Posts Tagged ‘Addyi’

When He’s Interested and She’s Not: A Common Dilemma of the Aging Couple

October 20, 2018

Andrew Siegel MD   10/20/2018

2018-05-26 16.21.35

Photo taken at Icelandic Phallological Museum, Reykjavik: note that the stallion is braying, stomping and ready in every respect, while the mare seems rather indifferent

This entry is based upon my more than 30 years of experience in the urological “trenches” with innumerable daily interactions with male patients (often accompanied by their spouses). I have observed that much of the time when it comes to sexuality, “men are from Mars and women from Venus.”  I do not intend in any way to be disparaging or offend females, but only to report—as I see it—the not uncommon finding of the discrepant and diverging sexual appetites of the aging male as opposed to the aging female.  When I use the term “aging,” I am not referring only to octogenarians, but also to middle-aged and perhaps even younger couples.

Sex is a vital aspect of human existence—instinctual, hard-wired and a biological imperative. Nature has created the ultimate “bait and switch” in which reproduction (procreation) is linked with a pleasurable physical act (recreation), ensuring mating and, ultimately, perpetuation of the species.

Yet sex is so much more than an act of physical pleasure. For men, it is emblematic of potency, virility, fertility, and masculine identity. For women, it represents femininity, desirability and vitality. For both genders, it is an expression of physical and emotional intimacy, a means of communication and bonding that occurs in the context of skin-to-skin, face-time contact that gives rise to happiness, confidence, self-esteem and quality of life. In addition to sexual health being an important piece of overall health, it also provides comfort, security and ritual that permeate positively into many other areas of our existence. No matter what our chronological age, our need for physical and emotional intimacy never perishes.

Considering that nature’s ultimate purpose of sex is for reproduction, perhaps it is not surprising that when the body is no longer capable of producing offspring, changes occur that affect the anatomy and function of the genital organs.  However, long after the reproductive years are over and parenthood is no longer a consideration, many humans still wish to be able to function sexually.  For men this entails possessing a satisfactory libido (sex drive), the ability to obtain and maintain a reasonably rigid and durable erection, the capacity to ejaculate and experience a climax and, of course, to please their partners.  For women this entails having adequate sexual desire and interest, the ability to become aroused and lubricated, and the capacity to achieve orgasm as well as please their partners.

The aging process can be unkind and Father Time (as well as the ravages of poor lifestyle habits, medical issues and their treatment and other factors) does not spare sexual function.  For men, all aspects of sexuality decline, although sexual interest and drive suffer the least depreciation, leading to men who are eager, but frequently unable to achieve a rigid erection—a frustrating combination.  Age-related changes that affect male sexuality include penile shrinkage, decreased libido, diminished erectile rigidity and durability, more feeble ejaculations (less semen, less force, less arc) and less climactic orgasms.  The male downswing in sexual function usually has a slow and gradual trajectory that is based on many factors, with the progressive decline in testosterone production that occurs with aging (“andropause”) one of the key contributing factors.

For women, all aspects of sexuality decline as well. Age-related changes that affect female sexuality include vaginal and vulval dryness, irritation and thinning, vaginal narrowing and shortening, reduced sex drive, decreased arousal and lubrication, diminished ability to achieve an orgasm and a tendency for painful intercourse. Issues such as urinary incontinence and pelvic organ prolapse can put a further damper on sexual function.  The female downswing in sexual function occurs more precipitously than the male decline—although on the basis of numerous factors, an important one is the cessation of estrogen production by the ovaries that occurs after menopause, typically in the early 50s.

In addition to the physical and hormonal factors that may contribute to decreased sexual activity of the aging couple, there are many other considerations that come into play: After many years of marriage, the novelty factor wears off; priorities change; couples are often busy and fatigued with work, child-rearing and other responsibilities; emergence of urological, gynecological, orthopedic/joint problems, etc., psychological conditions (anxiety, stress and depression having to do with aging, health and other causes); and side effects from medications.   Ultimately, emotional intimacy can become more important to one (or both) partner(s) than physical intimacy.

In the population of patients that I care for (which may be skewed since I am a urologist who often treat men with sexual issues), I have perceived that in general—with exception—the aging male has a more robust sexual desire than his partner.  I have observed many men eager for the possibility of improving erectile function via chemical and other means (Viagra, Cialis, etc.), while his partner does not share his enthusiasm.

In most first marriages (commonly age late 20s to early 30s), men are typically a few years older than the women they marry. However, the older that men are when they marry, the greater the differential in age between them and their spouses, holding true in both first and second marriages. Perhaps age-related diverging sexual desires among males and females are among the factors that may help explain this phenomenon.

So, what to do?

Each partner in a relationship should make an effort to be more understanding of and sympathetic to their partner’s situation and needs and strive to compromise and find middle ground. Psychological counseling may be of great benefit to the couple suffering with the issue of libido imbalance.  Urologists and gynecologists can help male and female patients, respectively, with libido and other issues of sexual dysfunction.

Whereas male sexual dysfunction has received considerable attention and many management options are available, female sexual dysfunction by comparison has received short shrift.  Fortunately, the tides are changing and female sexual dysfunction—paralleling the male situation—has come out of the closet, is the subject of ongoing research and is now a subspecialty of gynecology with numerous management choices available.

Decreased sexual desire in males and females can often be successfully managed with hormone replacement therapy, estrogen and testosterone, respectively, when used in the proper circumstances under medical supervision.  Addyi (Flibanserin)—sometimes referred to as “female Viagra”—is a recently available pill that can effectively manage decreased female sexual desire.  Over the counter lubricants and moisturizers can help manage vaginal dryness and discomfort associated with sexual intercourse. Small amounts of topically applied estrogen or DHEA can be helpful as well. Oral ospemifene (a selective estrogen receptor modulator) may also be used successfully for vaginal dryness and painful intercourse related to menopause.  Fractional carbon dioxide laser treatments applied to the vagina may also prove beneficial when used under the right circumstances.  For the male with erectile dysfunction, there are numerous options to help restore erectile rigidity in the event that the oral pharmaceuticals are ineffective.

Despite the importance of sex, for many couples emotional intimacy can be equally important to, if not more so, than physical intimacy. Furthermore, all forms of sex can be enjoyable and there are numerous ways one can sexually satisfy one’s partner aside from penetrative penile-vaginal intercourse with both partners capable of achieving sexual gratification and climax without the involvement of an erect penis.

Bottom Line: A mismatch in sexual desire is a common issue among partners. Important factors are gradually declining testosterone levels in men and the more sudden decrease in estrogen levels in women.  The recently introduced concept of “couple-pause” is a couple-oriented approach that strives to address the sexual needs of the couple as a whole, rather than an isolated approach to one individual of the pair.  The good news is that disparity of intensity of sexual drive and interest among partners as well as other forms of sexual dysfunction are issues that can be addressed and improved, if not resolved.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health


PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

New video on female pelvic floor exercises:  Learn about your pelvic floor



Addyi: Female Viagra Or What?

May 14, 2016

Andrew Siegel MD  5/14/16


Clearly, sexism exists in the field of sexual medicine with a large gender gap with respect to the recognition and treatment of sexual issues. Numerous medications and options are available for male sexual dysfunction, but choices are few are far between for females with sexual problems.  Men have pelvic floor muscle training, vibrational stimulation, vacuum suction devices, pills (Viagra, Levitra, Staxyn, Cialis, Stendra), testosterone replacement, urethral suppositories, penile injection therapy and penile implants. Women have Kegel exercise programs, vibrational stimulation and estrogen replacement.  It is only fair that women have equal sexual medical rights.

One of the issues underlying this sexual gender gap is the erroneous assumption that  by virtue of possessing vaginas, females are less prone to sexual dysfunction than men are. The word “vagina” derives from the Latin word for “sheath,” a cover for the blade of a sword. The sword and sheath metaphor is convenient and assumes that the male plays the fully active role and the female the passive one. A flawed thought pattern is that while a man needs a rigid erection to perform—a complicated nerve-blood vessel-muscular event—a woman can simply lubricate and be ready to go. The truth of the matter is that female sexual response, although more subtle and nuanced than the male response, results in genital anatomical changes as profound as those that occur in males, just less apparent and obvious because the vagina is internal. Under normal circumstances, the vagina is no more “primed” for sex than is a flaccid penis, the un-stimulated vagina being merely a potential space; however, when stimulated, the vaginal walls lubricate and the vagina expands, lengthens and widens in order to accommodate an erect penis, changes that are as dramatic as the transition of a flaccid penis to an erect penis. The bottom line is that the vagina is by no means simply a passive channel.

Female sexual dysfunction is a common condition that can give rise to one or more of the following symptoms: diminished desire; decreased sexual arousal; difficulty achieving orgasm; and pain with sexual intercourse. The most prevalent issue and the subject matter of this entry is decreased or lack of sexual desire, the formal medical title being hypoactive sexual desire disorder (HSDD), although I prefer the less formal, non-medical version: “Honey, I’m not in the mood.” Diminished sex drive is complicated and involves a number of underlying factors–biochemical, psychological, and social.

In terms of biochemical factors, the neurotransmitters norepinephrine and dopamine stimulate sexual desire, whereas serotonin inhibits it. The SSRI (selective serotonin reuptake inhibitors) class of antidepressants function by increasing serotonin levels and are associated with decreased sexual desire as well as difficulty with arousal and orgasm, suggesting the important roles that serotonin plays as a regulators of sexual desire. Additionally, the hormone testosterone is a libido stimulant in both genders.

Addyi was initially developed as an anti-depressant and was investigated in a clinical trial for the treatment of depression. Unfortunately, it failed to offer a meaningful benefit as an anti-depressant, but was found to increase sexual desire in females who had depression in combination with decreased libido, providing the rationale for further investigating it as a treatment for diminished libido.

Addyi is a non-hormonal treatment that acts on the brain to normalize neurotransmitter levels and thus enhance sexual desire. Perhaps TMI… physiologically Addyi is an agonist of the serotonin receptor 1A and an antagonist of serotonin receptor 2A, inhibiting the serotonin “anti-sexual” effects while promoting dopamine “pro-sexual” effects.

Addyi was FDA-approved even though the members of the advisory committee acknowledged that its effectiveness was modest. One of the committee members who voted for its approval stated: “It’s not a little magic pink pill.” Another committee member who voted against approval claimed that it was “a mediocre aphrodisiac with some side effects with marketing winning out over science.”

Addyi 100 mg daily has been shown to be safe and effective and superior to placebo in improving female libido. It is used to treat “pre-menopausal women with acquired generalized hypoactive sexual desire disorder characterized by low sexual desire that causes marked distress or interpersonal difficulty not due to coexisting medical or psychiatric issues, relationship problems or side effects from other medications.” It cannot be used with alcohol, so no romantic dinner with a nice bottle of wine if you are taking Addyi.

Last weekend I attended the San Diego American Urological Association meeting in San Diego, where Dr. Irwin Goldstein (a female sexual dysfunction expert with extensive experience prescribing Addyi) reported effectiveness in 60% of his patients with impaired libido, in some cases with life-changing results.

The adverse effects associated with Addyi –usually mild to moderate in severity–include dizziness, lightheadedness, nausea, dry mouth and sleepiness. On occasion it can cause reduced blood pressure (hypotension) and passing out (syncope), particularly if used with alcohol.

Bottom Line: Although Addyi may not be as effective in increasing libido in women as Viagra is in improving erections in men, in the properly selected female it can provide a meaningful improvement in sexual drive.  It is the first FDA-approved drug for sexual dysfunction in women and hopefully represents the beginning of the end of sexism in the field of sexual medicine. 

Reference: Gao Z, Yang D, Yu L, and Cui,Y: Efficacy And Safety Of Flibanserin Center In Women With Hypoactive Sexual Desire Disorder: A Systematic Review And Meta-Analysis. Journal of Sexual Medicine 2015; 12:2095 – 2104

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– newly available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo (paperback edition will be available soon).

Author page on Amazon:

Apple iBook:

Trailer for The Kegel Fix:  

Co-creator of Private Gym and PelvicRx: comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.  In the works is the female PelvicRx pelvic floor muscle training DVD. 

Pelvic Rx can be obtained at, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount. 

Testosterone For Females: Is There A Role?

October 31, 2015

Andrew Siegel MD   10/31/15

Many of my recent entries have been male-oriented. It’s time to give the fairer sex some equal time.


(Above image entitled: Mujer culturista mostrando la musculación de la espalda y los brazos, author: roonb, created November 2007, no changes to original image, creative commons license 2.0, link to license:

Female sexual dysfunction (FSD) is a common condition that may encompass diminished desire, decreased sexual arousal, difficulty achieving orgasm and pain with sexual intercourse. The most prevalent issue is decreased or lack of sexual desire, now given the formal medical title: Hypoactive Sexual Desire Disorder (HSDD), although I prefer the less formal, non-medical version: “Honey, I’m not in the mood.”

Testosterone (T)—the key male sexual hormone—has a strong role in stimulating sexual drive in both men and women and has long been used to manage diminished female libido and other sexual issues, despite it not being approved by the FDA for this intent. It has been shown to improve libido, arousal, sexual pleasure and overall sexual satisfaction.

Testosterone In Women

Although T is the major male sex hormone, it is also vital in females, similarly to how estrogen is the key female sex hormone, but has important functions in males as well.  In pre-menopausal women, the ovaries and adrenals (those paired glands that sit atop each kidney) each produce about 25% of T, with the other 50% produced by muscle and fat cells. The two biggest factors leading to a decrease in blood T levels are aging and menopause.

Pre-menopausal women produce about 0.25 mg T/day. (Men produce 6-8 mg T/day, about 25 times as much as females). Even after menopause, the ovaries continue to produce T.  Women who have their ovaries removed experience a dramatic decrease in T.

One of the major limitations of measuring T levels in females is the lack of reliable and accurate assays to precisely measure T levels at such low concentrations. Another shortcoming is that there is no concensus on what precisely is the lower level of T in females.

Symptoms of low T in females may include diminished libido, fatigue, lack of energy, decrease in well being, impaired concentration, depression and difficulties with arousal and orgasm. These symptoms of low T are very non-specific and have quite an overlap with the symptoms and changes that accompany normal aging, insufficient or poor quality sleep, overworking and/or an unhealthy lifestyle. Signs of low T in females are decreased muscle mass, increased body fat, thinning hair and bone wasting (osteopenia).

Decreased Female Libido

This is defined as absent or reduced interest in and arousal from sex, erotic thoughts, fantasies, or written, verbal, and visual cues.  There is usually a reduction in initiation of sex and reception to partner’s initiation attempts. When sexual activity does occur, there is often absent or reduced sensation (both genital and non-genital), excitement and pleasure. Although low T is an important cause of decreased sex drive, there are many other competing causes including other sexual issues such as pain with intercourse or inability to orgasm, medical diseases, medications, unhealthy lifestyle, fatigue, pregnancy, breast-feeding, menopause, boredom, stress, many other psycho-emotional factors and relationship issues.

Treatment Options

T has been shown to improve sexual function in both pre-and post-menopausal women. Testosterone replacement therapy (TRT) should only be a consideration after other causes of diminished libido have been eliminated.  It is challenging to predict which women will respond best to T therapy. Another concern is the safety and potential side effects with the long-term use of TRT.

There are currently no FDA-approved TRT products for women in the USA, so any usage is off-label. Products designed for TRT in males are available in a variety of preparations, including skin patches, gels and creams, buccal (gum) preparation, nasal gels, injections and long-acting pellets implanted in fatty tissue. Common side effects of TRT include unwanted hair growth, acne and mood or personality changes.

Addyi (Flibanserin) is a new oral medication for diminished libido.  It is currently being marketed largely to females, but is purportedly effective for both genders. It is the first FDA- approved prescription for diminished sex drive and has been referred to as “pink Viagra.” It is not TRT, but works centrally by affecting serotonin levels. It just became available this month.

Excellent reference on this subject: Khera, M. Testosterone Therapy for Female Sexual Dysfunction. Sex Med Rev 2015;3:137-144

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.