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Hypoactive Sex Desire Disorder - HSDD (Loss of libido)

By Dr J Kabyemela, MD

The prolonged absence of sexual desire or loss of libido leading to distress for the affected individual is medically described as ‘Hypoactive Sexual Desire Disorder’ or HSDD in short.

There are varying estimates as to the proportion of women who are affected by this condition at one time or another. It is difficult to be certain because of the very nature of the problem. However, studies have consistently shown that lack of sex desire is the most common sexual dysfunction problem followed closely by female anorgasmia (inability to reach orgasm).  One large study revealed a prevalence of the problem among women before the menopause at 6%. The figure was 9% for post-menopausal women who still have their wombs and 12% among those who have had a hysterectomy.

HSDD is a distinct problem

It is important to be clear that Hypoactive Sexual Desire Disorder (HSDD) is distinct from other forms of sexual dysfunction which may include difficulty with arousal (even though the desire is there) or inability to reach orgasm (with both desire and arousal remaining intact). The hallmark of hypoactive sexual desire disorder is absence of sexual thoughts and the idea of sexual activity is a turn off. Critically, for this diagnosis to be made, the situation must be causing distress to the affected woman. Simply lacking interest in sex does not qualify to be labelled as HSDD.

A woman with HSDD will allude to the fact that the situation is negatively affecting her overall quality of life, relationship, physical and emotional wellbeing and, in a nutshell, making her unhappy.

There are women who have never had any desire for sex and are perfectly happy and leading fulfilled lives. Such individuals cannot be said to suffer from HSDD.

Causes of HSDD

There is no doubt that causes of absent sexual desire are many and varied. It is a quite diverse group of problems under one umbrella and there is really no common causative strand.

Hormone deficiency: The issue of hormone deficiency has been prominent for many years in dealing with this condition. The hormone in question is Testosterone. Testosterone is the main hormone in the group of hormones called ‘androgens’. There is an unfortunate misconception among many people brought about by the description of testosterone as a ‘male sex hormone’. This is misleading. Whilst it is true that men produce a great deal more testosterone, women produce this hormone too and it is vital in their general wellbeing.

Testosterone deficiency will cause, among other things, a reduced or complete lack of sexual desire, reduced sexual receptivity whereby sexual advances will be unwelcome even from a loved one, a sense of general fatigue and lack of motivation and, overall, feeling out of sorts.

Normally, a woman’s testosterone production peaks in the mid-twenties and thereafter decline gradually with age. By the time she reaches menopause, normally in the early 50s; testosterone production will be around 50% of what it was at its peak two to three decades earlier.

Ovaries are responsible for about 50% of all the testosterone produced in the body and, crucially, they continue to play this vital role even after the menopause.  Whilst the production of estrogen will virtually cease, testosterone is still produced.

The role of ovaries in producing testosterone and the pivotal role this hormone plays in a woman’s sex life has influenced change in gynaecological surgical practise in the last two decades or so. It used to be the case that, women undergoing a hysterectomy, especially if they were approaching or were past the menopause, would have their ovaries removed at the same time. The logic was that, since they were at a stage of life where the ovaries were no longer ‘functional’, they were better out than in. It has since been realised that, for many such women, the result of this well-meaning but misguided extension of the surgery turned out to be a devastated sex life. We now know that ovaries continue to be functional after the menopause, playing a key role of maintaining a woman’s sex life. There is no doubt that the rate of HSDD is significantly higher among women who have had surgery and removal of both ovaries. In some cases, women who are a lot younger have had to lose both ovaries as a result of diseases such as cancer or severe endometriosis. For such women, the risk of HSDD is even higher.

Depression: There is strong evidence that absence of sex desire could be a manifestation of a depressive condition. One of the common features of postpartum depression, for instance, is markedly reduced or total absence of sex desire.

Psycho-social factors: In some cases, lack of sex desire can be traced back to events in a woman’s life and these could range from strict religious upbringing, sexual abuse, relationship problems or breakdown, severe financial and/or family problems, diagnosis of and treatment of a serious disease such as breast cancer etc. In fact, Hypoactive Sex Desire Disorder (HSDD) could be a result of multiple factors in any one sufferer.

Medication: One of the effects of common anti-depressants such as Venlafaxine (Effexor®) is curtailing the ability to reach orgasm. The depression will have had a negative effect of reduced sex desire and the medication could make that worse by affecting orgasm. A combination of the two could lead to a full-fledged HSDD.

Ironically, the main way of combating menopausal symptoms could have a negative effect on a woman’s sex drive. The taking of HRT could, in some cases, lead to reduced sex desire. Here is how that comes about. We know that testosterone plays a pivotal role in a woman’s sex desire. Testosterone has to be unbound i.e. free in circulation to have this or any other biological effect. As it happens, most of the testosterone is bound by a protein called SHBG rendering it biologically inactive. It fellows therefore, that, the more SHBG you have in circulation, the greater the proportion of testosterone that will be bound or locked away. When estrogen (for HRT) is taken orally, it has the effect of causing production of more SHBG and thereby indirectly resulting in more of the testosterone to be bound and unavailable. This could, potentially, lead to reduced sex desire. This effect can be easily avoided by having the HRT via a different route such as through the skin (patches or gel).

Chronic Pain: Chronic pain or pain affecting the lower genital tract in conditions such as Vulvodynia (pain at the vulva), vestibulitis (pain at the vaginal entrance) or pain experienced during sexual intercourse could, in the long run, lead to aversion to sex and loss of sex desire. We do, however, need to be careful here. Painful intercourse (also called dyspareunia) is a completely separate problem from HSDD. Many women who experience pain during sex retain their sex desire. They long to have normal sex and the issue is for them is identifying the cause and therefore a solution to the pain so they can continue having a fulfilling sex life.

Management of HSDD

Hypoactive Sex Desire Disorder (HSDD)  is almost always a challenging problem and a solution can be difficult to find for some of the sufferers. It can be difficult to pin down the underlying cause and, as mentioned above, multiple factors could be responsible. A very thorough history and detailed physical examination is need to begin with. If psycho-social factors are identified, they will need to be addressed regardless of whether there are physical findings also found. It follows, therefore, that treatment is sometimes multi-disciplinary, involving a gynaecologist, a psychologist and a psycho-sexual counsellor.

Testosterone: In Europe, testosterone replacement is licensed for HSDD. Testosterone patches available in the brand name Intrinsa® can be used for this purpose. A patch is applied twiIntrinsa patchce a week. The licence is restricted to women who have had a hysterectomy and had ovaries removed. However, the patches are used by many doctors ‘off label’ in women who fall outside this group but whose hormone profile blood tests confirm that they have low free testosterone levels. There is no doubt at all that testosterone replacement works when prescribed appropriately. However, this is clearly not a solution for many women who suffer from HSDD but whose testosterone production and blood levels are completely normal. In such cases, the problem and solution lies elsewhere. There is currently no licensed testosterone product for women in the United States.

Last update: September 26, 2012