Sexual Health Treatment for Women: New Medications & Lifestyle Guidance

[Dr. Amy Pearlman]:
Mo, I'm so glad you brought that up. It's interesting because yes, I'm a woman, but I've been treating men's health for much of my career. It wasn't until a couple of months ago that I took Dr. Rachel Rubin's course and learned how to do female sexual medicine. I had so many male patients that were coming in and they were saying, "Hey, I feel great. My libido is great. My wife doesn't want to have sex with me. Can you help her?" I was tired of telling them no, because the reality was I could, I just needed to learn how to do it.

I think that's another message, maybe for people listening, is we're already doing the things, all the medications that we're currently using in men-- I use a lot of medications off-label in men, like Addyi, like PT one-for-one. I know you use those medications too. They're approved in premenopausal women. I realized, "Oh my goodness. Now I can just use these medications on-label for these women that, historically, I didn't think I could help. Honestly, I'm embarrassed to say this. As a woman, I didn't think I could help women. Isn't that terrible?

[Dr. Mohit Khera]:
It's easy and you can, and now you know you can, because I know you've been doing it now. It's unbelievably easy. You're right. You can use the same medications, even testosterone. If you can prescribe testosterone for men, you can actually prescribe it for women. It's unbelievably effective, particularly when it comes to HSSD or low libido. Very effective. Yes, Addyi, bremelanotide, you can use it in men, but you can also use it in women on-label. You're already doing it. I will tell you, the satisfaction of improving both sexual functions is far greater than improving just one.

The amount of good that you're creating is far greater. When the couples come in and say, "Wow, on both sides, you've helped us both," that's where the magic starts. It's not just about just improving one partner's sexual function.

[Dr. Amy Pearlman]:
You were mentioning the great benefits of the low-dose daily Tadalafil in men. How about in women?

[Dr. Mohit Khera]:
Great point. I have not seen data, but I do use Tadalafil or Viagra in women for arousal disorder. She says, "I have decreased arousal, decreased blood flow to the genitalia, decreased lubrication." Men and women are not so different. It works for arousal. If she has arousal disorder, we use PDE5 inhibitors. If she has libido issues, I use either Addyi, bremelanotide, or testosterone. I like testosterone. I like Addyi a lot, also. I have medications for each one.

Even now, there's data to suggest that Addyi can help with orgasmic dysfunction. That was published in one of the meetings as an abstract that orgasmic – We don't talk about orgasmic dysfunction, but that's a big problem. When we talk about, in men or women, delayed orgasmia or anorgasmia, where's the treatment? There's no treatment.

[Dr. Amy Pearlman]:
It's to see a sex therapist and to teach the patient how to have sex. That's what the guidelines state.

[Dr. Mohit Khera]:
What do we do? We have to use medications, be creative. We published a very sad story. I had a 28-year-old gentleman who had anorgasmia, primary anorgasmia, which means he never had an orgasm in his life. We tried many things. We published this last year in JSM. We gave him many trials, but we used off-label Addyi, and the Addyi was helpful. Again, this is off-label. Just want to stress that, but it did make his first orgasm. I think you have to be creative in sexual medicine. You do, because there's always not going to be this textbook answer of what to do. You have to be creative in deciding how you're going to help the patient.

[Dr. Amy Pearlman]:
If I were to think of the most challenging patients that I see in my clinic, it is the men presenting with delayed ejaculation or reduced sensation. We really don't have any good therapies for them. Let's dive a little bit into the Addyi and the PT one-for-one, because that's where I'm using a lot of these medications off-label in men. The guy comes in with erectile dysfunction. When might you add one of those medications to, let's say, their Tadalafil regimen?

[Dr. Mohit Khera]:
I think those medications are more effective, particularly for libido. I think it makes a difference. I do think that if you look at a man who-- I always go with testosterone first. I always think it's important to optimize the erection. Daily Cialis. Remember that a man with ED will sometimes come in and say, "I have low libido." The reason he has this low libido is because, think about it, it's 10 o'clock at night, he's exhausted. He knows that he can try to have sex, and it's a 50% chance it'll work, but if it doesn't work, he's going to be frustrated, or he can go to sleep. Why is he going to go to sleep? Because he just has to deal with it.

He keeps doing that over and over again, and he thinks, oh, he's got low libido. She thinks he's got low libido, but in fact, he's just doing something called conscious aversion. He's just avoiding sex because he doesn't want to deal. Let's say you take that same man and you give him these most amazing erections every night when he goes to sleep, and these amazing erections every morning when he wakes up. You know what he's going to do? He's going to use them because it's there.

I'm just going to tell you, he's going to use them. Then he's going to say, "My libido went up." The reality is, your libido went up because your sexual function significantly improved. That's why your libido went up. Optimizing erectile function is more important than optimizing hormonal function. Remember, it's not just tea. We teach the residents the mnemonic PETT, prolactin, estrogen, thyroid, testosterone, PETT, P-E-T-T. Someone comes in with low libido, check the PETT, and make sure that nothing else is going on.

If you do that and you optimize lifestyle modification, fatigue and stress will shut down the B02. If you're tired or you're stressed, sometimes you're not willing to engage. Optimize lifestyle modification, diet, exercise, sleep, and stress reduction. Then if it's not effective, "Okay, what else do I have?" That's where I start crossing over to Addyi. I like Addyi a lot. It's a simple medication, and the concept is very similar. It just increases dopamine. If I increase dopamine and norepinephrine in someone's brain, they're going to want to have sex. That's what it does.

That's why we used to give Dostinex. That's why we used to give Wellbutrin before this came out. We were very creative. Anything that would increase dopamine would increase the desire for sex. There are neurotransmitters that are excitatory. There are neurotransmitters that are inhibitory. Serotonin is going to bring me down. Dopamine is going to bring me up. Melanotide, bremelanotide, melanocortin are excitatory. All we're trying to do is increase the positives above the negatives to induce desire and orgasmic function.