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Female Sexual Dysfunction
They have the blue pill, we have the patch

In 1996, a blue diamond shaped tablet, which was seen as revolutionary in male erectile dysfunction was licensed. Many women have since used the drug with the hope that it would have a beneficial effect on them. Female Sexual Dysfunction (FSD) has not received the amount of attention it warrants and is often managed by inexperienced gynaecologists. A 1999 survey in the Journal of the American Medical Association showed that 43% of females between the ages of 18-59 had sexual dysfunction, the causes of which are multiple. Is the patch the answer to at least some of their problems?

Throughout history, most societies have had foods and drinks thought of as capable of increasing sexual desire. Known as aphrodisiacs after the Greek goddess of sensuality, Aphrodite, they include oysters, rhinoceros horn, chocolate, strawberries and thousands more. Other "recreational" drugs such as Methamphetamine are associated with hypersexuality in the short term but are harmful with recurrent use. Alcohol depresses the nervous system and removes inhibitions and is not a stimulant. A new drug, Bremelanotide, which was originally developed, as a "sunless tanning agent" is currently undergoing phase III clinical trials. It is the first drug shown to affect both desire and erectile function in both sexes.

Although Testosterone is thought of as a male sex hormone, women also produce it in smaller amounts and it is required to maintain a healthy sex drive. The association between lack of testosterone and female libido has been reported since the 1930's. It is produced by the ovaries and the adrenal glands, including in postmenopausal ovaries be it in reduced quantities. Despite this knowledge, gynaecologists continue to remove ovaries from ever increasing numbers of women during hysterectomy in order to prevent the ovaries becoming cancerous at a later date.

An underreported condition called Hypoactive Sexual Desire Disorder (HSDD) has long been recognized to result from this so-called surgical menopause. This form of sexual dysfunction is defined as a lack of sexual desire or low libido that causes a woman personal distress. Most women accept it as a consequence of growing older and most doctors are ignorant of its existence.

The majority of gynaecologists counsel younger hysterectomised women about eostrogen replacement but few advocated testosterone use, which, until now, has been mainly available to women as a six-monthly implant. A few women who had eostrogen replacement as an implant would sometimes have testosterone as well as an adjunct to eostrogen implants. Notoriously, they often develop a form of eostrogen addiction known as tachyphalaxis, which is corrected by changing the route of administration thus also ending the regular testosterone implants for most women. A synthetic form of HRT, Tibilone, with androgenic properties and known to have positive benefits on libido has been available for many years but has not been prescribed widely for this indication.

The new testosterone patch, Intrinsa™, has been available on the NHS since April 2007. Its license restricts its use to the treatment of HSDD in women who have had both ovaries and the uterus removed and are on eostrogen therapy. It is an innovative route of administration and offers a more controlled and lower dose compared to other routes of administration and also offers convenience to the patient. It is not the panacea for all female sexual dysfunction. The many reasons why a woman may have sexual problems need to be explored in detail with a sympathetic and knowledgeable practitioner who need not be medically qualified. Female sexuality is different from that of the male in having greater emotional and psychological dimensions. Distinction should also be made between sexual desire and sex drive.

Most doctors in the field suggest that suitability for Intrinsa should be assessed on the strength of a laboratory blood test, but laboratory testosterone results vary from one laboratory to another and there is no agreed "abnormal" result. The effect of the Intrinsa may not be immediate but subjective results should be evident in three months when treatment should be reviewed.

There is little likelihood of this patch being abused as much as the blue pill for men but no doubt some women will, with justification, demand its prescription outside its narrow license in case it works for them. The side effect profile appears to be favourable.

Xavier Mmono
Consultant Gynaecologist