Minimal evidence of benefit from medications to increase sexual desire

Dr. Rosemary Basson (biography and disclosures)

Frequently asked questions I’ve noticed
Patients and referring physicians frequently ask about medications to increase sexual desire – especially for women.

Data that answers these questions
Aside from testosterone replacement to younger men with proven testosterone deficiency, evidence of benefit from hormonal or pharmacological therapy is minimal. Research has focused on women. Randomized controlled trials of sildenafil (phosphodiesterase type 5 inhibitor), bremelanotide (melanocyte – stimulating hormone analogue – agonist at MC1, MC3, MC4 receptors), and flibanserin (5HT1 agonist, 5HT2 antagonist, weak partial D4 agonist) have been discontinued due to lack of benefit. ¹

Transdermal testosterone supplementation in postmenopausal women to allow high premenopausal serum levels has shown modest benefit in most of the studies sponsored by Procter & Gamble but not in the most recent studies sponsored by BioSante.^{1, 2} Pooling the first sponsor’s studies together, active drug (testosterone patch of 300 µg) increased the women’s baseline frequency of two to three sexually satisfying events per month to some five per month, compared to four per month by placebo.

A major limitation of all studies to date is the recruitment criteria. When these details are given, the two to three satisfying sexual events per month represent 50 percent of the total.³ Partnered sex occurring weekly or slightly more often that is satisfying some 50 percent of the time does not reflect the complaints of clinical practice. Typically women present not only with lack of desire in between and at the outset of sexual engagements but report minimal pleasure, arousal, or triggering of any desire during the experience and rare or no orgasm (i.e. a generally muted response), which is consistent each time they sexually engage. Some will have discontinued sexual activity (i.e. would report no sexual engagement events per month) and others may be “going through the motions” perhaps hoping to strengthen their relationship, to placate their partner, or sometimes to lessen a sense of guilt or inadequacy. This clinical population has not been studied.

What I recommend (practice tip)
Explain the human sex response cycle clarifying that there are many reasons men and women agree to or instigate sex over and beyond ‘desire’ as in ‘drive’ or ‘libido’.⁴ Clarify that acting on all the other reasons to be sexual (e.g. to share intimacy and give and receive sexual excitement and physical pleasure with a loved partner), is strongly linked to mood, strength of the interpersonal relationship and stress.^{5, 6, 7} These three entities need first to be addressed. Feeling “sexually neutral” at the beginning a sexual experience is a normal occurrence but there needs to be appropriate and sufficient sexual stimulus and ability to attend and focus and not judge or critique what is happening. If these factors are satisfied then sexual arousal, pleasure, excitement and the physical changes of arousal follow. These changes themselves allow for more intense sexual stimuli to be wanted and to be effective. This explanation allows patients themselves to identify what is missing – for instance, the context or the type of stimuli, or more often their ability to stay focused and attend and not self-monitor or worry about their response.

New to sexual medicine therapy – and new to Western medicine generally – is the inclusion of mindfulness practice. Mindfulness promotes a state of detached awareness in which thoughts that enter consciousness are noted and then let go without any emotional attachment: so it is more than just concentration. Importantly, it involves a non-judgmental/accepting attitude to the present moment. Regular mindfulness practice is proving very beneficial to increase sexual desire and arousal, enjoyment and satisfaction such that sexual motivation is subsequently further increased.⁸ Sexual stimuli are felt more intensely (emotional and physical) and the mind stays focused. Clinicians of various backgrounds can include mindfulness in their treatment, but patients can enlist in community programs or download the practices from the internet. A number of helpful books outline the place of mindfulness in health and disease (e.g. Ronald Siegel: The Mindfulness Solution. Guilford Press 2009; Jon Kabat-Zinn: Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress Pain and Illness. Delta Trade Paperbacks 2005).

Finally it is helpful to briefly explain that, despite media reports, testosterone (and other ‘libido’ drugs), are lacking in both safety and efficacy data. Sexual motivation is complicated: there is no simple ‘desire deficit’ signal from the hypothalamus. It is more to do with the attractiveness of possible rewards from going ahead.

References  (Links might require login with CPSBC or UBC)

1. Basson R. Testosterone therapy for reduced libido in women. Ther Adv Endocrinol and Metab 2010; 1(4):155-164. (View article)
2. Snabes MC, Zborowski J, Siems S. Libigel (testosterone gel) does not differentiate from placebo therapy in the treatment of hypoactive sexual desire disorder in postmenopausal women. J Sex Med 2012; Vol 9;suppl 3:s171. (View abstract of a presentation with UBC or request from CPSBC)
3. Davis S, Moreau M, Kroll R, Bouchard C, Panay N, Gass M, et al: Testosterone for low libido in postmenopausal women not taking estrogen. N Eng J Med 2008; 359:2005-2017. (View with UBC or request from CPSBC)
4. Meston CM, Buss DM. Why Humans Have Sex. Arch Sex Behav 2007; 36(4):477-507. (View with UBC or request from CPSBC)
5. Burri A, Spector T. Recent and lifelong sexual dysfunction in a female UK population sample: Prevalence and risk factors. J Sex Med 2011; 8(9):2420-2430. (View with UBC or request from CPSBC)
6. Hartmann U, Philippsohn S, Heiser K, Rüffer-Hesse C. Low sexual desire in midlife and older women: personality factors, psychosocial development, present sexuality. Menopause 2004; Vol 11;(6, Part 2 of 2) Supplement:726-40. (View with UBC or CPSBC)
7. Maserejian NN, Shifren JL, Parish J, Braunstein GD, et al: The presentation of hypoactive sexual desire disorder in premenopausal women. J Sex Med 2010; 7:3439-3448. (View with UBC or request from CPSBC)
8. Brotto LA, Basson R, Luria M. A mindfulness-based group psychoeducational intervention targeting Sexual Arousal Disorder in women. J Sex Med 2008; 5(7):1646-1659. (View with UBC or request from CPSBC)

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Minimal evidence of benefit from medications to increase sexual desire

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