Posts Tagged ‘hypoactive sexual desire disorder’

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

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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).

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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.