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'Female Viagra' -- Libido Liberation or Gender Hype?

Is this new drug flianserin really the "female Viagra," or is it just a drug that empowers women to talk about gender discrimination?
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Is this new drug flianserin really the "female Viagra," or is it just a drug that empowers women to talk about gender discrimination? The FDA advisory committee has recently recommended approval of the still-experimental drug flibanserin (also known as Addyi) to help sexual dysfunction in women. After this action has generated many opinions about achieving gender equality for women, getting the FDA to approve a "female Viagra," and even prompted arguments that the FDA has been practicing gender discrimination, let's look at some of the facts and what it means for each of us today.

An illness, hypoactive sexual desire disorder (HSDD), is common (12-19 percent of women) but we do not hear much about it. The condition is characterized by women who have a reduced desire for sex and/or a reduced frequency of sexual fantasies, either of which cause personal distress for the woman, or result in difficulty in interpersonal relationships. Frequently this distress leads to depression and anxiety. Sometimes, it can even lead to divorce. In 10-15 percent of women, health-related quality of life is decreased.

Many conditions and situations can lead to HSDD by causing decreased desire, reduced sexual arousal, low vaginal lubrication, decreased orgasm and/or reduced sexual satisfaction. HSDD can occur as a side effect of diabetes, coronary heart disease, cancer and arthritis. Menopause raises the risk of the condition. After pregnancy, changes in hormones can cause HSDD. And removal of the ovaries (an oophorectomy frequently performed with a hysterectomy, or for treatment of cancer of the ovary, uterus or breast) reduces estrogen and testosterone in women resulting in HSDD.

This frustrating illness can also be seen in psychological conditions. Severe anxiety, depression or stress of any cause can cause HSDD. It is also more common after sexual abuse, or lack of trust in a woman's spouse or partner (often a consequence of infidelity).

Treatment of HSDD has been available but is of varying success. No drug has been approved in the United States for the condition, which makes the recent FDA committee action so encouraging. Vaginal dryness (which usually does not lead itself to decreased desire) or HSDD can be treated with vaginal or oral estrogen or estrogen/progesterone medications. Counseling has been used to help with psychological causes, to reduce the distress of HSDD, and to improve interpersonal relationships.

Approved in Europe but not in the United States, transdermal testosterone patches can increase sexual desire in women. In one trial, satisfying sexual episodes per month increased from 0.5 episodes without the patches to 2.1 with the patches. Also available in other countries but not in America, tibolone (a precursor of estrogen-like chemicals converted to estrogen and progesterone like chemicals in the body, also known as Livial in some countries) is reported to improve the condition. Sildenafil (Viagra) has not seemed to help.

But the excitement recently has been about the drug flibanserin. Initially developed as an anti-depressant that changes the concentrations of the neural compound serotonin in the brain, it was found to help HSDD. In an FDA summary of the application to the FDA, clinical trials of the drug were reported to show that satisfying sexual episodes increased from 2-3 per month by 0.5 to 1.0 episodes per month, that desire increased from 1.8-1.9 per month by 0.3-0.4 (seen 3-4 weeks after starting the drug and lasting for 6 months while on the medicine), and that distress associated with HSDD decreased from 3.2-3.4 by 0.2-0.4. Although not helping every woman in the trial, all these results were statistically significant (important to the FDA in considering approving the drug and to physicians when considering prescribing it for a patient). Side effects included dizziness (1.4 percent of women), nausea (10.4 percent), sleepiness (11.2 percent), fainting (0.5 percent), and some reduction in blood pressure. These side effects were greater with alcohol.

Putting these improvements in perspective, I look at the average sexual function of American adults published by the Kinsey report. In married or partnered adults, sexual intercourse occurred an average of 2-4 times per month (ages 25-29) to 3-12 times per year (ages 60-69). Episodes averaged 112 per year during ages 18-29, 86 per year ages 30-39, and 69/year ages 40-49. Of course, these numbers do not report the satisfaction (only 64 percent of women said they experienced orgasm in their last intercourse). These numbers are important when putting the HSDD flibanserin results in perspective. A 10-15 percent improvement from the drug can improve sexually satisfying intercourse into the "normal" range for older adults and reduce stress.

So it seems to me the drug flibanserin is not a cure-all. But the distress my patients have had with this condition can be so profound and consuming that this drug, once approved and with good counseling of the patient by doctors about side effects, will have great use and benefits in many women. Some of my patients will undoubtedly use it and see how well tolerated it is in them.

So here are my tips for you.

• Many patients (women and men) never tell their doctor about their sexual symptoms. To improve your sexual function and satisfaction, be certain you communicate information about any problems you are having with your sexual desire, performance, frequency and satisfaction to your physician and expect evaluation and treatment recommendations. For more advice on how to communicate better with your physician, see the chapter on communication in my book Surviving American Medicine.

• If you have HSDD or sexual problems, ask about hormonal therapy, counseling, testosterone patches, tibolone, or availability of the new drug flibanserin.

• If you do not get advice or if your doctor is not aware of treatments, consider getting a second opinion from another physician (an internist, gynecologist, urologist, endocrinologist, psychologist or sex therapist can be helpful). For more information about how to get a second opinion, see my chapter on second opinions in my book Surviving American Medicine.

Sexuality is an important part of being alive, healthy, and happy. Be certain you do not overlook how helpful your doctor can be in helping you to lead a more fulfilling life.

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