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Barakeh D, Mdaihly H, Karaoui LR. Pharmacotherapy of Hypoactive Sexual Desire Disorder in Premenopausal Women. Ann Pharmacother 2024:10600280241253273. [PMID: 38767282 DOI: 10.1177/10600280241253273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
OBJECTIVE This review aims to provide an overview of pharmacologic management for hypoactive sexual desire disorder (HSDD) in premenopausal women, with a focus on available agents. DATA SOURCES Through a literature search on PubMed, Google Scholar, and ClinicalTrials.gov from 1999 to 2024, studies were selected using the following MeSH search terms: hypoactive sexual desire disorder, premenopause, pharmacologic management, flibanserin, bremelanotide, buspirone, bupropion, and testosterone, excluding those involving postmenopausal women or other sexual disorders. Product monographs were also reviewed. STUDY SELECTION AND DATA EXTRACTION Relevant English-language studies or those conducted in humans were considered. DATA SYNTHESIS Hypoactive sexual desire disorder, characterized by a lack of motivation for sexual activity, predominantly affects women aged 45 years and older. Treatment involves a multimodal approach, including nonpharmacologic interventions such as psychotherapy and lifestyle adjustments, alongside pharmacologic options. Although bupropion and buspirone may be considered off-label treatments, flibanserin and bremelanotide are the sole medications approved by the Food and Drug Administration for generalized acquired HSDD in premenopausal women. However, caution is advised due to their limited efficacy, potential adverse effects, and transparency issues in reporting. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Hypoactive sexual desire disorder, while not life-threatening, significantly impacts well-being and relationships. Pharmacotherapy, including options like flibanserin and bremelanotide, is essential within a multidisciplinary approach. Validated tools and objective measures inform tailored premenopausal HSDD care plans and aid in striking a balance between potential risks and adverse effects while maximizing meaningful clinical benefits, including for transgender individuals. CONCLUSIONS Clinicians must discern important distinctions between flibanserin, bremelanotide, and other agents when managing premenopausal HSDD. Further research with the most suitable clinical endpoints and consideration of patient factors are crucial before widespread adoption of flibanserin and bremelanotide. Pharmacists are encouraged to embrace this opportunity to provide premenopausal HSDD care in ambulatory and community practice settings.
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Affiliation(s)
| | - Hadil Mdaihly
- School of Pharmacy, Lebanese American University, Byblos, Lebanon
| | - Lamis R Karaoui
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, Byblos, Lebanon
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Spielmans GI, Ellefson EM. Small Effects, Questionable Outcomes: Bremelanotide for Hypoactive Sexual Desire Disorder. JOURNAL OF SEX RESEARCH 2024; 61:540-561. [PMID: 36809187 DOI: 10.1080/00224499.2023.2175192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Efficacy outcomes are only informative to the extent that they are validated. We examined the measurement properties of efficacy measures from the phase III ("RECONNECT") bremelanotide trials for hypoactive sexual desire disorder (HSDD) in women. Continuous efficacy outcomes, including a) the Female Sexual Function Index (FSFI) and its Desire domain (FSFI-D) and b) the Female Sexual Distress Scale-Desire/Arousal/Orgasm (FSDS-DAO) and its item assessing distress due to low desire (FSDS-DAO #13) have questionable, at best, validity evidence for women with HSDD. We found no validity evidence for previously published categorical treatment response outcomes from the RECONNECT trials. All efficacy results should be reported, but results on 8 of the 11 clinicaltrials.gov-specified efficacy outcomes were heretofore unpublished (including FSDS-DAO total score, FSFI total score, FSFI arousal domain, and items from the Female Sexual Encounter Profile-Revised). We analyzed these outcomes, upon which effect sizes ranged from nil to small. Several other continuous and categorical outcomes generated modest apparent benefits, though nearly all of these outcomes were likely derived post-hoc. Across RECONNECT trial data from two prior publications and the current study, bremelanotide's benefits are statistically modest and limited to outcomes for which scant evidence of validity among women with HSDD exists.
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Affiliation(s)
- Glen I Spielmans
- Department of Psychology, Metropolitan State University, Saint Paul, Minnesota, USA
| | - Elaine M Ellefson
- Department of Psychology, Metropolitan State University, Saint Paul, Minnesota, USA
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Nappi RE, Tiranini L, Cucinella L, Martini E, Bosoni D, Righi A, Cassani C, Gardella B. Pharmacotherapy for female sexual dysfunctions (FSDs): what is on the market and where is this field heading? Expert Opin Pharmacother 2023; 24:135-143. [PMID: 35430926 DOI: 10.1080/14656566.2022.2066997] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Female sexual dysfunctions (FSDs) are common in women of any age and have a huge impact on quality of life and relationships. They have a multifaceted etiology limiting the development of pharmacotherapies with a high rate of effectiveness. Safety issues are also a concern. AREAS COVERED The authors report the most recent advances in pharmacotherapy for premenopausal and postmenopausal women with a main focus on hypoactive sexual desire disorders (HSDD) and associated sexual symptoms. Good levels of evidence have emerged for psychoactive agents, such as flibanserin and bremelanotide, as well as hormonal compounds (transdermal testosterone). The authors also report briefly on intravaginal DHEA (prasterone), local estrogen therapy (LET), and ospemifene to manage effectively vulvovaginal atrophy/genitourinary syndrome of menopause (VVA/GSM). In addition, they discuss promising therapeutic options highlighting the main reasons that hamper the availability of new labeled products. Finally, they include the importance of the multimodal approach to address FSDs. EXPERT OPINION Approved pharmacotherapies for FSD are limited. Validated multidimensional instruments and adequate objective measures of physical and mental responses to sexual external and internal incentives are mandatory to identify women suitable to chronic or on-demand treatments and to assess their pattern of response in research and practice.
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Affiliation(s)
- Rossella E Nappi
- Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS S. Matteo Foundation, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Lara Tiranini
- Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS S. Matteo Foundation, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Laura Cucinella
- Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS S. Matteo Foundation, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Ellis Martini
- Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS S. Matteo Foundation, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - David Bosoni
- Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS S. Matteo Foundation, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Alessandra Righi
- Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS S. Matteo Foundation, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Chiara Cassani
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.,Unit of Obstetrics and Gynecology, IRCCS S. Matteo Foundation, Pavia, Italy
| | - Barbara Gardella
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.,Unit of Obstetrics and Gynecology, IRCCS S. Matteo Foundation, Pavia, Italy
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Pharmacologic therapeutic options for sexual dysfunction. Curr Opin Obstet Gynecol 2022; 34:402-408. [PMID: 36036468 DOI: 10.1097/gco.0000000000000821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW Sexual problems are reported by up to 45% of individuals assigned female at birth. Although sexual function is a complex biopsychosocial construct, there are a number of pharmacologic treatment options aimed at addressing the changing vaginal hormonal milieu in postmenopausal individuals and moderating the excitatory and inhibitory aspects of the central nervous system in those with hypoactive sexual desire disorder. RECENT FINDINGS The last decade has seen an increase in the number and type of pharmacologic treatment options for dysfunction primarily associated with menopause and hypoactive sexual desire disorder. Recent publications and systematic reviews have strengthened the safety data of existing FDA-approved medications as well as off-label therapies. SUMMARY Pharmacologic treatment with local estrogen and testosterone replacement in postmenopausal individuals and with centrally-acting therapies such as flibanserin, bremelanotide, and testosterone in premenopausal individuals assigned female at birth are safe and can be used to improve sexual desire and sexual satisfaction.
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Vegunta S, Kuhle CL, Vencill JA, Lucas PH, Mussallem DM. Sexual Health after a Breast Cancer Diagnosis: Addressing a Forgotten Aspect of Survivorship. J Clin Med 2022; 11:6723. [PMID: 36431200 PMCID: PMC9698007 DOI: 10.3390/jcm11226723] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/12/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022] Open
Abstract
Breast cancer is the most common cancer in women. The life expectancy after a breast cancer diagnosis is improving steadily, leaving many more persons with the long-term consequences of treatment. Sexual problems are a common concern for breast cancer survivors yet remain overlooked in both the clinical setting and the research literature. Factors that contribute to sexual health concerns in breast cancer survivors are biopsychosocial, as are the barriers to addressing and treating these health concerns. Sexual health needs and treatment may vary by anatomy and gender. Multidisciplinary management may comprise lifestyle modifications, medications, sexual health aids such as vibrators, counseling, and referrals to pelvic health physical therapy and specialty care. In this article, we review the contributing factors, screening, and management of sexual difficulties in cisgender female breast cancer survivors. More information is needed to better address the sexual health of breast cancer survivors whose sexual/gender identity differs from that of cisgender women.
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Affiliation(s)
- Suneela Vegunta
- Division of Women’s Health Internal Medicine, Mayo Clinic, 13400 Shea Blvd, Scottsdale, AZ 85259, USA
| | - Carol L. Kuhle
- Menopause and Women’s Sexaul Health Clinic, Mayo Clinic, Rochester, MN 55905, USA
| | - Jennifer A. Vencill
- Menopause and Women’s Sexaul Health Clinic, Mayo Clinic, Rochester, MN 55905, USA
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, USA
| | - Pauline H. Lucas
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Scottsdale, AZ 85259, USA
| | - Dawn M. Mussallem
- Jacoby Center for Breast Health, Mayo Clinic, Jacksonville, FL 32224, USA
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Winter JR, Curtis K, Hu B, Clayton AH. Sexual dysfunction with major depressive disorder and antidepressant treatments: impact, assessment, and management. Expert Opin Drug Saf 2022; 21:913-930. [PMID: 35255754 DOI: 10.1080/14740338.2022.2049753] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Sexual dysfunction (SD) is a symptom of depression in ≈70% of patients presenting with major depressive disorder (MDD). Antidepressant medications (AD) and adjunctive treatments may further contribute to SD and complicate evaluation and management. AREAS COVERED A systematic literature search of PubMed, Ovid MEDLINE and Cochrane databases for MDD, SD, classes of antidepressants, etc. was performed with a focus on 2014 to June 2021. SSRIs are associated with 70% treatment-emergent sexual dysfunction (TESD), SNRIs and tricyclics have rates of TESD of 40 - 45%, and antidepressant medications without SRI effects or with additional unique mechanisms of action have rates similar to placebo (<10%). Appropriate assessment at baseline and throughout treatment, consideration of patient preferences in prescribing, addressing modifiable factors (comorbid medical/psychiatric conditions, substances, relationship difficulties), and utilizing management strategies of switching to an AD with less SD, adding an antidote/adjunctive therapy or lowering the dose are discussed. EXPERT OPINION MDD and antidepressant treatment contribute to SD in a high percentage of patients. Treating to remission reduces SD as a symptom of depression. Frequent assessment and targeted management strategies may be effective in preventing or addressing SD. Secondary outcomes like impact on adherence, relationships and self-image should also be considered.
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Affiliation(s)
- Joan R Winter
- Department of Psychiatry & Neurobehavioral Sciences, University of Virginia, 2955 Ivy Road, Suite 210, Charlottesville, VA, 22903
| | - Kimberly Curtis
- Department of Psychiatry & Neurobehavioral Sciences, University of Virginia, 2955 Ivy Road, Suite 210, Charlottesville, VA, 22903
| | - Bo Hu
- Department of Psychiatry & Neurobehavioral Sciences, University of Virginia, 2955 Ivy Road, Suite 210, Charlottesville, VA, 22903
| | - Anita H Clayton
- Department of Psychiatry & Neurobehavioral Sciences, University of Virginia, 2955 Ivy Road, Suite 210, Charlottesville, VA, 22903
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Clayton AH, Kingsberg SA, Portman D, Sadiq A, Krop J, Jordan R, Lucas J, Simon JA. Safety Profile of Bremelanotide Across the Clinical Development Program. J Womens Health (Larchmt) 2022; 31:171-182. [PMID: 35147466 DOI: 10.1089/jwh.2021.0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Bremelanotide, a melanocortin receptor agonist, is Food and Drug Administration (FDA)-approved for the treatment of premenopausal women with acquired, generalized hypoactive sexual desire disorder. Methods: Review of bremelanotide's safety profile from the clinical development program (phases 1 through 3). Results: The clinical development program comprised 3500 subjects in 43 completed studies. In the phase 3 studies, subjects took bremelanotide for up to 18 months. The most common adverse events (AEs) were nausea (40.0% vs. 1.3%), flushing (20.3% vs. 1.3%), headache (11.3% vs. 1.9%), and injection site reactions (5.4 vs. 0.5), bremelanotide versus placebo groups, respectively, in the integrated double-blind portion of the phase 3 studies (N = 1247). Nausea was the most common reason for bremelanotide discontinuation. There were no deaths; a few subjects experienced serious AEs. Focal hyperpigmentation was rare when bremelanotide was dosed in accordance with label recommendations, but it occurred in more than one-third of subjects following up to 16 consecutive daily dosings. Small and transient but statistically significant blood pressure increases were observed during ambulatory blood pressure monitoring. Most drug-drug interactions were not clinically significant, except for interactions that lowered plasma concentrations of indomethacin and naltrexone. In the double-blind portion of the integrated phase 3 studies, 70% of the bremelanotide group proceeded to the open-label phase of the studies versus 87% of those on placebo. Conclusions: The AEs associated with bremelanotide are mostly mild to moderate. Although not deemed clinically important, bremelanotide should be used with caution in patients at risk of cardiovascular disease, and blood pressure should be well controlled during treatment. Clinical Trial Registration number: NCT02333071 [Study 301] and NCT02338960 [Study 302].
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Affiliation(s)
- Anita H Clayton
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Sheryl A Kingsberg
- Department of Reproductive Biology and Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - Amama Sadiq
- AMAG Pharmaceuticals, Inc., Waltham, Massachusetts, USA
| | - Julie Krop
- AMAG Pharmaceuticals, Inc., Waltham, Massachusetts, USA
| | - Robert Jordan
- Palatin Technologies, Inc., Cranbury, New Jersey, USA
| | - Johna Lucas
- Palatin Technologies, Inc., Cranbury, New Jersey, USA
| | - James A Simon
- George Washington University and IntimMedicine™ Specialists, Washington, District of Columbia, USA
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