Female Urology Patients Should Be Checked for Low Sex Drive
May 16, 2011 (Washington DC) — Urologists should be on the lookout for the presence of hypoactive sexual desire disorder (HSDD) in all women who present to their practices, researchers reported here at the American Urological Association 2011 Annual Scientific Meeting.
Their study found that nearly one third of women who sought a urology consultation for a variety of reasons also met the criteria for a diagnosis of HSDD. Middle-aged women and women with extremes in body mass index (BMI) were at increased risk for the disorder.
"We believe that there is a strong rationale for screening all female patients presenting to a urologist for a possible sexual desire disorder, in particular HSDD," Michael Ingber, MD, a urologist specializing in female pelvic medicine and reconstructive surgery in Denville, New Jersey, told Medscape Medical News.
"For one, several conditions that we routinely treat can adversely affect sexual desire, with a recent survey showing that sexual dysfunction occurred in about two thirds of female urology patients from a major metropolitan area in the United States," he said.
"Also, about a fourth of premenopausal women and half of postmenopausal women in a recent survey of a nationally representative sample of American women were diagnosed with low sexual desire. Our data show how widespread the disorder is in female urology patients, regardless of their underlying condition."
He emphasized that women are not likely to voluntarily share information about their sexual function and sexual desire.
Screening Tool Aids Detection
In Dr. Ingber’s practice, women routinely complete a brief questionnaire known as the Decreased Sexual Desire Screener (DSDS), which is a widely validated tool for diagnosing generalized acquired HSDD and, importantly, obviates the need for an extensive interview, which can be time-consuming and awkward for the patient.
"Most of our female patients said they were comfortable with the nature and content of the questionnaire," he said.
Dr. Ingber explained that after a diagnosis of low sexual desire has been established, clinicians aim to rule out conditions like pelvic muscle spasm or vulvodynia, which might cause significant pain with intercourse, and thereby reduce libido.
If low sexual desire is determined not to be secondary to any condition or treatment, testosterone testing is recommended. Women with a low free testosterone level might be offered an off-label prescription for topical testosterone. Currently, topical testosterone can only be prescribed off label to women in the United States because it is only approved for use in men who either no longer produce testosterone or produce it in very low amounts. In 2007, more than 2 million testosterone gel prescriptions were written for women.
HSDD in a Urology Practice
The investigators analyzed responses to the DSDS, which was completed by 339 women, 18 years of age or older, who presented to a urologist at any Cleveland Clinic–affiliated site within the greater Cleveland, Ohio, area during a 3-month period. Patients had scheduled a visit with a urologist for a range of complaints, including kidney stones, hematuria, prolapse, and urinary incontinence.
The DSDS consists of the following questions:
- In the past, was your level of sexual desire/interest good and satisfying to you?
- Has there been a decrease in your level of sexual desire/interest?
- Are you bothered by your decreased level of sexual desire/interest?
- Would you like your level of sexual desire/interest to increase?
In a fifth question, women are asked to note any factors from the following list that they feel might have contributed to a loss of sexual desire or interest:
- medications, drugs, or alcohol you are currently taking
- pregnancy, recent childbirth, menopausal symptoms
- other sexual issues you may be having (pain, decreased arousal, or orgasm)
- your partner’s sexual problems
- dissatisfaction with your relationship or partner
- stress or fatigue
If a woman answers "yes" to questions 1 through 4 and "no" to all of the factors in question 5, she might satisfy the criteria for a diagnosis of generalized acquired HSDD.
Overall, 273 (81%) women had a decrease in sexual desire. Ninety-five women (28%) answered "yes" to the first 4 questions, qualifying for a possible diagnosis of HSDD on the basis of the DSDS.
Further analysis revealed that 37% of women 41 to 52 years of age qualified for a possible diagnosis of HSDD on the basis of their responses to the first 4 questions, as did 17% of women 61 years of age or older.
Women with extremes in BMI — for example, above 32.7 kg/m2 or below 22.8 kg/m2 — were more likely to qualify for a diagnosis of HSDD than normal-weight women.
No demographic or clinical characteristic was predictive of low sexual desire or an actual HSDD diagnosis.
Dr. Ingber noted that he was surprised by the finding that low sexual desire was not more common in women with pelvic-related disorders than in women without these disorders. "We had assumed that women with urinary incontinence, pelvic organ prolapse, or pelvic pain would be more likely to have low sexual desire than women with other conditions that we routinely see, such as kidney stones, hematuria, or urinary tract infections," he said. "However, low sexual desire was found with all conditions."
He also said that women who completed the questionnaire as part of this study commented that "they were thrilled" that a study on female dysfunction was being conducted, given the numerous studies to date on male sexual dysfunction.
HSDS Is Overlooked
"While hypoactive sexual desire disorder is the most common type of sexual dysfunction in women, it’s clearly underdiagnosed and undertreated," Tobias Köhler, MD, MPH, assistant professor of andrology at Southern Illinois University School of Medicine in Springfield, and AUA spokesperson, told Medscape Medical News. "It’s therefore essential that we intensify our efforts to screen patients."
Importantly, he added, the patient is often unaware that the disorder can do more than significantly impair her quality of life and that of her partner. "Just like erectile dysfunction in a man can be a sign of heart disease, sexual dysfunction in women can be a tip-off to a range of health conditions. HSDD might signal depression or hormonal deficiencies, among other diagnoses," he said.
In lieu of a formal screen like the Berlin questionnaire, Dr. Köhler favors a conversation involving open-ended questioning. "You can say to the patient: ‘If you have a problem, tell me about it’; and ‘You might want to consider getting it checked out’."
"Regrettably, treatment for female sexual dysfunction is in its infancy," he said. "We’ve been treating male dysfunction and doing good scientific studies on male sexual dysfunction for 40 or 50 years. Women have been historically underserved."
The study received no outside funding. Dr. Ingber and Dr. Köhler have disclosed no relevant financial relationships.
American Urological Association (AUA) 2011 Annual Scientific Meeting: Abstract 911. Presented May 16, 2011.