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The Obstetrician & Gynaecologist 10.1576/toag.12.4.237.27615 http://onlinetog.org 2010;12:237–243 Review

Review Hypoactive sexual desire

disorder
Authors Janice Rymer / Kevan Wylie / Tricia Barnes / Anthony Mander /
Helen Buckler / John Dean

Key content:
• Hypoactive sexual desire disorder (HSDD) is the persistent or recurrent deficiency
and/or absence of sexual thought/fantasies and/or receptivity to sexual activity,
which causes distress or interpersonal difficulties.
• Sexual desire is a complex issue involving physical drive and motivation; the latter is
influenced by previous experiences and the quality and duration of the relationship.
• HSDD frequently occurs in women who have had oophorectomy because a
significant source of their testosterone has been removed. They may respond to
androgen replacement therapy.

Learning objectives:
• To raise awareness of the effect that oophorectomy can have on sexual function.
• To acknowledge that sexual function is complex and involves biological,
psychological, relationship and socio-cultural factors.

Ethical issues:
• Should clinicians raise the subject of sexual problems more routinely?
• Is the treatment of sexual dysfunction an appropriate use of health service
resources?
• Can the pharmacological treatment of HSDD lead to the medicalisation of female
sexuality?
Keywords androgen replacement / biopsychosocial contexts / hysterectomy /
oophorectomy / testosterone
Please cite this article as: Rymer J, Wylie K, Barnes T, Mander A, Buckler H, Dean J. Hypoactive sexual desire disorder. The Obstetrician & Gynaecologist 2010;12:237–243.

Author details
Janice Rymer MD FRCOG FRANZCOG FHEA
Professor of Obstetrics and Gynaecology
King’s College School of Medicine,
Department of Women’s Health, 10th Floor,
North Wing, St Thomas’ Hospital, Westminster
Bridge Road, London SE1 7EH, UK
Email: janice.rymer@kcl.ac.uk
(corresponding author)
Kevan Wylie MD DSM FRCP FRCPsych
Consultant in Sexual Medicine
Porterbrook Clinic, 75 Osborne Road,
Nether Edge Hospital, Sheffield S11 9BF, UK
Tricia Barnes BA MA CQSW BASRT accred UKCP Reg
Psych
Director of Clinical Services and Research
TBA Practice, 21 Upper Wimpole Street,
London W1G 6NA, UK
Anthony Mander FRCOG
Consultant in Obstetrics and Gynaecology
The Highfield Hospital, Manchester Road,
Rochdale OL11 4LZ, UK
Helen Buckler BMed Sci DM FRCP
Consultant Endocrinologist and
Senior Lecturer
Department of Endocrinology, Salford Royal NHS
Foundation Trust, Stott Lane, Salford M6 8HD, UK
John Dean FRCGP
St Peter’s Andrology Centre, 145 Harley Street,
London W1G 6BJ, UK

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Introduction
Sexual dysfunction affects a large proportion of
women at some point in their lives. Hypoactive
sexual desire disorder (HSDD) is one of the most
common types of female sexual dysfunction and it
can affect women of all ages. It is defined as the
persistent or recurrent deficiency or absence of
sexual thought, fantasies or receptivity to sexual
activity, which causes distress or interpersonal
difficulties.1 Despite the prevalence of sexual
dysfunction, the subject is often not a priority for
physicians, many of whom may lack training in the
diagnosis and treatment of such disorders. In view
of the degree of personal misery that sexual
dysfunction can cause, it is perhaps surprising that
so little attention is devoted to it. This review
focuses on the prevalence, diagnosis and treatment
of HSDD and investigates the role of testosterone as
both a causative factor and a possible treatment for
the disorder.
Sexual response among women
To understand HSDD, it is useful to be aware of the
current models of sexual response of women.2
Masters and Johnson initially proposed a linear
model of sexual response consisting of four stages:
excitement (arousal), plateau, orgasm and
resolution.2 Later, Helen Kaplan added the concept
of desire and condensed the response into a
triphasic process of desire, arousal and orgasm.2
However, in 1997, Whipple and Brash-McGreer
introduced a circular model of female sexual
response which described pleasure and satisfaction
during sexual experience leading to a ‘seduction
phase’ which facilitated the desire to engage in
further sexual activity.2 Subsequently, Basson
described a nonlinear model of female sexual
response, with initiation of sexual activity primarily
based on intimacy rather than on spontaneous
Figure 1
Non-linear model of female sexual
response developed by Basson3
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sexual drive. This process is influenced by both
biological and psychological factors, as well as by a
satisfactory outcome of previous sexual experience
(Figure 1).3 This model fits well with published
observations regarding women’s motivations for
sexual activity.4
Sexual desire is a complex issue and, in cases of
sexual dysfunction, sexual desire may be influenced
by a wide variety of factors (Box 1). The perception
of desire is associated with feelings of attraction
and fantasies. Sexual desire can be seen to consist of
two main components: physical drive (biological)
and motivation (psychological). Physical drive is
modulated mainly by age, general health, hormone
requirements and mood, whereas motivation is
modulated by previous experiences and factors
such as relationship quality and duration.
Epidemiology
The complex dynamics of desire and the multifactorial
aetiology of HSDD make epidemiological research
difficult. It is important to recall that HSDD is
distinct from low sexual desire (which is often a
normal life experience) and has a number of subtly
different definitions in the literature. Epidemiological
data should, therefore, be examined with caution
and attention paid to the precise definitions of
HSDD or low desire, the population studied and
other variables. For example, the prevalence of low
desire has been found to vary between 11% and
53%, depending on the population studied.5
However, only 22–65% of these women reported
the associated distress required for a diagnosis of
HSDD.5 Furthermore, one study6 reported that
duration of low desire also has an impact on
apparent prevalence: low desire of short duration
had a prevalence of 54%, compared with 16% for
low desire of long duration.
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A recent study7 of 2467 women aged between 20 and
70 years used validated questionnaire instruments
to assess both sexual function and associated distress,
to determine the relationship between HSDD and
ageing. The prevalence of low desire showed a
positive correlation with age, whereas the distress
associated with low desire showed a negative
correlation; as a consequence, the prevalence of
HSDD (low desire with associated distress) showed
only a slight increase with age. The prevalence of
HSDD among premenopausal women aged between
20 and 49 years was 7%, rising to 9% among naturally
menopausal women aged between 50 and 70 years.
The prevalence was higher among surgically
menopausal women, i.e. 16% among women aged
between 20 and 49 years and 12% among women
aged between 50 and 70 years. The high incidence
of HSDD observed among surgically menopausal
women suggests that there may be a hormonal
factor contributing to the development of HSDD.
Recognition and diagnosis
Primary care is ideally placed to take a holistic and
integrated approach to sexual health and represents
the first port of call for many women with sexual
problems. The general practitioner (GP) is a trusted
and accessible resource to women seeking advice
about all aspects of health care. Furthermore, the
discussion of sexual issues is familiar to GPs and
would not normally be perceived as inappropriate
or unwelcome by women consulting. Several
aspects of primary healthcare team activity, such
as contraceptive care, cervical screening and Well
Woman services, provide opportunities to deliver
sexual health care. However, primary care is not the
only point at which women with HSDD present;
many women consult gynaecologists in particular,
with sexual dysfunction or concerns relating to it.
Consequently, it is important for physicians across
a range of disciplines to develop an understanding
of the diagnosis and management of this condition.
For a diagnosis of HSDD to be made, a reduction or
absence of sexual desire and the presence of
associated personal distress must be found, with
personal distress being key to the diagnosis. The
reduced desire should be beyond the normative
changes that may occur with the life cycle and the
duration of relationship. Minimal spontaneous
sexual thinking, fantasising or desire ahead of sexual
activity does not necessarily constitute disorder;
indeed, for many women this is completely normal.
However, when motivation to be sexual for any
reason is minimal, or sexual stimulation does not
cause arousal and concurrent desire to continue, then
disorder may be present.1 It is crucial to avoid basing
such diagnosis on normal responses to circumstances
such as excessive tiredness or the adverse effects of
prescribed medication. External or contextual
factors, such as distractions by children, work or
attempting sexual intercourse at the end of the day
© 2010 Royal College of Obstetricians and Gynaecologists
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2010;12:237–243 Review
Any one of the factors listed below can impact on a woman’s Box 1
sexual desire system, but they usually present comorbidly. Integrated model of sexual
dysfunction
Biological
• Ageing process
• Menopausal symptoms
• Mood and psychiatric conditions
• Medical conditions, medications and treatments
Psychological
• Intrapersonal difficulties
• Misuse of alcohol, recreational drugs, food
• Sense of attraction/desirability as a woman
• Awareness of altered sexual needs, desires and changed
experience of sex
Relational
• Changes in dynamic of relationship: conflict, lack of
intimacy, distancing
• Changes in family structure and caretaking role
Socio-cultural
• Life events: loss, bereavement, retirement, financial
insecurity
• Cultural attitudes, expectations and practices
• Religion
(when one or both partners may be exhausted),
should also be taken into account.
Several validated instruments for diagnosing
HSDD now exist.8 For example, questionnaires
such as the Brief Profile of Female Sexual Function
(B-PFSF©)9 have been validated in the clinical
setting for the diagnosis of HSDD. Hand in hand
with the use of such tools is the need to establish a
detailed history, in order to identify comorbidities
or external causes. Other sexual function problems
experienced by both women and their partners
may also be important. For example, women with
low desire may experience associated arousal or
orgasmic disorders and sexual pain.10 Furthermore,
premature ejaculation can affect sexual experience
and relationship satisfaction11 and women whose
partners have erectile dysfunction are more likely
to experience low desire.12
Emotional and psychological
impact of HSDD
By definition, HSDD has a substantial emotional
impact on those who experience it and the effects
are diverse. To determine the impact of HSDD on
the individual (and her partner), the clinician
must assess the presenting features and subjective
experiences in cultural and biopsychosocial contexts
(Box 1). The predisposing, precipitating and/or
maintaining nature of the various relevant factors
should be positioned in a temporal relationship to
the onset and nature of the sexual disorder.13
Individuals vary in their propensity for sexual
inhibition and excitation in the brain and HSDD
may be protective and adaptive and, therefore, needs
to be understood within the individual’s intimate,
social and cultural framework. Characterisation
of problems presenting at these different levels is
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Figure 2
Low sexual desire with associated
100
distress strongly influences 90
women’s well-being and
relationships14
80
70
60 HSDD
% 50
40 Normal
30
20
10
0

Inadequate

Troubled
Concerned

Disappointed

Frustrated
Insecure
Upset
Unhappy

Hopeless

Like a sexual failure

Ashamed
Sad
Less feminine

Bitter
Angry

Low self-esteem
I was letting my partner down

crucial, as they have different implications for an essential part of the history-taking process
treatment. comprises both current and past sexual relationships.
Unfortunately, talking about personal sexual
A woman may have sexual intercourse with a matters, including sexual disorders and difficulties,
partner with a variety of objectives, including to is often an uncomfortable experience for both
increase emotional closeness; to evoke a sense of doctor and patient. Furthermore, in undergraduate
well-being; to feel more attractive, desirable and education the teaching of communication skills
powerful; or to give and receive pleasure.4 Equally, does not always extend to sexual topics.15 Importantly,
women may have sex to obtain or please a partner, in a recent review of the literature on clinicians’
or to manage a partner’s moods.4 Other well- handling of sexual issues, Cordingley et al.15
recognised motivations include avoiding the identified that women are often reluctant to broach
negative effects of infrequent intercourse, such as the subject of sexual function, but welcome their
accusations of frigidity or of disinterest in a doctor raising the subject.1 This implies that it may
partner’s needs, and fear of losing a partner if be good practice to initiate this conversation during
intercourse is not regular.4 A woman with HSDD consultations and that clinicians could benefit from
may, therefore, feel like a sexual failure both in specific training on discussing sexual topics with
terms of experiencing a lack of internal sexual drive women.
or incentive for wanting sexual experiences, as well
as worrying that she is not meeting the perceived or Hysterectomy and HSDD
declared needs and expectations of her partner The impact of hysterectomy on sexual function
(Figure 2).14 This can result in a loss of intimacy has always been of great concern and a source of
and attachment to her partner and may become a preoperative anxiety for women and their partners.
cause of unresolved friction in the relationship. Indeed, this concern seems justified in view of the
Furthermore, sexual interest disorders frequently increased incidence of HSDD among surgically
coexist with subjective arousal and genital arousal menopausal women compared with premenopausal
disorders among women, which can alter the and naturally menopausal women. Unfortunately,
motivational forces behind sexual desire. Such women seldom articulate this concern and often
additional arousal problems can further add to a it is not recognised or discussed by clinicians.
woman’s sense of being a sexual failure. Hysterectomy is one of the most common procedures
performed by gynaecologists, with almost 38 000
Communication skills such procedures performed in England in 2004–5,16
It can be particularly complex to unravel the suggesting that this issue is of high importance. It is
aetiology and impact of sexual desire disorders, as good practice to provide written information on
women frequently do not disclose the full extent of sexual function to women and their partners before
their sexual difficulties because of feelings of shame hysterectomy, to enable them to understand the
or fear of hurting their partner’s feelings. However, issues and raise any concerns. There are certain

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preoperative factors that may be predictive of
sexual dysfunction after hysterectomy, such as
pre-existing sexual dysfunction, depression, poor
relationship with the partner or lack of support.
Postoperative risk factors include physical and
hormonal changes and changes in the woman’s
perception of herself and her body image.16 Equally,
dissatisfaction with the indication or outcome of
the operation are also risk factors. This underlines
the importance of both preoperative counselling
and psychological preparation for surgery and
post-hysterectomy assessment and psychotherapy
if indicated—in most UK units none of these occur
at present.
There has been a considerable decline in the number
of hysterectomies performed by the National Health
Service, largely because of the increasing use of the
levonorgestrel-releasing intrauterine system or
LNG-IUS (Mirena®, Bayer plc, Newbury, UK) for
women with heavy periods. A recently published
randomised, controlled study17 compared the effects
of hysterectomy or the LNG-IUS on sexual function
among women with menorrhagia. The results
demonstrated that sexual satisfaction increased
and sexual problems decreased among women
treated with hysterectomy, whereas satisfaction
with the partner was reduced among women
treated with the LNG-IUS.17
Treatment of HSDD
The multifactorial aetiology of HSDD means that
the contributory factors will vary widely between
women, indicating that there may be no single
treatment option suitable for all. Taking a detailed
history, therefore, allows treatment to be tailored to
the individual. The treatment of HSDD should
begin with an examination of possible aetiological
factors, such as underlying medical conditions,
which may need to be addressed. Subsequent referral
to a specialist or sex therapist allows various options
to be explored, such as cognitive behavioural therapy
(CBT), psychosexual therapy, mindfulness, short-
term psychotherapy or couple therapy. If judged to
be appropriate, a pharmacological approach may
be taken. In view of the multifactorial aetiology of
HSDD, a multifaceted approach to therapy is likely
to be the most appropriate. Indeed, this is well
supported by the literature, and a detailed review
and case summary of this approach has been
presented previously.18
HSDD management from an
endocrine perspective
It has been proposed that androgens have a part in
female sexual behaviour. They are involved with
sexual desire, arousal and orgasm, as well as playing
a key role in bone physiology and muscle mass. In
particular, reduced levels of testosterone among
women have been associated with loss of libido,
© 2010 Royal College of Obstetricians and Gynaecologists
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2010;12:237–243 Review
reduced sexual activity, fatigue and diminished
feelings of physical well-being.19
In order to evaluate the role of testosterone in
HSDD, it is important to understand the changes
in testosterone levels that occur at the menopause.
The production rate of testosterone among
premenopausal women is approximately 300 g
per day, but during the menopause the serum
concentration of testosterone is reduced.20,21
However, there is no further age-related decline
in testosterone after the menopause and the
postmenopausal ovary remains an important
source of testosterone. In contrast, women who
undergo bilateral oophorectomy, either before or
after the menopause, experience a sudden and
significant decline in testosterone levels, resulting
in significant androgen deficiency.22 Notably, a
greater proportion of surgically menopausal
women have low sexual desire compared with
premenopausal or naturally menopausal women
and such women are more likely to have HSDD.23
This suggests that testosterone deficiency may be a
causative factor for HSDD. However, because of
the complexity of the endocrine system and
interindividual variation, direct evidence of a link
is difficult to discern. For example, a community-
based cross-sectional study24 did not find any
significant association between androgen levels
and sexual dysfunction, concluding that the
measurement of androgens in women is not an
accurate diagnostic tool for sexual dysfunction.
Despite this, there is accumulating evidence that
the addition of testosterone to conventional
hormone replacement therapy has a beneficial
effect on sexual functioning among surgically
menopausal women.25 Although there is a certain
degree of controversy surrounding this issue, several
clinical trials have demonstrated significantly
increased sexual desire associated with testosterone
therapy.26–29
Most of the early studies of testosterone therapy
for HSDD used preparations designed for
androgen replacement therapy among men with
hypogonadism. Depot preparations, such as
subcutaneous implants and injectable testosterone,
may produce supraphysiological levels of
testosterone among women, potentially resulting
in unwanted virilising effects and hepatic
impairment. Oral preparations also produce
supraphysiological levels, with wide interindividual
variation in testosterone levels and unpredictable
absorption.30 Consequently, transdermal
testosterone delivery systems specifically designed
for women, which deliver testosterone through the
skin with a physiological pharmacokinetic profile,
have been developed. The low-dose transdermal
testosterone system (TTS) has been demonstrated
in several clinical trials26–29 to be an effective
treatment for HSDD among surgically menopausal
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women receiving concomitant estradiol therapy.
A 300 g/day dose of testosterone (equivalent to
endogenous levels of testosterone among
premenopausal women), delivered transdermally,
gave rise to significant improvements in sexual
function, with increases in sexual desire and in
frequency of satisfying sexual activity and decreased
distress.26–29 Furthermore, TTS at 300 g/day was not
associated with significant virilising effects or other
adverse events.26–29 A study31 of women using the
300 g/day TTS patch for 2 years also demonstrated
that longer-term use did not confer an increased
risk of adverse effects. Possible effects of low-dose
testosterone on metabolism or on the breast and
endometrium have not yet been elucidated.
Following the menopause, either surgical or natural,
the decline in estradiol levels may affect female
sexual function because of associated hot flushes,
sweats, sleep disturbance, mood changes and
vaginal dryness. All women for whom these factors
influence HSDD, therefore, should receive adequate
estrogen replacement as part of a holistic approach
to therapy. Conjugated equine estrogens and oral
estrogens are not suitable: they cause a large increase
in sex hormone-binding globulin, which decreases
free testosterone levels. This may either blunt or
ameliorate the action of testosterone. However, it is
interesting to note that one study31 of postmenopausal
women undergoing testosterone therapy without
concomitant estrogen reported significant
improvements in sexual function. This suggests that
testosterone therapy alone may represent a valuable
treatment option for a wide range of HSDD
sufferers, although further research is required.
Discussion
Sexual dysfunction is a considerable cause of
unhappiness and distress, yet for many doctors it
remains a subject about which they lack knowledge
or are uncomfortable discussing. Hypoactive sexual
desire disorder is characterised by reduced or absent
sexual desire and associated personal distress. It is a
common female sexual dysfunction, with significant
numbers of women affected at some point in their
lives. Unfortunately, women are often reticent with
regard to sexual problems and may not mention
them during consultations. However, many women
appreciate their doctors introducing the topic,
therefore, a key aim for gynaecologists should be
the development of communication skills to
facilitate open discussions on this subject.
To avoid overdiagnosing HSDD, it is important to
rule out lifestyle factors such as excessive tiredness,
the effects of medication or comorbid sexual
dysfunction. Validated tools, such as the B-PFSF,
can be a useful aid to diagnosis. Sexual desire is
complex and multifactorial, meaning that one size
does not necessarily fit all when it comes to treating
HSDD. It is, therefore, important to understand a
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woman’s symptoms in a bio-psychosocial context.
Taking a detailed history is an essential step in
developing treatment strategies tailored to the
individual.
Women presenting with HSDD may be referred to
a specialist or sex therapist, where a variety of
short-term psychotherapy or psychosexual
therapy interventions can be utilised. However, a
pharmacological approach may also be considered,
particularly for surgically menopausal women.
Transdermal testosterone patches have been
developed specifically for women, to deliver
physiological levels of testosterone. Several clinical
studies have demonstrated significant improvements
in sexual activity with this therapy, with minimal
androgenic adverse effects.
Increased professional awareness of the importance
of sexual function, together with knowledge about
effective therapeutic interventions, are vital steps
towards improving HSDD management and hence
represent a key goal for avoiding the distress and
negative feelings associated with HSDD.
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