Getty ImagesBy all measures Viagra has been a wildly successful drug, and is now used by 20 million men worldwide to boost their sex lives. But a woman might ask: "Why no quick fix for me?"
It's not for lack of trying by pharmaceutical companies. Even before Viagra hit the shelves in 1998, the search was on for a drug that could ramp up women's sex lives. But more than a decade later, still nothing.
The latest disappointment is flibanserin, a contender to be the first approved drug that enhances sexual desire in women. A Food and Drug Administration advisory panel recently reviewed this experimental drug, and advised against its approval. (The FDA usually follows the advice of such panels.) The modest increase in women's sexual satisfaction did not outweigh the side effects, which include fatigue and depression, the panel said.
Some women do have sexual dysfunction. The problem, experts say, is often a lack of desire for sex rather than the ability to perform it, which would be akin to male sexual dysfunction. In fact, some experts object to the creeping medicalization of women's sexual dysfunction, and say there's a potential to overdiagnose women with hypoactive sexual desire disorder (HSDD), a condition characterized by low sexual desire, to the point it causes distress.
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Karen M. Hicks, PhD, an adjunct professor at Lehigh University, in Bethlehem, Pa., and a founding member of the Consortium for Sexuality and Aging, says a lack of sex drive has been "framed by the medical community as a disease state that you need to be, or could be, cured from with a pill," says Hicks. For many women, however, sexual problems may be better treated with therapy or other approaches. "Taking a pill is the easy way out," she says.
Although experts agree that some women could get sexual healing from a pill, they're not sure how many women are actually in this group. The fact is that even if there were such a drug on the market, it's unlikely to be a one-size-fits-all cure like Viagra is for men with erectile dysfunction.
Next Page: What's killing your sex drive? [ pagebreak ]What's killing your sex drive?
About one in 10 women overall in the U.S. experience some type of HSDD, based on nationwide surveys conducted in 2006 and 2008, which were funded by pharmaceutical companies."Ten percent is a good estimate," says Sheryl A. Kingsberg, PhD, a clinical psychologist and chief of behavioral medicine at University Hospitals Case Medical Center, in Cleveland.
There is no such thing as a "normal" sex drive that dictates how often women should want to have sex, says Kingsberg. But low sex drive can become a problem if there is a "relative change in what a women thinks is normal in her own life."
In addition to HSDD, there are two other common sexual issues in womenarousal and orgasmic disorder. In the 2006 survey, about 5% of women reported that they had trouble getting physically aroused or having orgasms.
So how do you know what's killing your sex drive, and whether you can fix it? If you feel frustrated by a low sex drive, the most important step is to talk to a doctor, says James A. Simon, MD, a clinical professor at George Washington University and medical director of Women's Health and Research Consultants, in Washington, D.C. A 2009 survey found that about two-thirds of women did not bring up sexual problems at doctors' visits because they were embarrassed or felt their doctor wasn't interested.
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Dr. Simon says that it is difficult to delve into the topic in the last few minutes of an appointment because the diagnosis is complicated, and other medical and psychological conditions may be involved.
Sharon Parish, MD, an associate professor of clinical medicine at Albert Einstein College of Medicine, in New York City, says it's "a really good idea" to make a specific appointment to address sexual problems instead of trying to talk about it during your regular appointment.
The cause of a lack of desire may vary with age. Like HSDD, arousal and orgasm problems are not uncommon in women between ages 45 and 64. In this group, hormonal changes that occur around menopause are the usual culprits of sexual dysfunction. Drugs like flibanserin purport to tweak the levels of brain chemicals to spur an interest in sex. However, they would probably do nothing for other common causes of low sexual desire: fatigue, depression, and low self-esteem.
Dr. Simon says that if you're more interested in sex when you're on vacation and caught up on sleep, fatigue may be the cause of low sexual desire. In those cases, making lifestyle changes or counseling may be more likely to get your mojo back than a pill that alters brain chemicals. And sometimes medications, such as birth control pills or antidepressants, can suppress sex drive too.
"I have no doubt that some women will benefit from drugs [like flibanserin]," says Dr. Simon. But "I've got to eliminate all of the other stuff first to see if my patient really has HSDD."
Next Page: Treatments available now [ pagebreak ]Treatments available now
Depending on the cause of sexual dysfunction, the therapies pioneered in the 1960s that teach patients to feel positively about sex are still some of the go-to treatments for women with HSDD, especially those who have had long-term low sexual desire. "I absolutely believe that the best therapy is sex education, where people become more comfortable with their own sexuality and knowledgeable about their anatomy," says Hicks.
Hicks also recommends couples counseling to patients who have relationship problems to help them work on communication or becoming a better lover.
This form of therapy could also serve women with medical conditions that commonly erode sexual desire: diabetes and thyroid problems. These conditions "affect weight and body image, which could impact a woman's desire," Dr. Simon says. "In some cases, I would recommend therapy or maybe a trip to the gym." Urinary incontinence is also frequently associated with embarrassment and low sexual desire.
In addition to these triggers, experts like Kingsberg suspect that physiological changes, such as hormonal levels, can directly lead to HSDD. "For biologic causes of low sexual desire, unfortunately, there are no FDA-approved pharmacologic options to treat HSDD," she says.
Levels of testosterone, an enhancer of sex drive, dip in women after menopause. One treatment is the off-label use of testosterone in post-menopausal women or women who have had their ovaries removed (surgical menopause). This hormone promotes the release of dopamine, which is a key neurotransmitter for enhancing sexual desire.
"It can make empirical sense to try three months of testosterone [therapy] in post-menopausal women," Kingsberg says, adding that about 20% of testosterone prescriptions are written off-label for women. While she says the side effects of testosterone therapy are "usually mild" and include oily skin and thinning hair, its long-term safety has not been well studied.
Next Page: Other drugs in the pipeline [ pagebreak ]Other drugs in the pipeline
Like testosterone, flibanserin seems to promote the dopamine pathway, based on studies in animals. However, these studies suggest that flibanserin acts at a different point in the dopamine reaction.
Dr. Parish says that many of her patients feel that treatments like flibanserin are a ways off, and, so far, all signs suggest that the drug will be rejected at an FDA hearing coming up in the next few months. In the clinical trial, pre-menopausal women receiving flibanserin for six months had a moderate increase in the number of reported sexually satisfying experiences compared with the placebo group. But unexpectedly, the women who received the treatment did not notice a difference in their level of sexual desire.
If this drug is rejected, Hicks expects that Boehringer Ingelheim, the maker of flibanserin, will next test its effect in post-menopausal women. Even with an FDA rejection, Hicks predicts that pharmaceutical companies would continue their "race to the finish line for the first female drug [for sexual dysfunction]."
Currently, the only other drug that could be close to filing for FDA approval is LibiGel, a testosterone cream made by BioSante Pharmaceuticals. Women apply the cream to their arm, where it gets absorbed and enters the bloodstream. In an early clinical trial, LibiGel increased the number of sexually satisfying events in surgically menopausal women by 238%, and the company is now looking at the safety of the cream in women using it for a year.
Kingsberg thinks that no single drug is likely to work for all women whose low sexual desire stems from hormonal levels. Having drugs with different effects on neurotransmitters could be important.
"We don't really know what the exact neurotransmitter or hormone needs to be," she says, "I don't think it's a one-size-fits-all [but] fine-tuning the best option for each woman."