When your Mojo is a No-Show, Can a Drug Make it Go-Go?

Bremelanotide (Vyleesi), the drug that was recently FDA approved, may end up being used by millions of women that are experiencing the monotony of monogamy as opposed to treating women who have hypoactive sexual desire disorder (HSDD.)  And that may not be a bad thing.

At a recent meeting with my staff at The Northwestern Medicine Center for Sexual Medicine I presented the scientific data that precipitated FDA approval of bremelanotide, an on demand drug indicated for the treatment of HSDD in pre-menopausal women.  I described how bremelanotide needs to be auto-injected in the thigh or abdomen forty-five minutes prior to anticipated sexual activity and works by stimulating the pathway in the brain, which results in the release of dopamine, the neurotransmitter that enhances sexual feelings. Essentially, bremelanotide turns the libido OFF switch to ON.” 

The overwhelming response of my staff comprised of female physicians, advanced practice nurses, and sex therapist was, “Wow, I can’t wait to try it!”

These are not women with HSDD, who by definition are very distressed by a lack of sexual desire, and are highly motivated to do something about it. These are women in loving long-term relationships who enjoy sex but are looking to feel the rush of incredible excitement and heart racing sex typically experienced in a new relationship.  While acknowledging that this drug is not approved for that purpose, we quickly realized that as medical professionals we would have to decide if “wanting to try it” would be a legitimate reason to prescribe it (for someone other than ourselves). 

The treatment of true HSDD is controversial. Some even argue that HSDD is not even a real thing. Those that acknowledge it as a medical disorder disagree if the approach should be pharmacologic, talk therapy or both. 

When flibanserin, the first drug to treat HSDD was released, there was a passionate New York Times op ed written by Emily Nagoski, the author of Come As You Are, asserting that HSDD should never be treated with a pill. I generally agree with her approach, and like many, if not most sexual medicine experts, my feeling is that true HSDD, (loss of libido not explained by painful intercourse, history of trauma, a medical condition, medication or partner issues), is complicated, multifactorial and requires a complete evaluation before determining a treatment course- a treatment course that ideally includes talk therapy with a trained, certified sex therapist.

But, having said that, there is a great deal of credible scientific research which supports the biologic component of HSDD, and in many cases there may be benefit from a little pharmacologic help (in addition to talk therapy) to give those critical neurotransmitters a push in the right direction. An intact libido depends not only on sociocultural, psychological, and interpersonal influences but on intact biology as well.

But, returning to the original issue, what about the woman who does not have HSDD?  What about the typical woman who used to have a terrific libido but has settled into the monotony of monogamy? In nature, the desire to have sex is driven by the need to reproduce. Once that is no longer an option or is biologically undesirable, there are a number of mechanisms in place that decrease libido resulting in the “cycle of sex”. In your twenties, it’s all about sex, all the time. During the baby- making years, it's sex with a purpose. And then, before you know it, the bedroom is a place where all we want to do is get a decent night’s sleep after a long day. Even if you love your partner. Even if he/she is sexy, interesting and wonderful. This is normal. But many women in long-term unions would love to have that “I have to have you RIGHT NOW “ feeling experienced in the early days of a relationship. Is she a candidate for this new drug? Should we, after informed consent that this is an off label use, and disclosure of possible side effects such as nausea, vomiting, flushing and in rare cases a transient rise in blood pressure deny the opportunity to our female patients who do not have HSDD but are looking to restore that new relationship excitement? We were hard pressed to come up with a reason why we would not.

Sildenafil (Viagra) is not recommended for men who do not have erectile dysfunction, and arguably doesn’t even have a benefit. Yet, a guy who desires an enhancer, or maybe just insurance that he will rise to the occasion, will often pop it like Pez in spite of possible side effects such as nasal congestion, muscle pain, nausea, dizziness, heart attack, death, and that infamous erection that doesn't abate for hours…  

Should a woman, once fully informed, also have the opportunity to enhance her sexual experience? Is denial of this drug just one more example of the disparity between the importance of female sexual pleasure versus male sexual pleasure? 

At this point, with no data and no clinical experience prescribing bremelanotide to women without HSDD, I don’t have an academic, evidence-based answer. But as an expert who has treated thousands of women, both with and without HSDD, I think I have a pretty good idea, for better or worse, how this drug is going to be used.