Pharmaceutical and Energy-Based Management of Sexual Problems in Women

[madman]

BACKGROUND TO A NEW ERA

To discuss “a new era” in the management of sexual dysfunction implies progress from a previous norm, so that discussion must begin with an understanding of the historical foundations and associated assumptions undergirding that progress. This is particularly true of the diagnosis of female sexual dysfunction (FSD), which is a prerequisite to application of the novel and experimental therapeutic interventions that are the focus of this article. FSD is a category of diagnoses infamous for its changeability and its constancy over time: in the past three decades, its nomenclature and classification have gone through multiple iterations by various national and international organizations1; at the same time, historical and now medically anachronistic terms, such as “frigidity,” continue to be used in the context of doctor-patient encounters and popular discourse about female sexuality.

Despite incontrovertible progress in medical science and the evolution of social norms since the early modern period, medical historians describe remarkable continuity in the terms of debate about FSD. These have included arguments over whether sexual problems in women deserve significant medical attention (given that they do not necessarily preclude successful reproduction, in contrast with male erectile dysfunction [ED]) and the extent to which they signify a moral or psychological disorder versus a problem of anatomy or physiology.2 The residue of these debates persists today, in the inequitable distribution of research funding and clinical attention to male sexual dysfunction and FSD, and in the tension between different classification systems used to define and diagnose these diseases.


*NAVIGATING NOMENCLATURE

*CRITIQUING FEMALE SEXUAL DYSFUNCTION

*PHARMACEUTICAL MANAGEMENT
-Phosphodiesterase-5 Inhibitors
-Psychoactive Medications
-Flibanserin
-Bremelanotide
-Hormonal Medications: a Blast From the Past

*ENERGY-BASED MANAGEMENT
-Vaginal Lasers
-Radiofrequency
-Low-Intensity Extracorporeal Shockwave Therapy
-Neuromodulation: Sacral and Percutaneous Tibial Nerve Stimulation
-Neuromodulation: Vagal Nerve Stimulation




SUMMARY

The enthusiasm with which energy-based treatments for sexual dysfunction have been adopted for sale in the medical marketplace is disproportionate to the amount of data that are currently available to support their clinical use. Neuromodulation and focal induction of a healing response hold promise for the improvement of tissue quality, genital arousal response, and related FSD symptoms. Caution and further study are required to determine whether this promise will be fulfilled and if indeed fulfillment will lead to relief of sexual problems. Given the limited scope of action for most of these devices, the widely ranging biopsychosocial factors that are implicated in the manifestation of FSD, and the characteristic discordance of female arousal, it is likely that their helpfulness will be specific to defined FSD symptomatology and/or specific populations of women with relevant comorbidities.

Pharmacotherapy for FSD (Table 3) has considerably more research evidence to justify its use and the potential to promote sexual desire, cognitive and genital arousal, and orgasmic response. The functional improvements that are produced by these medications are generally small, and their benefits may not outweigh the bother of taking medications and hazarding their potential AEs. There is sufficient demand for medical treatment of sexual dysfunction that studies continue in an effort to expand the demographic for whom the drugs are FDA-approved to include older women and possibly men. It is essential that patients in all of these groups be empowered to make an informed, autonomous determination as to whether the ratio of risk to reward favors the use of pharmacotherapy, energy-based therapy, or some other treatment intervention.

 

[madman]

Table 1 Evolution in female sexual diagnostic nomenclature over the past 25 years

 

[madman]

Table 2 Laser devices

 

[madman]

Table 3 Clinical care points: medications for HSDD

 

[madman]

Hormonal Medications: a Blast From the Past

The pharmaceutical industry’s most recent forays into the treatment of FSD have had somewhat ambiguous results. PDE5i medications target the genitalia to boost arousal response without adequately addressing the cognitive or emotional aspects of sexual function. Flibanserin and bremelanotide target the CNS, to produce only slight improvements in sexual interest and responsiveness when compared with placebo. An alternative to these is the off-label use of older, hormonal medications, which act simultaneously on mind and body. It is not surprising that pioneering sexologist William Masters began his clinical research career in the 1940s with a focus on the positive effects of estrogen replacement therapy on hypogonadal women.47 At the same time, androgens were also studied and used in women for the treatment of various medical problems, including sexual dysfunction.48 Both sex steroids act within the CNS to stimulate sexual appetite31 and within the genitalia to maintain vulvovaginal tissue integrity.49

Testosterone therapy, in isolation and in combination with estrogen (and sometimes progesterone), has been shown in many randomized controlled trials to increase sexual desire and satisfaction in postmenopausal women with HSDD.50 Clinical application of these data remains a persistent challenge because it remains uncertain: (1) to what degree testosterone, and not the estrogen into which it may be aromatized, is the relevant actor51; (2) whether testosterone supplementation might safely and effectively address sexual problems in premenopausal women52; and (3) how to most reliably dose this medication in a regulatory and financial environment that discourages the development of testosterone products for women.53 The risk of AEs, including hirsutism, acne, vocal changes, and clitoromegaly, is necessarily increased when products intended to produce adult male levels of testosterone are prescribed for women.54 The probability of these AEs is reduced with careful monitoring and dose titration to maintain free testosterone within the normal female range,55,56 but the optimal testosterone regimen for women has yet to be determined.

 

[madman]

KEY POINTS

*Female sexual dysfunction (FSD) has been inconsistently defined and characterized so that changes in nomenclature complicate its diagnosis and treatment

*Whether and how FSD ought to be medicalized is controversial, with associated problems of biomedical nihilism and unregulated proliferation of quack remedies under the aegis of “wellness”

*Because of frequent discordance of cognitive and genital sexuality in females, therapeutic interventions that benefit genital tissue are not necessarily helpful for overall sexual function

*Medications and energy-based interventions available for FSD provide small, statistically significant improvements in sexual function, as measured by the Female Sexual Function Index; whether these improvements are clinically significant is a question that is most reliably answered by each individual patient