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Try out PMC Labs and tell us what you think. Learn More. Over the decades, female sexual dysfunction FSD has grown to be an increasingly potential problem that complicates the quality of life among women. In the current review, FSD refers to recurrent and persistent problems with sexual orgasm, desire, or response. One of the most common subtypes of FSD that has evoked increased research interest in the scientific community is hyposexuality. Today, there is a consensus that hyposexuality is a multifactorial condition that manifests with reduced sexual desire resulting in ificant interpersonal distress.
The objective of the current review was to examine how hormonal profile triggers propagate hypoactive sexual desire disorder HSDD , and to highlight effective treatment interventions that can be used to manage the condition. The current review describes HSDD as a sexual dysfunction characterized by the absence or lack of sexual desire and fantasies for sexual activities.
The review argues that even if the role of sexual hormones is essential in modulating HSDD through therapeutic interventions, an effective comprehension of the biologic mechanisms underlying HSDD is necessary. There is a consensus in the literature that HSDD still poses ificant challenges due to the lack of properly formulated treatment regimens and absence of clear clinical guidelines. That is, a better intervention consisting of both psycho-relational and biologic aspects is compulsory if tailored management and accurate diagnosis of HSDD in clinical practice are to be realised.
The review concludes that, to date, a reliable clinical intervention to manage hyposexuality is still absent and more interventions, in terms of safety and efficacy, are required. Thus, additional investigation is required to document precise hormonal or non-hormonal pharmacotherapeutic agents for individualised care among patients with HSDD. The problem of low sexual desire affects women of all ages, which contributes to potential negative outcomes including reduced well-being and quality of life 1 , 2.
Over the years, low sexual desire has been widely regarded as part of broader female sexual dysfunction FSD conditions 3 , of which HSDD is more prevalent 4 , 5. A similar claim has also been supported by the American Foundation for Urologic Disease, on the basis that both sexually-related individual distress and low sexual desire should be observed for a person to be positively diagnosed as having HSDD 7 , 8. Often, when cases of low sexual desire are reported, the most common diagnosis is assumed to be generalised acquired HSDD. HSDD is mostly not reliant on a specific situation, and often develops at a time when the desire for sex is assumed to be ordinary 8.
As such, the presence of HSDD may manifest as a comorbidity in addition to a dysfunctional sexual experience, even if no exclusive connection can be made with the physiologic effects of a therapeutic agent or medical conditions 9. Recently, the International Consultation on Sexual Medicine 10 recommended the need to redefine HSDD because of the diverse heterogeneity among women and their sexual responses.
Today, the aetiology of HSDD has not been holistically agreed upon, although scholars and researchers agree that the condition is multifactorial To elaborate, HSDD has been elucidated to be triggered by factors such as psychiatric issues 12 , behavioural components 13 , and neuroendocrine changes 14 , studies largely centred on understanding how biologic and behavioural aspects contribute to HSDD, with a primary focus on assessment tools; the use of hormonal assays and validated behavioural questionnaires Irrespective of their use, however, these methods have not completely helped in resolving the puzzle and yielding satisfactory elaboration for the development and cause of FSD conditions, and specifically HSDD.
The next section discusses how ageing factors, such as menopause, are associated with HSDD. Second, the correlation between hormonal profile and HSDD will be detailed, taking into medical factors that can result in a hormonal imbalance. Third, the psychological and psychosocial factors and their effect on HSDD are also outlined. Fourth, the current treatment plans for HSDD are discussed before offering concluding remarks on the current review issue.
Moreover, this claim has been supported by a survey 17 undertaken on 31, women aged 18 years and above in the United States of America. The study found that the higher prevalence of HSDD was in women above the age of 45 years, and distress was reported to be a major concern among younger women Although sexuality is essential to both young and older women, lack of a satisfying sexual life negatively impacts on the overall quality of life The trend is particularly reflected among female groups that experience an unexpected rapid decline in hormone levels as a result of chemical menopause or even post-surgical events.
Figure 1 shows hormone production as a function of age, both before and after menopause As evident, between the age of 20 and 40 years, there is an increase in the production of sex hormones, before a gradual decline is experienced during menopause and post-menopause years of 45 years and above.
On the contrary, other scholars argue that based on longitudinal findings, relationship issues and other non-biologic factors can strongly impact on the overall sexual experience of women other than menopausal changes alone Nonetheless, anxiety, depression, and other relationship changes including conflict in the family, the condition of the relationship, sexual function, and health of a partner can contribute to substantial FSD The common assumption is that menopause contributes to reduced sexual desire as a result of low production of hormones from the ovaries, resulting in loss of oestrogen and reduction in testosterone.
The next subsections elaborate on the relationship between low testosterone and oestrogen levels on HSDD. Scholars have reported that low production of testosterone plays a central role in HSDD. One of the key reasons in support of this claim is that testosterone initiates sexual activities and proliferates sexual desire and behaviour. In addition, testosterone is essential in modulating clitoral and vaginal physiology to facilitate genital lubrication, sensation, and engorgement Therefore, a lack of testosterone has been reported to contribute to low libido and to reduced sexual pleasure and receptivity Also, low levels of testosterone have been correlated with lack of sexual motivation, fatigue, distress, and overall reduce the sense of well-being Figure 2 shows that there is a ificant decline in the production of testosterone four years before menopause, during menopause, and two years into menopause.
It is not unusual for women in their pre-menopausal years with functional ovulatory cycles to report HSDD. Hence, there seems to be a close relationship between the production of testosterone and reduced sexual desire, with more effects felt among older women in their post-menopause years and women who have undergone oophorectomy compared with younger ladies and those in their premenopausal years Figure 3 further shows that with increasing age, the levels of testosterone reduce and by the time a woman reaches menopause, the levels of testosterone are almost a quarter of what they were in their early 20s.
According to Simon et al. Besides low testosterone levels, low sex drive among women can also be affected by reduced levels of oestrogen during postmenopausal years. Low levels of oestrogen in vulvovaginal dryness and atrophy in addition to initiating changes of genital function through reduced sensory perception and decreased clitoral blood flow As such, it becomes apparent that lack of oestrogen is associated with vaginal discomfort due to dryness and genital insensitivity, making it difficult for an individual to actively respond to sexual expression and cues, considering a reduced impact on desire Researchers have recommended the use of oestrogen therapies to treat dyspareunia and vaginal dryness resulting from vulvovaginal atrophy However, oestrogen-based therapies have been questioned as to whether they contribute to the effect after precise use in managing low sexual desire, in the event that low sexual events from issues such as loss of genital pleasure, sensation, or as a consequence of pain Figure 4 shows the variation in oestrogen production during years of fertility, perimenopause, menopause, and post-menopause.
As evident from Figure 4 , there is a high variation in oestrogen production during menopause, and these fluctuations levels contribute to decreased sex libido among women. Besides, both peri- and post-menopausal individuals can experience HSDD due to low levels or deficiency in oestrogen hormone production 30 , Laumann et al.
In this case, oral oestrogen therapy is often recommended as a replacement to relieve mood changes, hot flashes, and alleviate irregular sleep patterns and improve the quality of life among women 33 , 34 , However, a study by Laumann et al. One of the reasons for this is that oral oestrogen can increase the levels of circulating sex hormone-binding globulin SHBG among menopausal women 37 , 38 , O elaborate, SHBG has been reported as a protein that can bind testosterone and as a result, lead to lowering of free testosterone levels in the blood Therefore, if the levels of SHBG are high, the level of free testosterone in plasma will be lower.
In addition, Simon et al. Warnock et al. As such, the ovarian release of oestrogen is suppressed, and as a result, sexual libido is also affected. However, the levels of SHBG can be reduced using testosterone replacement therapy, which works by raising the levels of free testosterone and potentially decreasing potential s and symptoms of HSDD 43 , In women, androgens are C19 steroids generated from cholesterol, where the main sources of release are from the adrenal glands, peripheral tissues, and the ovaries.
Figure 5 shows steroidogenesis of androgens in women. Androgens are released from peripheral tissues such as cutaneous, muscle, and adipose tissues. Figure 1 shows that testosterone T represents the final product in the androgen pathway and it from the conversion of androstenedione A present in plasma. As noted from the ageing factors associated with FSD, women can experience the effcets before and after menopause as a result of androgen hormone deficiency Long before menopause, and specifically from the second half of the pre-menopausal years when a woman is aged between 30 and 50 years, the development of androgen hormones reduces from the ideal rate observed during puberty and up to the late 20s or early 30s 47 , However, from the mids, the normal activities of the ovaries reduce, and the process of ovulation becomes irregular.
As shown in Figure 6 , in irregular ovulation cycles, there is less progesterone release, and in cycles where there is no ovulation, there is no release of progesterone As such, as the levels of progesterone start to fall, the menstrual cycle becomes shorter and the lack of progesterone in a hormonal imbalance where there is oestrogen dominance.
The oestrogen dominance is shown in Figure 3 , in relation to progesterone levels that are lower than normal among pre-menopausal women Some of the symptoms linked to increased production of oestrogen at this age include depressive mood and anxiety. As an individual transitions into menopause perimenopausal age , the irregular release of androgen hormones become longer, and women may have reduced sexual desire for prolonged months because they receive irregular menstrual cycles 50 , 51 , At the age of 50 years, most women experience a ificant reduction in the amounts of androgen, while the values for testosterone and oestrogen reach their minimum levels 53 , 54 , Even so, the natural development of menopause can also result in reduced production of androgens 56 , In most cases, androgen deficiency is difficult to identify, and most women correlate their reduced sexual desires with lifestyle issues or psychological distress as opposed to biologic changes in their bodies Some of the experiences can result in an inexplicable lack of energy, tiredness, low self-motivation, disturbed sleep, a complete lack of sexual desire, and low self-esteem or poor general well-being 59 , Low levels of androgens in women and reduced sexual desire can be diagnosed by examining levels of SHBG and testosterone because initial findings reported from women that have undergone surgery are as elaborated below.
Even if the changes in hormone profile among young women who have undergone hysterectomy and oophorectomy might not entirely affect sexual expression, the increased prevalence of HSDD in young women compared with pre- and post-menopausal women is a strong indicator for the affect of hormonal levels on sexual desire 61 , 62 , The age-associated reduction in androgen hormones parallels the age-linked increase in HSDD among women, mainly in those who have reached natural levels of menopause with low sexual desire compared with pre-menopause women, further indicating the central role that hormones play in HSDD 64 , As discussed earlier, low levels of oestrogen are largely associated with dyspareunia and vulvovaginal mucosa changes, a move that can contribute to reduced sexual desire among affected women 46 , In past studies, women who have undergone oophorectomy have shown to have associated low levels of sexual desire and increased distress or poor overall well-being.
One study found lower levels of androgen hormones in healthy pre-menopausal women who reported having low sexual desire compared with women without a similar problem The marked decline in low levels of testosterone after surgery has been linked to low sexual desire 67 , 68 , because most studies have focused on safety, efficacy, and testosterone-route therapy to treat reduced sexual desire.Women want sex Casper
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Role of hormones in hypoactive sexual desire disorder and current treatment