Hypoactive Sexual Desire Disorder in Men (HSDD)

Content written by Irwin Goldstein MD

OVERVIEW:

Hypoactive sexual desire disorder is the persistent or recurrent deficiency or absence of sexual fantasies (dreams, fantasy persons, celebrities), sexual thoughts, desire for sexual activity or receptivity to sexual activity that causes either marked distress or interpersonal difficulty and cannot be explained by other factors such as psychiatric illness, medical illness or medications.

Hypoactive sexual desire disorder may be lifelong or primary and present since the onset of sexual functioning. Hypoactive sexual desire disorder may also be acquired or secondary and develops after period of functioning without the dysfunction. Hypoactive sexual desire disorder may be generalized and not limited to certain types of stimulation, situations, or partners. Hypoactive sexual desire disorder may also be situational and limited to certain types of stimulation, situations or partners.

Hypoactive sexual desire disorder is associated with changes in quality of life measures. In men with low sexual desire, the odds ratio for low physical satisfaction is 3.14 that for low emotional satisfaction 1.57 and low general happiness 2.61. In one study of 129 women, 26% of women who stated that they had more desire than their male partners.

In a study of sexual desire in a nationally representative Danish population, 72%, 69%, 45% and 14% of men age 16-24, 25 – 44, 45 – 66 and > 67 years stated that they often had sexual desire. In that study, men who had the least sexual interest were divorced or widowed, had less than 10 years education, were retired before age 65 years and had no children in the household less than age 15 years.

The top ten reasons why men have sex are as follows: 1) I was attracted to the person, 2. It feels good, 3. I wanted the physical pleasure, 4. It’s fun, 5. I wanted to show my affection, 6. I was sexually aroused and wanted the release, 7. I was “horny”, 8. I wanted to express my love, 9. I wanted an orgasm, 10. I wanted to please my partner. Of interest, the top ten reasons why women have sex were very similar. Not surprising, the number one reason men and women had sex was because they were attracted to each other. The top reasons men had sex related to physical gratification and love and affection. You always hear how men have sex for pleasure and women have sex for love but such gender stereotype findings are not supported. Many men have sex because they wanted to feel connected to their partners or because they were in love. Of note, many women have sex purely because of their physical gratification, because it feels good, it’s exciting, it’s fun, they wanted an orgasm, they were horny, and they wanted the pure physical pleasure.

CAUSES:

Many factors influence why men want to have sex. Other sexual dysfunctions may adversely influence sexual interest in men. Men who have erectile dysfunction, premature ejaculation, delayed/absent ejaculation, or Peyronie’s disease may also have less sexual interest. General medical conditions may adversely influence sexual interest in men. Men who have diabetes mellitus, hypercholesterolemia, obesity, hypothyroidism, cardiovascular disease and metabolic syndrome may have low sexual interest. Sexual dysfunction in the partner may adversely influence sexual interest in men. Women partners who themselves have hypoactive sexual desire, vaginal dryness, anorgasmia or sexual pain may cause their male partner to have low sexual interest. Genitourinary conditions may adversely influence sexual interest in men. Men who have stress urinary incontinence or urge incontinence have lower sexual interest. Men with prostate cancer who have been treated by radical prostatectomy or radiation treatment may have low sexual interest.

Hypoactive sexual desire disorder may be best explained by the “Dual Control Model” of Bancroft. In the “Dual Control Model” two opposing processes are hypothesized to control sexual response. There are inhibitory processes that protect against risky/unpleasant sexual activity, are related to social cultural prohibitions and/or are associated with anxiety, depression, or stress. There are excitatory processes that promote sexual activity and procreation. The inhibitory and excitatory process are opposing processes and are independent of each other. Both psychologic and biologic factors affect inhibition and excitation. Using the “Dual Control Model”, men with hypoactive sexual desire disorder have high inhibition and low excitation. Central neurochemicals that are known to facilitate excitation include dopamine, noradrenaline, oxytocin and melanocortins. Central neurochemicals that are known to facilitate inhibition include serotonin and prolactin. Sex steroid hormones, testosterone, estrogen and progesterone, are involved in the synthesis of critical excitatory neurochemical receptors. Testosterone is thought to drive thoughts or fantasies about sexual activity. Dopamine is thought to drive sexual behaviors such as initiation of sexual activity. Progesterone is though to drive receptivity to approach by the partner.

DIAGNOSTIC TESTS:

A recent functional magnetic resonance imaging study in women with no history of sexual dysfunction showed high blood flow in regions of the brain within the thalamus and hypothalamus while in those with hypoactive sexual desire disorder, there was markedly reduced blood flow in regions of the brain within the thalamus and hypothalamus.

The take home messages are that sexual desire is controlled by a common set of brain regions, that inhibitory and excitatory neurochemical pathways control sexual desire, and that rational approaches to p

TREATMENT:

Low sexual interest is common in men. There are no approved drugs for men with low sexual interest.

TREATMENT (OFF LABEL)

Hypoactive sexual desire disorder treatment may be rationally provided by dopamine agonists, prolactin antagonists, sex steroid hormones, nitric oxide agonists, and serotonin antagonists. Dopamine agonists include bupropion, cabergoline, pramipexole, and ropinirole. Cabergoline is also a prolactin antagonist. Data concerning the effectiveness of these agents in men with hypoactive sexual desire disorder is limited. There are placebo controlled double blind data that demonstrate safety and efficacy in women with hypoactive sexual desire disorder.

The sex steroid hormone testosterone is a well-recognized strategy to improve sexual drive in men with hypoactive sexual desire disorder who have hypogonadism. There are short-acting testosterone therapies such as testosterone intramuscular injections, testosterone topical gels, testosterone topical patches, and testosterone buccal systems. There are long-acting testosterone therapies such as subcutaneous testosterone pellets and testosterone undecanoate intramuscular injections.

Phosphodiesterase type 5 inhibitors have been reported to increase low desire in men.

TREATMENT (EXPERIMENTAL)

The newest pharmacologic strategy for hypoactive sexual desire disorder that is undergoing approval for pre-menopausal women with low sexual interest is flibanserin. This drug is a serotonin 1A agonist that reduces the serotonerigc inhibitory signal. The drug is also serotonin 1B antagonist that reduces serotonergic inhibition of dopamine and norepinephrine. Flibanserin thus reduces inhibitory serotonergic function and increases excitatory dopamine and noradrenergic function. There are no data with this drug in men with hypoactive sexual desire disorder.

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