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Methodological Challenges in Studying Testosterone Therapies for Hypoactive Sexual Desire Disorder in Women. J Sex Med 2020; 17:585-594. [DOI: 10.1016/j.jsxm.2019.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/04/2019] [Accepted: 12/07/2019] [Indexed: 11/19/2022]
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Pyke R, Clayton A. What Sexual Behaviors Relate to Decreased Sexual Desire in Women? A Review and Proposal for End Points in Treatment Trials for Hypoactive Sexual Desire Disorder. Sex Med 2017; 5:e73-e83. [PMID: 28041924 PMCID: PMC5440628 DOI: 10.1016/j.esxm.2016.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/09/2016] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Counts of satisfying sexual events (SSEs) per month have been criticized as an end point in treatment trials of women with hypoactive sexual desire disorder (HSDD) but grounding improvement in sexual desire by assessing changes in sexual behavior remains of some importance. METHODS We conducted a literature review to find validated measurements that are specific sexual behavioral correlates of low sexual desire. We compared expert-proposed criteria for dysfunctional desire, expert-developed sets of scale items, and self-rated scales developed before issuance of, or in accordance with, the Food and Drug Administration's guidance on developing patient-reported outcomes. Behavioral measurements of HSDD were isolated from these sets of criteria or scales. MAIN OUTCOME MEASURES We outline a plan to evaluate such behavioral measurements of HSDD with reference to SSEs. RESULTS Eleven rating scales, four expert-originated and seven self-rated scales mainly derived from patient input were identified as well validated and relevant to HSDD. Three recent sets of diagnostic criteria for conditions such as HSDD were compared with the scales. Twenty-four different symptoms were found in the scales. Content found relevant to HSDD during development of the rating scales varied highly among measurements, including the self-rated scales developed in conformity with current recommendations for patient-reported outcome measurements. The only item on all sets was desire for sexual activity. Four other items were in approximately at least half the sets: sexual thoughts or fantasies, frequency of sexual activity, receptivity, and initiations. Sexual thoughts or fantasies were in every expert-derived set but in only three of the seven patient-derived sets. Receptivity was in five of the seven expert-derived sets vs two of the seven patient-derived sets. Frequency of sexual activity was in one of the seven expert-derived sets but in five of the patient-derived sets. Initiation was in approximately half the two sets. All other items were on one to three sets each. We identified three sexual behaviors of validated specificity for female HSDD: frequency of sexual activity, receptivity, and initiations. Six or seven items are relevant and informative. The item on frequency of sexual activity in the Changes in Sexual Functioning-Female scale is the only item that covers frequency of dyadic and solitary sexual activity. An item in the Female Sexual Desire Questionnaire (FSDQ) covers the intuitively relevant topic of frequency of sexual activity motivated by the woman's desire. Three FSDQ items on initiations and two items on receptivity reflect expert opinion on the sexual behaviors of most relevance to HSDD, but the FSDQ has not been validated in women with HSDD. CONCLUSIONS SSEs have been discredited as the primary measurement in clinical trials of women with HSDD, but it would be meaningful to include at least one sexual behavioral symptom specific to HSDD as an end point. Expert-recommended sexual behaviors specifically related to HSDD are irregularly represented in self-rating scales whether developed as in the Food and Drug Administration guidance on patient-reported outcomes or not. Six or seven items on sexual behavior in self-rated scales can be recommended for relevance to women with HSDD in clinical trials. Items on female sexual behavior should be tested in comparison with SSEs in women with HSDD for relevance and for treatment sensitivity, and responder and functional and dysfunctional cutoffs should be determined before incorporation into large-scale clinical trials. Pyke R and Clayton A. What Sexual Behaviors Relate to Decreased Sexual Desire in Women? A Review and Proposal for End Points in Treatment Trials for Hypoactive Sexual Desire Disorder. Sex Med 2017;5:e73-e83.
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Affiliation(s)
- Robert Pyke
- S1 Biopharma, Inc, Medical, New Fairfield, CT, USA.
| | - Anita Clayton
- Psychiatry and Behavioral Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
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Derogatis LR. Review of Patient-Reported Outcome Measures for Sexual Dysfunction. CURRENT SEXUAL HEALTH REPORTS 2015. [DOI: 10.1007/s11930-015-0052-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Heiman JR, Rupp H, Janssen E, Newhouse SK, Brauer M, Laan E. Sexual desire, sexual arousal and hormonal differences in premenopausal US and Dutch women with and without low sexual desire. Horm Behav 2011; 59:772-9. [PMID: 21514299 DOI: 10.1016/j.yhbeh.2011.03.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 03/18/2011] [Accepted: 03/30/2011] [Indexed: 01/23/2023]
Abstract
The interaction between women's hormonal condition and subjective, physiological, and behavioral indices of desire or arousal remains only partially explored, in spite of frequent reports from women about problems with a lack of sexual desire. The present study recruited premenopausal women at two sites, one in the United States and the other in the Netherlands, and incorporated various measures of acute changes in sexual desire and arousal. A sample of 46 women who met criteria for Hypoactive Sexual Desire Disorder (HSDD) was compared to 47 women who experienced no sexual problems (SF). Half of each group used oral contraceptives (OCs). The specific goal was to investigate whether there is a relationship between women's hormone levels and their genital and subjective sexual responsiveness. Background demographics and health variables, including oral contraceptive (OC) use, were recorded and hormones (total testosterone (T), free testosterone (FT), SHBG, and estradiol) were analyzed along with vaginal pulse amplitude and self-report measures of desire and arousal in response to sexual fantasy, visual sexual stimuli, and photos of men's faces. Self-reported arousal and desire were lower in the HSDD than the SF group, but only for women who were not using oral contraceptives. Relationships between hormones and sexual function differed depending on whether a woman was HSDD or not. In line with prior literature, FT was positively associated with physiological and subjective sexual arousal in the SF group. The HSDD women demonstrated the opposite pattern, in that FT was negatively associated with subjective sexual responsiveness. The findings suggest a possible alternative relationship between hormones and sexual responsiveness in women with HSDD who have characteristics similar to those in the present study.
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Affiliation(s)
- Julia R Heiman
- The Kinsey Institute for Research in Sex, Gender, and Reproduction, Indiana University, Bloomington, IN 47405, USA.
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Abstract
Sexuality is a critical issue at menopause for many women. Several biological, psychological and socio-relational factors are related to women's sexual health and they may negatively affect the entire sexual response cycle, inducing significant changes in desire, arousal, orgasm and satisfaction. Age- and menopause-related events may impair the integrity of multiple biological systems involved in the normal sexual response of women, including hormonal environment, neuromuscular substrates and vascular supplies. Sex hormones, namely low levels of estradiol, physical and mental well-being and, very importantly, feelings for partner are extremely relevant for women's sexuality in natural menopause. Even a significant lack of androgens, as more frequently occurs in surgical menopause, has a negative impact on women's desire and sexual responsiveness. Sexual history and clinical evaluation may help doctors to accurately diagnose sexual symptoms causing personal and relational distress and to identify the best therapeutic approach.
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Affiliation(s)
- R E Nappi
- Research Center for Reproductive Medicine, Department of Morphological, Eidological and Clinical Sciences, & Unit of Gynecological Endocrinology and Menopause, IRCCS Maugeri Foundation, University of Pavia, Italy
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Abstract
Sexuality is innate within all women to a greater or lesser extent, and is affected by a number of extrinsic factors that occur in the menopausal transition. Assessing hormone status is difficult as evidence exists that sex hormones may differ between ethnic groups, and that bio-assays may be insensitive at lower testosterone levels. Data are available on the prevalence of female sexual dysfunction, but results from cross-sectional studies differ from those of longitudinal studies. The original traditional models of human sexual response have been challenged, and new models have been defined which show more complex interaction between intrinsic and extrinsic factors. Definitions of sexual dysfunction have been redefined. There are a limited number of randomized, placebo-controlled trials of drugs to improve sexual function. These include sildenafil citrate, tibolone and hormone replacement therapy. Randomized controlled trials on testosterone replacement in naturally and/or surgically menopausal patients with female sexual dysfunction have been criticized for a high placebo response rate and short duration. This chapter seeks to put sexuality into perspective and to define both function and dysfunction.
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Affiliation(s)
- Joan Pitkin
- Northwick Park; St Marks Hospital, N.W. London Hospitals, NHS Trust, Watford Road, HA1 3UJ, UK.
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Ghoniem G, Stanford E, Kenton K, Achtari C, Goldberg R, Mascarenhas T, Parekh M, Tamussino K, Tosson S, Lose G, Petri E. Evaluation and outcome measures in the treatment of female urinary stress incontinence: International Urogynecological Association (IUGA) guidelines for research and clinical practice. Int Urogynecol J 2008; 19:5-33. [PMID: 18026681 PMCID: PMC2096636 DOI: 10.1007/s00192-007-0495-5] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Accepted: 10/14/2007] [Indexed: 02/06/2023]
Affiliation(s)
- G Ghoniem
- Cleveland Clinic Florida, Weston, FL, USA.
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Symonds T, Spino C, Sisson M, Soni P, Martin M, Gunter L, Patrick DL. Methods to determine the minimum important difference for a sexual event diary used by postmenopausal women with hypoactive sexual desire disorder. J Sex Med 2007; 4:1328-35. [PMID: 17727352 DOI: 10.1111/j.1743-6109.2007.00562.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Recently, there has been much discussion in the literature about how to determine the meaningfulness of results generated from a patient-reported outcome measure. A number of reviews have shown that there are two main approaches: anchor- and distribution-based approaches for determining the minimum important difference (MID) for a new measure. There are issues with calculating an MID using each method: Will the two approaches give the same estimate? If the estimates differ, how do you decide on one estimate? Would asking patients directly be more beneficial? AIM A case study was presented to address these issues based on a newly developed diary assessing number of satisfactory sexual events (SSEs) per week in women with hypoactive sexual desire disorder (HSDD). METHODS Anchor- and distribution-based estimates were generated from data gathered in two double-blind, placebo-controlled, parallel group trials for the treatment of HSDD (N = 788). A novel interview study was used to ask women directly about an MID for SSEs (N = 77). MAIN OUTCOME MEASURES Defining the MID for an SSE diary in women with HSDD. RESULTS The estimates varied, producing a range of mean MID estimates between 0.04 and 0.46 SSEs per week. CONCLUSION We recommend that rather than defining the MID, a range should be selected from the set of estimates formed by the limits of the 95% confidence intervals.
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Rust J, Derogatis L, Rodenberg C, Koochaki P, Schmitt S, Golombok S. Development and validation of a new screening tool for hypoactive sexual desire disorder: The Brief Profile of Female Sexual Function (B-PFSF). Gynecol Endocrinol 2007; 23:638-44. [PMID: 17926163 DOI: 10.1080/09513590701592306] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
AIM To develop a screening tool to allow a postmenopausal woman to determine whether to seek evaluation for hypoactive sexual desire disorder (HSDD). METHODS The Brief Profile of Female Sexual Function (B-PFSF) was developed using items from the Profile of Female Sexual Function (PFSF) and the Personal Distress Scale (PDS). Logistic regression analysis was used to select items best able to discriminate between women with HSDD (n = 743) and controls (n = 226) and a screening cut-off score was identified. Cross-validation analyses were conducted using PFSF and PDS responses from an independent group of 147 HSDD women and 104 controls. Forty cognitive interviews were additionally conducted to assess validity of the final tool. RESULTS A seven-item instrument was found to provide good discrimination between postmenopausal women with HSDD and controls and to be a reliable and valid tool. Ninety-six percent of women with HSDD and 97% of control women in the independent validation were classified correctly using the identified cut-off score. In the cognitive interviews, all women stated that the questionnaire was easy to complete and covered relevant aspects of sexual function. CONCLUSION The Brief Profile of Female Sexual Function (B-PFSF) is psychometrically valid and appropriate for use as a self-administered screening tool.
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Affiliation(s)
- John Rust
- The Psychometrics Centre, University of Cambridge, Cambridge, UK.
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Abstract
The recent recognition of the high prevalence of sexual dysfunctions and disorders in our society, along with the substantial investment of the pharmaceutical industry in the field of sexual functioning, has resulted in a significant expansion in the development of valid and reliable measures of sexual function/dysfunction. The instruments tend to be brief self-report inventories, typically requiring 10-20 min of patient time for completion. Most measures were initially developed as screening and outcomes measures for use in clinical drug trials of new treatments for sexual dysfunction, but are beginning to see more widespread use in the clinic. All these instruments must adhere to recently prescribed rigorous guidelines set forth by the Food and Drug Administration, and have been demonstrated to be valid and reliable indicators of the status and quality of sexual functioning in both men and women. The constructs that form the framework of our diagnostic system for sexual dysfunctions are not amenable to direct physical measurement, so that currently they must be assessed via these self-report scales. Although not as precise as physical measures, these inventories do an admirable job of quantifying and registering sexual functioning status in a concise and reliable manner, and have become indispensable tools in our clinical and research programs.
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Affiliation(s)
- L R DeRogatis
- Center for Sexual Medicine, Sheppard Pratt Health System and Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD 21285, USA.
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Nijland E, Davis S, Laan E, Schultz WW. REVIEW: Female Sexual Satisfaction and Pharmaceutical Intervention: A Critical Review of the Drug Intervention Studies in Female Sexual Dysfunction. J Sex Med 2006; 3:763-777. [PMID: 16942521 DOI: 10.1111/j.1743-6109.2006.00285.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION A considerable number of double-blind randomized controlled studies investigating the effects of pharmaceutical intervention on female sexual functioning have been published in recent years. However, a comparison between outcomes of various studies is difficult as no generally accepted/correct approach to research has been established yet. To be able to translate trial results to daily clinical practice, current limitations and issues in drug intervention studies in female sexual dysfunction (FSD) need to be clarified. AIM To evaluate the needs in research into intervention in FSD by reviewing published studies. METHODS A systematic review of double-blind randomized controlled intervention trials on FSD. MAIN OUTCOME MEASURES Definitions of study populations, inclusion and exclusion criteria, use of power calculations, outcome measures and treatment duration. RESULTS A total of 25 double-blind randomized controlled trials investigating the effects of pharmaceutical intervention on female sexual functioning have been published. Of these, 11 studies required the diagnosis of FSD as an inclusion criterion. A standard methodology for research in this field is lacking. Significant differences in population inclusion requirements and tools for the measurement of change in sexual functioning were identified as major limiting factors. CONCLUSIONS The investigation of FSD is an evolving area in that new definitions and a new model for female sexual functioning have been recently proposed. There is a need for experts in the field and regulating authorities to reach a consensus regarding appropriate inclusion and exclusion criteria for FSD trials and main outcome measures appropriate for the evaluation of drug interventions. This consensus should also determine which treatment effect is considered to be clinically relevant. Treatment efficacy and clinical relevance should be related to outcomes which are meaningful for affected women.
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Affiliation(s)
- Esmé Nijland
- Organon-Medical Services Women's Health, Oss, the Netherlands.
| | - Susan Davis
- Alfred Hospital-Women's Health Program, Monash University, Clayton, Australia
| | - Ellen Laan
- Department of Sexology and Psychosomatic Obstetrics/Gynecology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Abstract
INTRODUCTION Hypoactive sexual desire disorder (HSDD) is a common problem that is often treatment refractory. This refractoriness to treatment is reflective of our lack of knowledge concerning the determinants of sexual libido in women. AIM To review the development and current status of information concerning the diagnosis and treatment of HSDD. METHODOLOGY Literature on HSDD published between 1950 and 2005 was reviewed. RESULTS Historically, HSDD was considered to be a psychiatric disorder. Thus, the diagnostic criteria utilized in studies of interventions for this disorder are based on the Diagnostic and Statistical Manual of the American Psychiatric Association. This system was never designed to encompass organic causes of sexual dysfunction and has evolved by expert opinion. If the syndrome is poorly defined by these diagnostic criteria, this could limit progress in this field. Epidemiological studies have found that approximately 24-43% of women complain of low sexual desire in the preceding year. The percentage of the population meeting diagnostic criteria for HSDD is probably much lower. There has been considerable progress in the development of psychometrically sound instruments for the assessment of libido. The development of approaches to treatment was reviewed. Approaches to treatment have evolved in three major areas: psychological, hormonal, and use of psychopharmacological agents. There is some evidence of efficacy utilizing all three approaches. The major evidence of efficacy concerns the use of testosterone therapy. Long-term safety data concerning this treatment are absent. CONCLUSION There is a rapidly expanding knowledge base concerning the diagnosis and treatment of HSDD. However, the contemporary clinician is faced with the absence of an approved treatment for this disorder and the lack of clear guidelines concerning the indications and safety of the use of non-approved agents.
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Affiliation(s)
- Robert Segraves
- Department of Psychiatry, MetroHealth, Cleveland, OH 44122, USA.
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Althof SE, Dean J, Derogatis LR, Rosen RC, Sisson M. Current Perspectives on the Clinical Assessment and Diagnosis of Female Sexual Dysfunction and Clinical Studies of Potential Therapies: A Statement of Concern. J Sex Med 2005; 2 Suppl 3:146-53. [PMID: 16422791 DOI: 10.1111/j.1743-6109.2005.00130.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The assessment and diagnosis of female sexual dysfunction (FSD) are in a state of transition because of evolving concepts of female sexuality and suggested changes to the FSD diagnostic framework. AIM To review the problems with current FSD diagnosis. METHODS Multidisciplinary experts from five countries were assembled to convene a "Postmenopausal FSD Roundtable on specific topics related to FSD." MAIN OUTCOME MEASURE Expert opinion was based on a review of evidence-based medical literature, presentation, and internal discussion. RESULTS Current FSD diagnosis is challenging because of poorly defined distinctions between normal and abnormal, a limited ability to integrate subjective and objective findings and an inability to incorporate contextual factors that play a significant role in sexual behavior. The availability of self-administered questionnaires (SAQs) that assess various domains of female sexual function, as well as those developed specifically for postmenopausal women, suggests that a more structured approach to assessment and diagnosis may be possible. Several SAQs reflecting proposed changes to the FSD diagnostic framework by the American Foundation for Urologic Disease (AFUD), including the Sexual Function Questionnaire (SFQ) and the Female Sexual Distress Scale (FSDS), have been introduced and recently incorporated into a Structured Diagnostic Method (SDM). Recent regulatory decisions and events affecting the development of FSD interventions have highlighted the lack of consensus with regard to clinically meaningful FSD outcomes, as well as shortcomings in a U.S. Food and Drug Administration draft document that provides the primary guidance for conducting FSD clinical studies in the United States. CONCLUSIONS Given the high cost and inherent risk of clinical studies, continued development efforts toward FSD therapies are unlikely to proceed in the absence of significant changes in regulatory guidance that reflect the current understanding of FSD and incorporate validated assessment tools.
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Affiliation(s)
- Stanley E Althof
- Department of Psychology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
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