Several treatments produce modest, but statistically significant, clinical increases in sexual desire and function in women. The testosterone transdermal patch improves hypoactive sexual desire disorder (HSDD) in postmenopausal women (strength of recommendation [SOR]: A, 2 randomized controlled trials [RCTs]). Bupropion may be effective for HSDD in premenopausal women (SOR: B, 2 RCTs). Sildenafil improves HSDD associated with selective serotonin reuptake inhibitors (SSRIs) (SOR: B, 1 RCT)

Handler, Lara

Hobbs, Keia

English

University of Missouri: MOspace

Evidence-based answers from the Family Physicians Inquiries Network102 ThE JourNal oF FamIly PracTIcE  |   FEBruary 2013  |   Vol 62, No 2clinical inquiriesKeia Hobbs, MDUniversity of North  Carolina at Chapel HillLara Handler, MSLSHealth Sciences Library, University of North Carolina at Chapel HillASSiStAnt EDitORAnne L. Mounsey, MDUniversity of North  Carolina at Chapel HillEvidEncE-basEd answErA	 Which	treatments	help		women	with	reduced	libido?		 	 several treatments	 produce	 	 modest,	but	statistically	significant,	clinical	increases	in	sexual	desire	and	func-tion	in	women.	The	 testosterone	 transdermal	 patch	improves	 hypoactive	 sexual	 desire	 disor-der	 (HSDD)	 in	 postmenopausal	 women	(strength	 of	 recommendation	 [SOR]:	 A,	2	randomized	controlled	trials	[RCTs]).	Bupropion	may	be	effective	for	HSDD	in	premenopausal	women	(SOR:	B,	2	RCTs).	Sildenafil	 improves	 HSDD	 associated	with	 selective	 serotonin	 reuptake	 inhibi-tors	(SSRIs)	(SOR:	B,	1	RCT).	Evidence summaryTwo	 RCTs	 examined	 the	 effect	 of	 testoster-one	 on	 postmenopausal	 women	 with	 HSDD.	One	 trial	 randomized	 272	 women	 ages	 40	 to	70	 years	 to	 a	 300-mcg	 transdermal	 testoster-one	patch	(TTP;	142	women)	or	placebo	(130	women).1	At	 6	 months,	 women	 using	 the	 TTP	reported	 more	 sexually	 satisfying	 episodes	(1.69	 vs	 0.59	 episodes	 in	 4	 weeks;	 P=.0089)	and	a	minimal	increase	in	sexual	desire	scores	(12.2	vs	4.56	on	a	100-point	sexual	desire	scale;	P=.0007)	compared	with	women	using	placebo.	A	 second	 trial	 randomized	 814	 post-menopausal	 women	 (mean	 age	 54.2	 years)	to	placebo	(277	women),	a	150-mcg	TTP	(267	women),	 or	 a	 300-mcg	 TTP	 (270	 women).2	At	24	weeks,	women	taking	300	mcg	(but	not	150	 mcg)	 of	 testosterone	 reported	 a	 greater	number	 of	 satisfying	 sexual	 episodes	 than	women	 taking	 placebo	 (2.1	 vs	 0.7;	 P<.0001).	The	 300-mcg	 TTP	 caused	 more	 unwanted	hair	growth	than	placebo	(19.9%	vs	10.5%;	no	P	value	given).	The	study	didn’t	continue	long	enough	to	assess	cardiovascular	risks.Bupropion may improve sexual  function in premenopausal womenTwo	 RCTs	 found	 benefit	 from	 bupropion	 for	premenopausal	 women	 with	 HSDD.	 In	 the	first,	 investigators	 randomized	 232	 women	20	 to	 40	 years	 of	 age	 to	 bupropion	 sustained	release	 (SR)	 150	 mg	 daily	 or	 placebo.	 They	assessed	 sexual	 function	 at	 12	 weeks	 with	the	 Brief	 Index	 of	 Sexual	 Functioning	 for	Women—a	scale	with	scores	ranging	from	−16	(poor	 functioning)	 to	 +75	 (maximum	 func-tioning),		with	a	mean	value	in	normal	women	of	 33.6.3	 Women	 taking	 bupropion	 reported	greater	increases	in	scores	than	women	taking	placebo	 (15.8	 to	 33.9,	 vs	 15.5	 to	 16.9;	 P=.001)	and	no	serious	adverse	events.A	second	RCT	randomized	66	premeno-pausal	women	(mean	age	36.1	years)	to	take	either	bupropion	SR	150	mg	daily,	increased	to	300	mg	daily	after	one	week,	or	placebo.4	Researchers	 measured	 sexual	 responsive-ness	 (arousal,	 pleasure,	 and	 orgasm)	 using	the	Change	in	Sexual	Functioning	Question-naire	at	baseline	and	on	Days	28,	56,	84,	and	112.	 Women	 taking	 bupropion	 had	 higher	scores	by	Day	28	than	women	taking	placebo	and	maintained	the	difference	through	Day	112	 (P=.05).	 The	 authors	 indicated	 that	 the	clinical	significance	of	the	change	is	unclear.Sildenafil increases low sexual desire  associated with antidepressantsA	 double-blind	 RCT	 enrolling	 98	 premeno-pausal	 women	 (mean	 age	 36.7	 years)	 with	sexual	dysfunction	related	to	SSRIs	found	that	coNTINuEd oN PagE 112112 ThE JourNal oF FamIly PracTIcE  |   FEBruary 2013  |   Vol 62, No 2clinical inquiriesreferencessildenafil	 (50-100	 mg)	 improved	 sexual	 func-tioning	 more	 than	 placebo	 using	 the	 7-point	Clinical	 Global	 Impression	 score	 (sildenafil:	1.9	 points;	 95%	 confidence	 interval	 [CI],	1.6-2.3;	 placebo:	 1.1	 points;	 95%	 CI,	 0.8-1.5;	P=.001).5	The	investigators	didn’t	specify	whether	the	 change	 was	 clinically	 significant.	 How-ever,	another	RCT	that	studied	881	pre-	and	postmenopausal	 women	 with	 HSDD	 unas-sociated	 with	 SSRIs	 found	 no	 difference	 be-tween	sildenafil	(10-100	mg)	and	placebo.6Recommendations The	 US	 Food	 and	 Drug	 Administration	doesn’t	 recommend	 androgens	 for	 female	sexual	dysfunction.	The	 Endocrine	 Society	 says	 that	 bupro-pion	may	be	used	for	HSDD	(although	it	isn’t	licensed	 for	 such	 use)	 and	 doesn’t	 recom-mend	long-term	use	of	testosterone	because	of	inadequate	safety	studies.7	The	North	American	Menopause	Society	recommends	 testosterone	 therapy	 for	 post-menopausal	women	with	HSDD.8		               JFP	 1.			Panay	N,	Al-Azzawi	F,	Bouchard	C,	et	al.	Testosterone	treatment	of	 HSDD	 in	 naturally	 menopausal	 women:	 the	 ADORE	 study.	Climacteric.	2010;13:121-131.		 2.			Davis	SR,	Moreau	M,	et	al.	Testosterone	for	low	libido	in	women	not	taking	estrogen.	N Engl J Med.	2008;359:2005-2017.		 3.			Safarinejad	 MR,	 Hosseini	 SY,	 Asgari	 MA,	 et	 al.	 A	 randomized,	double-blind,	placebo-controlled	study	of	the	efficacy	and	safety	of	 bupropion	 for	 treating	 hypoactive	 sexual	 desire	 disorder	 in	ovulating	women.	BJU Int.	2010;106:832-839.		 4.			Segraves	RT,	Clayton	A,	Croft	H,	et	al.	Buproprion	sustained	re-lease	for	the	treatment	of	hypoactive	sexual	desire	in	premeno-pausal	women.	J Clin Psychopharmacol.	2004;24:339-342.		 5.			Nurnberg	HG,	Hensley	PL,	Heiman	JR,	et	al.	Sildenafil	treatment	of	 women	 with	 antidepressant-associated	 sexual	 dysfunction.	JAMA.	2008;300:395-404.		 6.			Basson	R,	McInnes	R,	Smith	MD,	et	al.	Efficacy	and	safety	of	silde-nafil	citrate	in	women	with	sexual	dysfunction	associated	with	fe-male	sexual	arousal	disorder.	J Womens Health Gend Based Med.	2002;11:367-377.		 7.			Wierman	 M,	 Basson	 R,	 Davis	 SR,	 et	 al.	 Androgen	 therapy	 in	women:	an	Endocrine	Society	Clinical	Practice	Guideline.	J Clin Endocrinol Metab.	2006;91:3697-3710.		 8.			Braunstein	 GD.	 The	 Endocrine	 Society	 Clinical	 Practice	 Guide-line	and	The	North	American	Menopause	Society	position	state-ment	on	androgen	therapy	in	women:	another	one	of	Yogi’s	forks.	J Clin Endocrinol Metab. 2007;92:4091-4093.	Family Practice Physician Physical Disability Board of ReviewAlexandria, VirginiaMedPro Technologies, LLC.	 is	 a	 provider	 of	 direct	 healthcare	 services	 to	 government	 agencies,	 including	 Military	 Treatment	 Facilities	(MTF)	both	stateside	and	overseas	and	is	nationally	recognized	for	excellence	in	supporting,	managing	and	staffing,	the	mission	of	our	cus-tomers	through	medical,	applied	sciences	and	research	and	development.	Please	visit	our	website	www.medpro-tech.usThe	Family Practice Physician	primary	function	will	be	to	review	Disabled	Veterans	Administration	(DVA)	disability	rating	for	the	specifically	military	unfitting	condition(s)	with	the	Physical	Evaluation	Board	(PEB)	combined	disability	rating	and	consider	any	variance	in	its	deliberations	and	any	impact	on	the	final	PEB	combined	disability	rating,	particularly	if	the	DVA	rating	was	awarded	within	12	months	of	the	Service	member’s	separation.	The	Family	Practice	Physician	shall	also	review	the	complete	case	record	that	served	as	the	basis	for	the	final	Military	Department	PEB	rating	determination	and,	to	the	extent	feasible,	collect	all	the	information	necessary	for	competent	review	and	recommendation.SCOPE OF: Physical	Disability	Board	of	Review.	The	PDBR	adjudicates	cases	upon	which	review	is	requested	or	undertaken	on	its	own	mo-tion.	The	PDBR	has	no	greater	obligation	to	our	wounded,	ill,	and	injured	Service	members	and	former	Service	members	than	to	offer	fair	and	equitable	recommendations	pertaining	to	the	assignment	of	disability	ratings.	BACKGROUND:The	Warrior	Care	Policy	is	responsible	to	ensure	Wounded,	Ill,	and	injured	transitioning	warriors	receive	high	quality	care	and	seamless	transi-tion	support	through	proactive	leadership,	responsive	policy,	and	effective	oversight	and	interagency	collaboration	and	the	Physical	Disability	Board	of	Review	(PDBR)	in	their	mission	to	ensure	service	members	receive	a	fair	and	accurate	reassessment	of	their	DoD	disability	rating.	Services	will	be	performed	at	the	Physical	Disability	Board	of	Review,	Hoffman	Building	200	Stovall	Street,	Alexandria,	Virginia.	Requirements:1.	 Completion	of	residency	or	fellowship	in	Family	Medicine	acceptable	to	the	Surgeon	General,	HQ	USAF	or	PDBR.	2.	 Current	board	certification	by	the	American	Board	of	Family	Medicine.	3.	 	At	least	24	months	of	experience	within	the	last	36	months.	Must	have	experience	with	military	or	Veterans	Affairs	Medical	Evaluation	Board.4.	 Military	Background	desirable,	not	required.5.	 Familiarity	with	post	traumatic	stress	disorders	highly	desirable6.	 	The	Family	Practice	Physician	shall	have	and	maintain	a	current	unrestricted	license	to	practice	medicine.	Must	meet	all	licensing	and	certification	requirements	to	perform	as	a	Family	Practice	Physician,	currently	licensed	in	the	United	States,	the	District	of	Columbia,	the	Commonwealth	of	Puerto	Rico,	Guam,	or	the	US	Virgin	Islands.If interested, please forward CV/Resume to ruben.perez@eagle-app-sci.com or contact me at 210-477-2798.PracTice OPPOrTuniTiescoNTINuEd From PagE 102

Which treatments help women with reduced libido?

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Which treatments help women with reduced libido?

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