Hypoactive sexual desire disorder

1. Hypoactive sexual desire disorder
(HSDD)
=
low libido
Dr Nasser Mogharabian
Assistant Professor of Andrology and Urology
Shahroud university of medical sciences

2.  Spontaneous desire
 Reactive desire
HSDD

3.  Loss of libido (sex drive) is a common problem affecting up
to one in five men – and even more women – at some point
in their life.
 It's often linked to professional and personal stress, or
important life-changing events,
 however, an unexpected loss of libido – especially when it
lasts for a long time or keeps returning – can also indicate an
underlying personal, medical or lifestyle problem.

6. *
*Feedback occurs through androgen receptors (ARs) in hypothalamic
neurons and in the pituitary.
*Steroid negative feedback results mainly from AR binding to
testosterone, with a smaller contribution from estradiol binding.
*Testosterone hypothalamus - LH
*Estrogen pituitary - FSH
*inhibin from Sertoli cells

10. *
*The IIEF, which contains 15 items that address and quantify five
domains:
1. erectile function
2. orgasmic function
3. sexual desire
4. intercourse satisfaction
5. overall satisfaction
*A known limitation of self-administered questionnaires is that they
do not distinguish an etiologic basis for ED

11. * IIEF-5 five
1. severe(5 to 7)
2. moderate (8 to 11)
3. mild to moderate (12 to 16)
4. mild (17 to 21)
5. no ED (22 to 25)

13.  pubertal development
 gonadotoxin exposure
 sources of stress
 history of depression or anxiety disorder
 prior libido
 sexual history
 relationship history
 Symptoms of hypogonadism
 medications, especially those that were recently initiated
Hx and Phx

14.  10-point libido rating scale, where “10” = libido level of the
patient when he was 18 years old and “0” = complete
absence of libido
 Defining whether the libido change was sudden or gradual
 Focused physical examination of the genitals

15.  All men with low libido should have morning serum total testosterone
(T) levels
 if these levels are abnormally low, they should be repeated
 total T
 free testosterone (fT)
 luteinizing hormone (LH)
 estradiol (E2)
 sex hormone binding globulin (SHBG)
 low LH PRL
 TFTs for patients with significant symptoms of thyroid dysfunction
Endocrinopathies

16.  low libido
 decreased nocturnal erections
 decreased ease of arousal
 orgasm delay
 poor erectile function
hypogonadism

17.  More than half of men with hypothyroidism have
been shown to have HSDD
 nearly a quarter of men with hyperthyroidism have
HSDD

18.  Severe hyperprolactinemia (>35 ng/mL or 735 mIU/L) impairs
libido, T level, and erectile function
 Pituitary tumors (mass effect and PRL-induced suppression
of gonadotropin secretion)
 Selective serotonin reuptake inhibitors (SSRI)
 Heavy opiate

19.  Low libido occurs in up to 40 % of men with
depression
 Antidepressant medications independently impair
libido as well
 Other psychological factors lowering libido include
anxiety disorder, chronic stress, or fatigue.

20.  Any chronic sexual dysfunction (e.g., ED, delayed orgasm, and Peyronie’s disease)
 avoidance behavior (secondary to low sexual self-confidence)
 This may be perceived by him and his partner as low sex drive
 The practitioner should be able to distinguish, with further questioning, whether they
have truly low libido or whether they are merely sexually frustrated
sexual dysfunction

21.  Body dysmorphic disorder (BDD) is a psychiatric condition
that is strongly associated with low libido.
 The excessive focus on body image is associated with
depression, obsessive-compulsive disorder, and social
phobia.
Body dysmorphic disorder

22. Medications

23.  Three strategies exist for addressing medications
implicated in causing low libido:
1. discontinuing the medication
2. switching medication to another in its class (or
using a similar drug)
3. adjusting the dose
Medications

24.  Any long-term medical condition can affect your sex drive. This
may be a result of the physical and emotional strain these
conditions can cause, or it may be a side effect of treatment.
 For example, a low libido can be associated with:
 heart disease
 diabetes
 an underactive thyroid disease
 cancer
 major surgery – for example, surgery to remove the ovaries and
womb in women
Underlying health problems

25.  Relationship problems are among the most common causes of
loss of libido.
 If you've been in a relationship for a long time, you may have
become overfamiliar with your partner and feel a degree of erotic
dissatisfaction.
 Another thing to consider is whether the problem is a
performance issue that makes sex difficult or unfulfilling.
Relationship issues

26.  falling levels of sex hormones
 age-related health problems
 the side effects of medication
Getting older

27.  If no clear issue or factor is identifiable or no
resolution is achieved satisfactorily, then the
patient should be referred for psychosexual
counseling.

29. 1. Early Detection
2. Goal-Directed Management
3. Role of Partner Interview
4. Health Risk Assessment
5. Step-Care Approach
6. Shared Decision Making and Treatment Planning
7. Specialist Referral
8. Follow-up Care
MANAGEMENT PRINCIPLES

30.  Partner interviews have been shown to impact diagnosis and treatment
in as much as 58% of cases
 The partner may be the source of important information that:
 guides optimal intervention and response to therapy
 share a new and different perspective on sexual issues affecting the Couple
 provide insight into the quality of the couple’s relationship
 relate his/her role in the sexual dysfunction
Role of Partner Interview

31.  The partner’s involvement and attitude may also impact the patient’s
initiation of and adherence to therapy
 partners’ wellbeing may be affected by the patients’ ED conditions
 women partners of men with ED are themselves more likely to have
sexual dysfunction or to cease sexual activity entirely

32. The therapeutic plan may vary for every patient and couple and depends
on:
1. patient considerations
2. clinical indications and contraindications
An informed decision-making process
Shared Decision Making and treatment Planning

33.  referred to a urologist
 failure of initial treatment
 younger patients with a history of pelvic or perineal
 patients with significant penile deformity
 medicolegal reasons
 referred to an endocrinologist
 complicated endocrinopathies
 referred to a psychiatrist
 complicated psychiatric or psychosexual disorders (e.g., refractory depression,
hypoactive sexual desire)
 referred to a neurosurgeon
Specialist Referral

34.  There is a wide natural variation in people's sexual desires and libido. It
is important to note that having a lower libido than other people is not
necessarily a bad thing.
 Low libido is a complex issue, with relationship, psychological, and
physical components. Knowing the cause can help a person find the
best treatment.
 Because low libido, or a sudden shift in libido, can be a sign of a health
condition, it is safest to talk to a doctor before trying libido boosters.
Note

35. 1. Manage anxiety
2. Improve relationship quality
3. Focus on foreplay
4. Get good-quality sleep
5. Eat a nutritious diet
6. Try herbal remedies (maca, tribulus, gingko, ginseng)
7. Get regular exercise
8. Maintain a healthful weight
9. Try sex therapy (both psychological and physical components)
10. Quit smoking
10 ways to boost libido

36.  It has been shown that treatment discontinuation occurs at high rates
among patients who are not reassessed regularly:
1. To prevent treatment discontinuation
2. Reassess medical and psychosocial conditions adversely libido
3. Reassess success of therapy
4. evaluate the need for dosage titration or treatment substitution
5. monitor adverse drug interactions or drug interaction effects
6. Educational opportunities for patient and partner with regard to addressing sexual
health concerns
7. guidance for related health care matters
Follow-up Care

37. ‫آقای‬35‫حدود‬ ‫از‬ ‫جنسی‬ ‫میل‬ ‫واضح‬ ‫کاهش‬ ‫و‬ ‫نعوظ‬ ‫اختالل‬ ‫با‬ ‫ساله‬12
‫است‬ ‫داشته‬ ‫پیشرونده‬ ‫سیر‬ ‫که‬ ‫قبل‬ ‫ماه‬.
‫از‬ ‫توجه‬ ‫قابل‬ ‫وزن‬ ‫افزایش‬1.5‫قبل‬ ‫سال‬
‫افراد‬ ‫سایر‬ ‫با‬ ‫ارتباط‬ ‫در‬ ‫و‬ ‫زمان‬ ‫و‬ ‫مکان‬ ‫هر‬ ‫در‬ ‫جنسی‬ ‫تحریک‬ ‫عدم‬
‫مونث‬
NPT‫مختل‬
Masturbation‫مختل‬
‫مشکل‬‫ندارد‬ ‫همسر‬ ‫با‬ ‫ارتباطي‬
LH , T‫دارد‬ ‫باال‬ ‫کبدي‬ ‫آنزیم‬ ‫و‬ ‫کلسترول‬ ‫و‬ ‫پایین‬----‫د‬ ‫ویتامین‬‫پایین‬
‫است‬----‫استرادیول‬‫باالست‬
‫سالم‬ ‫غذایی‬ ‫رژیم‬ ‫و‬ ‫وزن‬ ‫کاهش‬ ‫به‬ ‫توصیه‬
Case 1

38. ‫همزمان؟‬ ‫دو‬ ‫هر‬ ‫یا‬ ‫یا‬ ‫جنسی‬ ‫مشکل‬ ، ‫ای‬ ‫زمینه‬ ‫عوامل‬ ‫درمان‬
‫شده؟‬ ‫تجویز‬ ‫داروهای‬
hCG‫نه؟‬ ‫یا‬ ‫شود‬ ‫تجویز‬
‫سواالت‬

39. ‫آقای‬35‫از‬ ‫جنسی‬ ‫میل‬ ‫کاهش‬ ‫با‬ ‫ساله‬6‫قبل‬ ‫ماه‬
NPT‫قبل‬ ‫از‬ ‫کمتر‬ ‫ولی‬ ‫نرمال‬
Masturbation‫نرمال‬
‫نرمال‬ ‫آلت‬ ‫معاینه‬
‫گرید‬ ‫واریکوسل‬3‫دردناک‬ ‫چپ‬
‫راست‬ ‫از‬ ‫کمتر‬ ‫اندکی‬ ‫چپ‬ ‫ولی‬ ‫نرمال‬ ‫ها‬ ‫بیضه‬ ‫حجم‬
‫خاله‬ ‫فوت‬‫در‬ ‫بیمار‬9‫مادرش‬ ‫در‬ ‫آن‬ ‫به‬ ‫ثانوی‬ ‫سایکولوژیک‬ ‫مسائل‬ ‫و‬ ‫قبل‬ ‫ماه‬
‫نرمال‬ ‫هورمونی‬ ‫بررسی‬
‫نرمال‬ ‫اسپرموگرام‬
Case 2

40. ‫بیمار؟‬ ‫جنسی‬ ‫مشکل‬ ‫ایجادکننده‬ ‫علل‬
‫اول؟‬ ‫قدم‬ ‫در‬ ‫دو‬ ‫هر‬ ‫یا‬ ‫سایکولوژی‬ ‫مشاوره‬ ،‫دارویی‬ ‫درمان‬
‫خیر؟‬ ‫یا‬ ‫شود‬ ‫جراحی‬ ‫واریکوسل‬
‫سواالت‬

41. ‫آقای‬35‫ساله‬‫با‬‫خانم‬30‫ساله‬‫با‬ED‫و‬‫کاهش‬‫لیبیدو‬‫پیشرونده‬‫از‬
‫یکسال‬‫قبل‬
‫ازدواج‬4‫ساله‬‫و‬‫ناباروری‬3‫ساله‬
‫انواع‬‫درمانهای‬‫طبی‬‫ناباروری‬‫و‬3‫نوبت‬IUI‫ناموفق‬
NPT‫نرمال‬
Masturbation‫نرمال‬
‫خانم‬‫طی‬2‫سال‬‫اخیر‬‫در‬‫اثر‬‫مشکالت‬‫ناباروری‬‫و‬‫مصرف‬‫داروهای‬
‫ناباروری‬‫دچار‬‫چاقی‬‫و‬‫کمبود‬‫لیبیدو‬‫شده‬‫است‬
Timing intercourse‫از‬2‫سال‬‫قبل‬
Case 3

42. ‫جنسی؟‬ ‫مشکالت‬ ‫علل‬ ‫یا‬ ‫علت‬
‫آن؟‬ ‫درمانهای‬ ‫و‬ ‫ناباروری‬ ‫نقش‬
‫پیشنهادی؟‬ ‫درمانهای‬
‫سواالت‬