Invited lecture Delivered in BOGSCON (The Annual Conference of Bengal obstetric and Gynaecological Society) 44 in December 2018 at Kolkata

1. Decreased Libido
SUJOY DASGUPTA
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (OBGY)
MRCOG (London)
• Consultant, Reproductive Medicine, Genome Fertility
Centre, Kolkata
• Secretary, Website and Bulletin Committee, BOGS-
2017-18
• Managing Committee Member, BOGS- 2017-18

2. Most Powerful behaviour in Human !!!

3. Normal Sex Response
Male
Desire
Erection
Penetration
Orgasm
Female
Desire
Lubrication
Penetration
Orgasm

4. Hypoactive Sexual Disorder (HSD)
• F52.4 in ICD-10
• Deficiency or absence of sexual fantasy or
desire for sexual activity
• Females are more affected (40%) than males
(30%)

5. Effects of HSD
• Chronic stress
• Anxiety
• Depression
• Lack of concentration
• Insomnia
• Irritability
• Relationship conflict
• Social withdrawal

7. What your mind does not know, eyes cannot see
Physiological Drugs
Pregnancy Antihypertensives (Beta Blockers)
Menstruation Antiandrogens
Menopause Antiepileptics
Lactation Antidepressants
Systemic Disease Previous bad experience
Diabetes Painful sex
Thyroid disorder Erectile/ Ejaculatory disorders
Hyperprolactinaemia Sexual assault
Hypopituitarism Fear
Gonadal Failure Guilty feeling
Hypertension Fear of STI/ Pregnancy
Fatigue Relationship Problems
Depression Interpersonal conflict
Renal/ Liver Disease Monotony
Infertility Sexual orientation

8. Case 1
• A 52-year-old lady underwent menopause 3
years ago and is no longer interested in sex
• No issue with lubrication or pain
• Feeling difficulty due to obesity

9. Low libido after menopause
• Misconception
• Obesity- Mechanical difficulty in certain sex
positions
• Kegel’s exercise

10. Hormone Therapy for Post-Menopausal
Low Libido
• HRT- may improve general well being and libido
• Vaginal estrogen- With/ systemic HRT
- can be considered when
systemic HRT is contraindicated
• Tibolone- Androgenic
Does not stimulate breast/endometrium

11. Most Preponderant Female Sex Hormone

12. Testosterone Preparations
• Oral – Methyltestosterone, micronized
testosterone, DHEA
• Transdermal – Testosterone patches and gels;
testosterone ointment or cream (1% or 2%)
• Injectable or implants – Intramuscular
testosterone injections, testosterone implants

13. Side Effects of Testosterone
• Cosmetic- hirsutism and acne, usually mild
• Irreversible, virilizing changes (eg, voice
deepening, clitoromegaly) are rare, occur only
with excessive dosing.
• Most androgens are aromatized to estrogens;
thus, risks of estrogen therapy are also possible
with androgen treatment.

14. Can we use Testosterone?
• The transdermal testosterone patch is licensed
in Europe for the treatment of HSD in
surgically menopausal women on concomitant
HRT.
• No pharmacologic therapy is currently
approved for the treatment of HSD in
premenopausal or naturally postmenopausal
women and further research is urgently needed
in these populations.

15. Case 2
• Couple happily married for 5 years, having a
baby girl
• Man said “She is not interested in sex” for last
one year
• She said “having enough desire and lubrication
but soon after penetration, lost further interest”

16. Early Orgasmic Response (EOR)
• Equivalent to “premature ejaculation” in men
• Orgasm ≠ ejaculation
• Orgasm ≠ vaginal contraction
• After-play is important
• SSRI- Paroxetine 20 mg- 2 -4 hours before sex

17. Case 3
• A 32-year-old woman presented with low
libido after C section done 6 months ago
• Previous sex life- normal
• Adequate lubrication, penetration, orgasm

18. Postpartum Low Libido
• Change position
• Cross leg
• Kegel’s exercise
• Lubrication
• Episiotomy stitch
• Reconstructive surgery
• Rejuvenate the romance- ambience, bath
together, remove boredom of the bedroom

19. Idiopathic Low Libido
• Lifestyle changes
• Improving body image
• Sex therapy
• Psychotherapy
• Pharmacotherapy

20. Lifestyle Changes
• Reducing stress
• Exercise, yoga or other relaxation techniques,
or support groups
• Regular "date night“- to spend one or two
nights away from family responsibilities

21. Improving Body Image
• Weight reduction
• Bariatric surgery
• Treating pelvic floor dysfunction

22. Sex Therapy
• Educating women and male
• Addressing cultural or religious concerns
• Assigning specific exercises
• Direct patients to a wide range of helpful
resources, including book lists, visual aids, and
devices.

23. Sensate Focussing

24. Pharmacotherapy
Fibranserin A centrally acting serotonin receptor agonist/antagonist that results
in transient decreases in serotonin and increases in dopamine and
norepinephrine in certain regions of the brain
Only drug approved by the FDA for female sexual dysfunction
common adverse effects- somnolence, dizziness
Buproprion Second line of treatment
As a centrally acting agent, the mechanism of action is likely
similar to that of flibanserin.
off-label nature of use.
Buspirone Can be helpful, particularly in SSRI-induced low libido
PDE5 Inhibitors generally have not proven effective in women.
Studies of sildenafil -inconsistent results
Positive effects have been demonstrated in premenopausal
women with SSRI-associated sexual dysfunction
Ginseng oriental herb
Drug interaction, post menopausal bleeding
Yohimbine Improves genital blood flow
Amyl nitrate headache, palpitation

25. • DHEA might slightly improve sexual function
compared to placebo
• No evidence that DHEA improved sexual function more
than HRT

26. Placebo
• Vitamin tablets can work !!!

27. Best Aphrodisiac
• “an interesting and interested partner”-
Masters and Johnson

28. Relationship with new partner
• Research on sexual function consistently
demonstrates- increased libido and pleasure in
new relationships.
• “Where there is marriage without love, there
will be love without marriage”- Benjamin
Franklin

29. Case 4
• Young couple had very happy sex life
• Consulted doctor for Infertility of one year
duration
• Advised Timed Intercourse (TI) from day 12-
18
• Husband suffered from lack of interest and
described sex as “Mechanical entity”

30. Timed Intercourse

34. Infertile couples with low libido
Testosterone in men-
• Only as HRT in men with hypogonadism
• In male with normogonadotropism, can impair
spermatogenesis
Lubricant in women-
• May be spermicidal
• Best lubricant- adequate foreplay → vaginal
fluid

35. Case 5
• Young couple presented 6 months after
marriage
• Woman not interested in sex after first few
episodes
• O/E- hollow pouch near the urethra

36. Lack of anatomical knowledge
• Female can guide the male
• In dark, its easier to put the food in your own
mouth, rather than trying to feed someone

37. Case 6
• Young woman presented soon after marriage
with loss of libido after first night
• Enough lubrication, penetration, no pain
• Fantasized about man with “large penis”

38. Size matters ???
• Archer is known
by his aim, not by
the length of his
arrow path

39. History taking in low libido
• Misconceptions, unrealistic expectations
• Disturbed interpersonal relationship
• Details of sequences-
Desire → Erection/ Lubrication → Penetration
→ Orgasm
• Orgasm during masturbation
• Orgasm with other partners

40. Seeing Together
• Both partners- together and separately
• The couple is the unit

41. Male and Female Thinking Process

42. Male and Female Thinking Process

43. Differences in sexuality
Female
• The majority of adult men think
about sex at least once a day
• Want sex at the start of a
relationship, in the middle of it,
and after many years of it
• Attach little emotion
• Want lots of sex only
Male
• Only about one-quarter of women
think about sex daily
• Want commitment throughout
the relationship
• Lots of emotion to sexual
encounter
• Want lots of sex with the
partners they love, in suitable
ambience

44. Approach
• Non-judgemental
• No assumption
• Acknowledge- difficulty in conversation
• Let them speak

46. Take Home Messages
• Low libido is under-reported, under-evaluated,
under-treated
• Proper history taking will disclose the diagnosis
in most cases
• Problems- in between two legs !!!
• Problems- in between two ears !!!
• Both the partners should be seen together
• Non-pharmacological interventions often work
well