side effects of dizziness, sleepiness, and nausea. Flibanserin must not be taken with alcohol or with a class of other drugs – called 3YP34a inhibitors – that can interfere with metabolism in the liver. Because of these issues, doctors who wish to prescribe flibanserin must seek special approval from the FDA. Further, patients will need to sign a written consent before receiving the medication.

Flibanserin isn’t for every woman with hypoactive sexual desire. It has significant side effects and precautions . Some women may not want to treat their low desire; other women may prefer to use behavioral tools alone. This is an individual choice based upon the amount of distress. But, for those who do want to try something new, flibanserin may be an interesting new option.

Richard Grunert, MD, is a urologist at The University of Vermont Medical Center, whose private practice became integrated into UVM in 2013. He is also an assistant professor at the Larner College of Medicine at UVM. He is a Fellow of both the American College of Surgeons and European Commission on Sexual Medicine.

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