Melissa L. Dawson, Nima M. Shah, Rebecca C. Rinko, Clinton Veselis, and Kristene E. Whitmore are in the Department of OB/GYN at Drexel University College of Medicine in Philadelphia.
Dr. Whitmore discloses that she receives grants/research support from Allergan (makers of Botox), as well as from Astellas Pharma US and Coloplast Corp. Drs. Dawson, Shah, Rinko, and Veselis report no potential conflict of interest relevant to this article, which originally appeared in The Journal of Family Practice (2017;66[12]:722-728).
The treatment of FSD may require a multimodal systematic approach targeting genitopelvic pain. But before the best options can be found, it is important to first establish the cause of the pain. Several drug formulations have been effectively used, including hormonal and nonhormonal options.
Conjugated estrogens are FDA approved for the treatment of dyspareunia, which can contribute to decreased desire. Systemic estrogen in oral form, transdermal preparations, and topical formulations may increase sexual desire and arousal and decrease dyspareunia.39 Even synthetic steroid compounds such as tibolone may improve sexual function, although it is not FDA approved for that purpose.40
Ospemifene is a selective estrogen receptor modulator that acts as an estrogen agonist in select tissues, including vaginal epithelium. It is FDA approved for dyspareunia in postmenopausal women.41,42 A daily dose of 60 mg is effective and safe, with minimal adverse effects.42 Studies suggest that testosterone, although not FDA approved in the United States for this purpose, improves sexual desire, pleasure, orgasm, and arousal satisfaction.39 The hormone has not gained FDA approval because of concerns about long-term safety and efficacy.42
Nonhormonal drugs including flibanserin, a well-tolerated serotonin receptor 1A agonist, 2A antagonist shown to improve sexual desire, increase the number of satisfying sexual events and reduce distress associated with low sexual desire when compared with placebo.43 The FDA has approved flibanserin as the first treatment targeted for women with hypoactive sexual desire disorder (HSDD). It can, however, cause severe hypotension and syncope, is not well tolerated with alcohol, and is contraindicated in patients who take strong CYP3A4 inhibitors, such as fluconazole, verapamil, and erythromycin, or who have liver impairment.
Bupropion, a mild dopamine and norepinephrine reuptake inhibitor and acetylcholine receptor antagonist, has been shown to improve desire in women with and without depression. Although it is FDA approved for major depressive disorder, it is not approved for female sexual dysfunction and is still under investigation.
Tricyclic antidepressants, such as nortriptyline and amitriptyline, may be effective in treating neuropathic pain. Starting doses of both amitriptyline and nortriptyline are 10 mg/d and can be increased to a maximum of 100 mg/d.44 Tricyclic antidepressants are still under investigation for the treatment of FSD.
Muscle relaxants in oral and topical compounded form are used to treat increased pelvic floor tension and spasticity. Cyclobenzaprine and tizanidine are FDA-approved muscle relaxants indicated for muscle spasticity.
Cyclobenzaprine, at a starting dose of 10 mg, can be taken up to three times a day for pelvic floor tension. Tizanidine is a centrally active alpha 2 agonist that’s superior to placebo in treating high-tone pelvic floor dysfunction.44
Other medications include benzodiazepines, such as oral clonazepam and intravaginal diazepam, although they are not FDA approved for high-tone pelvic floor dysfunction. Rogalski et al evaluated data for 26 patients who received vaginal diazepam for bladder pain, sexual pain, and levator hypertonus.45 They found subjective and sexual pain improvement assessed on FSFI and the visual analog pain scale. PFM tone significantly improved during resting, squeezing, and relaxation phases. Multimodal therapy can be used for muscle spasticity and high-tone pelvic floor dysfunction.
