Ever find yourself saying “Honey, I have a headache”' more often than you'd like? You’re not alone. In this episode, Dr. Rahman reveals the hidden reasons behind persistent low libido and offers practical solutions to help break the cycle and reignite intimacy.

Dr. Rahman dives deep into hypoactive sexual desire disorder (HSDD), the most common form of female sexual dysfunction, affecting up to 40% or more of women. This episode is packed with valuable insights, from the biological intricacies of libido to the innovative treatments available today.

Dr. Rahman’s thorough exploration of HSDD helps listeners understand the vast influence of factors like brain neurotransmitters, hormonal imbalances, and socioeconomic conditions on women’s sexual health. She emphasizes that understanding these elements is key to effective treatment and overall quality of life.

Dr. Rahman's episode is a must-listen for anyone dealing with low libido or in search of a better understanding of women's sexual health. This episode is packed with actionable information, making it clear that acknowledging and addressing sexual dysfunction is essential for living a fulfilled life.

Highlights:

• Understanding HSDD: Discover how HSDD impacts women and why addressing it is crucial. From fluctuating libido to distressing low sexual desire, Dr. Rahman explains it all.
• Biopsychosocial Approach: Learn how Dr. Rahman assesses HSDD through a comprehensive lens, looking at biological, psychological, and social factors.
• Groundbreaking Treatments: Get familiar with innovative treatments like Flibanserin (Addyi), Bremelanotide (Vyleesi), and the off-label use of testosterone. Dr. Rahman shares her clinical experiences and patient outcomes with these medications.
• Impact of Mental Health: Understand the significant role of mental health in sexual function. Whether it’s anxiety, depression, or the side effects of medications like SSRIs, Dr. Rahman elaborates on how these factors interplay with HSDD.
• The Role of Self-Care: Dr. Rahman underscores the importance of self-care beyond the physical, emphasizing the need for mental and emotional well-being.

Remember, no one can advocate for your health better than you can. Dr. Rahman’s mission is to empower you with information so you can make informed decisions about your health.

Who else should we feature on Gyno Girl Presents: Sex, Drugs, and Hormones? Tune in, like, share, and leave a 5-star review on Apple Podcasts to help more listeners discover this invaluable resource

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Hey, y'all, it's doctor Samina Rahman. Gyno girl. I'm a board certified gynecologist, a clinical assistant professor of Ob GYN at Northwestern Feinberg School of Medicine, and owner of a private practice for almost a decade that specializes in menopause and sexual medicine. I'm a south asian american muslim woman who is here to empower, educate, and help you advocate for health issues that have been stigmatized, shamed, and perhaps even prevented you from living your best life. I'm better than your best girlfriend and more open than most of your doctors. I'm here to educate so you can advocate. Welcome to Gyno girl presents sex, drugs, and hormones. Let's go.

Hey, y'all, it's me, doctor Samina Rahman. Gyno girl. Welcome to another episode of Gyno Girl Presents, sex, drugs and hormones. I am doctor Samina Rahman. I am a board certified gynecologist and sex med and menopause specialist with the office and practice in downtown Chicago. I am a board member for the International Society for the Study of Women's sexual health ishwish and a menopause specialist and certified physician. I also licensed to practice in Indiana, Wisconsin, California, and Arizona. So if you are in those locations and you need my help, we can help you.

But welcome back to another episode. I also have a platform on YouTube called Guy no girl tv, and I'm on Instagram as Gynell girl. So I post there all the time. So let's get at it. Today I want to talk to you guys about an issue that comes up in my office very frequently, and it has to do with when women feel horrible about themselves or frustrated about themselves because they have a lack of libido. Remember, libido is a mood often dictated by your brain, which is the biggest sexual organ. And there are times when our libido fluctuates, and that's totally normal. But when it's persistent and it's happening all the time and you do not have.

When you do not have a spontaneous desire to have intercourse with someone you love and have a great relationship with, when you do not feel that you can reciprocate, when it is otherwise, you're getting approached and it's like, ah, no, I'm sorry, I got a headache kind of thing. Then, you know, oftentimes it starts to bother my patients. I have patients who come to me like, you know, I don't feel like myself. I feel dead inside. I feel like I'm not the same person that I used to be. And of course, there's so many reasons that can be happening, but when the dictating factor is the fact that, like, I used to have this great sexual experience and responses and desire, and it's no longer there that decreased desire with distress is known as hypoactive sexual desire disorder, HSDD. It is the most common form of female sexual dysfunction. 40% or more women suffer from this.

And the numbers increase as we age. Okay? So as we age and we go through natural or surgical menopause, women have more low desire with distress, upwards of 44% in that midlife time. But if it's a surgically induced menopause, meaning that you've had your ovaries removed, it can be up to 72%. And so it varies. And I always say that, like, you know, especially for midlife women, there's so much going on in their life, right? You're balancing so many things at once. You may be someone that works, and if you work, you might be at the pinnacle of your career or about to transition and pivot into a new form of something else. You know, you may have gone from teacher to consultant. You may have gone from clinician and physician to, you know, social media like content creator.

You may do all of the following and have, you know, kids that are in middle school, high school, parents that are aging. And on top of that, you might be experiencing a divorce or a death in the family, and you're trying to be the person for everyone, but you're not being the person for yourself. Right? That's where self care comes in line. And I just. I'm not talking about getting a massage or a facial. It's really taking care of your own health and finding out what's distressing to you and what's impeding your quality of life. For me, I'm an board certified Ob gyn. I used to do a lot of Ob.

I used to do a lot of surgeries. And a lot of my colleagues often ask me, like, don't you miss doing those exciting ectopic pregnancies where you saved someone's life by surgically, you know, removing their tube or stopping their bleeding or saving that baby? And I loved that period of time in my life. And nowadays, I'm helping and saving, you know, patients and women in different ways. Right. Because, you know, saving them from themselves sometimes that, you know, you're in this kind of distress, and you're not enjoying the quality of your life, and I'm gonna. I'm here for it, you know, but what really happens with this hypoactive sexual desire disorder is you want to have sex, you want to have that good relationship again, you want to experience that pleasure with somebody that you love or have been with, and it's not there. Something is stopping you. Is it something biologically happening to you? Is there a biologic component to remember? We always talk about the biopsychosocial when it comes to sexual dysfunction.

Is there something biologically happening in the level of your brain? Your brain is the biggest sexual organ that you have. There. Are there. We believe in this dual control model when it comes to, like, sexual desire. And what's your sexual tipping point? There are things that put us into stimulation or excitation mode and things that put us into inhibition mode. So when we're talking about these things, it may be like the neurotransmitters that communicate with each other in your brain that activate desire, arousal, and orgasm. Right. And what are the neurotransmitters that are important for that? It's dopamine.

It's that feel good neurotransmitter. It's norepinephrine. It's melanocortins. We have hormones like oxytocin, like testosterone. These all mediate libido desiree, which is your lip desire, arousal, orgasm, and everything else. And then there are things that might, you know, inhibit you from wanting to have sex. What happens to some patients when they go on SSRI's? Their serotonin increases. When you have high serotonin levels, guess what? A lot of people get impeded orgasms.

Decreased desire. It's. We call it SSRI induced sexual dysfunction. And it's real. It's real for men. It's real for women. We have to be cognizant as clinicians about what we're giving patients and really counsel them on the risks, because you might think it's not anything, but when I have a patient who has extreme HSDD, they are in the office. They are crying about how they don't feel like themselves.

They are frustrated. They do not like how they feel. They do not like how they respond, you know, to their partner. They make them feel bad, like, not tonight, huh? Not tonight. I have a headache. Whatever the case may be, you can joke about it, but this is distress. This is frustration. This is a real quality of life issue.

Starts hurting people's relationships. I have patients, especially my midlife patients, who are dealing with everything, and then they have this little libido on top of it, and they kind of joke about it. Oh, I just do it to make my partner happy. Other patients, they're on the same page with their partner, right? Their partner is now in midlife. And remember how we always say sexual health is health, erectile dysfunction for men, that's one of the first signs sometimes that something's going on vascularly for you. Is it diabetes? Is it hypertension? Is it cardiovascular disease? So when men have erectile dysfunction or other conditions like Peyronie's disease and their partners have problems, whether or not it's painful sex or decreased libido, sometimes they're on the same page. Sometimes neither one of them want to, like, have intimate relations and they just cuddle or, like, they're just BFF's and they're okay with that. They're okay with having a non, you know, almost a sexless marriage, right, less than ten times a year.

But other patients are not. And it bothers them, and it is very distressing. So hypoactive sexual desire disorder is real. It's bothersome, and. But there are things that we can do about it. If you're a clinician listening, or if you're a patient listening, you know, the first thing that I do is I listen to your story and I figure out what's been going on in your life that might be disrupting you. Right? What's been happening? Where are we at, you know, hormonally, what? And then I look at your medical conditions. Do you have hypertension, high blood pressure? Do you have Parkinson's? Do you have neurologic disorders? Do you have anything and taking any medicine that might be inhibiting your sexual function, is there depression and anxiety? Is there mood instability? You know, most people, it.

Studies have shown that when they have, you know, decreased desire with distress, they have a lot of negative feelings, they have poor self image, they have mood instability, they have depression. And this can sometimes strain their relationships and their partners. So we look at all of that, right? And I want to take a look at those list of medications. Are you like, like I said, are you on an antihypertensive? Are you on a antifungal that might be disturbing you? Are you on other medications? Are you on birth control pills? Yes. Remember birth control pills that cause provoked vestibulodynia in a subset of women can also do the same for your libido. For my patients who are not in midlife or in midlife taking birth control pills, then, of course, you know, things like cancer and other medical conditions that really can disrupt how you feel about yourself and the medications that are used chemotherapeutic agents. The hormonal agents can be very difficult. And then, of course, we got to do that exam, right? You got to take a look at that.

Arousal tissue is in your vulva. I got to look at your vestibule, that vulvar vestibule, that thin little area of tissue between the labia minora to your hymen remnant, up to your urethra, down to your perineum, that slither of tissue that is so rich in androgen receptors and testosterone, you got to look at that, and we got to say, like, does someone have provoked vestibulodynia? Do you have the genital urinary syndrome or menopause? I did an episode on the genitourinary syndrome of hormone deficiency or menopause. These are all real factors that give people, as my friend and colleague, doctor Lauren Striker says, sandpaper, sex. It hurts, it burns, it feels like the Sahara. Does it? People tell me that all the time. Do you want to have. If you're not someone who enjoys pain, you're not going to want to have sex, and that's secondarily going to affect your libido. So all of these biological factors have to be looked at, and they have to be treated.

And that's the first step to everything. And also just giving yourself grace, right. When I tell patients that how common this is and how different things are, you know, might be affecting them, I mean, some people have real epiphanies when I tell them that, like, this sSRi you been on, you know, can affect your sexual function, and they've never been counseled on that. And it's like, whoa, no one ever told me that. Like, would it have stopped them from using it? I don't know, but at least they would have gone in there with this bit of information so they could be made aware of it. I definitely have patients with anxiety and depression who can't have sex. They're ruminating too much in their head because of their anxiety and OCD or OCD with depression. You know, there's this sensation called anhedonia, your lack of desire for anything.

Nothing brings you joy. So, of course, sex isn't going to bring you joy if you have complete and Hadonia. Believe me, sex is the last thing on your mind. So there are patients in major depressive disorders or situational depression who go on SSRI's who don't have that awful side effect of low libido. They actually have corrected their anhedonia and can now work toward improving their libido and, you know, their desire does come back. So it's not, you know, a one size fits all kind of thing. But I. Those are, you know, very important factors that I look at as a sex med doc when I'm looking at you as a patient.

So think about that. What you're taking, what medications, what hormones, all of the things. And then we have to look at your social situation. Right? There are different forms of HRT, but husband replacement therapy is not one of the things that I'm an expert in. So, you know, I feel like we have to get that under control. The relationship has to be looked at. Do you need counseling with your partner? Is there. Are there things that you can't get past? Are there things you can get past that has to be analyzed and fixed? And then we got to look at, you know, all the other social factors, what cultural things are involved.

Are you sleeping? Are you stressed out? What's on your plate? What's on your agenda? We got to look at all that. And then, of course, the psych stuff that I talked about, mental health issues, anxiety, depression, all the things that can affect women and can get worse in midlife. We know that there's a 40% increase in some of these symptoms in midlife. So we got to look at that. The anxiety and the depression and the cognitive distress that comes with it. So that's sort of the biological approach in the biopsychosocial. What do we do if we've looked at the pain and treated the pain and we've done all the other things? Pelvic floor therapy, you're peeing on yourself, you're having pain with sex, you get pelvic flu therapy, things improve. What do we do now? The libido is still not there.

Well, you know what? Good news is we have medications now available for hypoactive sexual desire disorder. HSDD. Okay. We have medications for this lack of motivation for sexual activity, the reduced spontaneous desire or sexual thoughts, the absent responsive desire or erotic cues like you're just not going to respond to them. And the feeling that you get, the personal distress, frustration, grief, incompetence, sadness. All the things. We have medicine for this. Is it a magic bullet? Is it going to fix everything? No.

But for some patients, it's a big deal. So, again, after looking at your medical conditions that may impact you, the blood pressure, the diabetes, metabolic syndrome, urinary incontinence, neurological stuff like Parkinson's disease, cancer stuff, which is very debilitating for so many people, for many reasons. Looking at the medications looking and treating pain, all the things then we look at. Okay, are you a candidate or do you want to try some of these medications? They're great medications. In fact, I hope to have the CEO of Sprout Pharmaceuticals on my podcast. Coming up, Sydney Eckerson to see whether or not she can talk about the ups and downs that she went through to get an FDA approved version of a medication for hyperactive sexual desire disorder, which is the first of its kind. The trade. The trade name is Addy.

The generic name is Flabanserin. It's a medicine I use in my office quite frequently. Does it work for midlife women, Peri and postmenopausal? Yes, it does. Is it approved for you to take by the federal, the Food and Drug Administration? No, it's not. And what does that mean? That means it's off label and that when I prescribe it to patients, they have to pay out of pocket, usually, unless they get lucky. So flabanterin, what does it do? It is a pill that you take every day? You take it every day. We have to use it, you know, may take up to four weeks, but the maximum effects are really felt or the full effects are really felt by eight to twelve weeks. We usually discontinue it in two to three months if you don't really feel any change in any parameters or sexual function.

But what it does is it works centrally at that brain, that's that biggest organ that you have in the brain, that sex, that sexual organ, to put you into excitation mode. How does it do that? It's a stimulation mode, works by antagonizing your serotonin receptors. So it decreases your serotonin, and it works by an agonist way to increase your dopamine and norepinephrine. So when we work with these neurotransmitters and we change it around, we see a maximum benefit. And for some patients, up to 60% of females will find a positive response. And that positive response increase includes increasing libido arousal and even orgasm. So remember, for women, it's not a linear thing like masters and Johnson said, it's really circular. So our sexual function is really, you know, more of, you know, including all the factors that can improve our desire, libido, arousal, orgasm, all that stuff is circular.

And I'll talk about that at some point. But when we talk about this medication, it's 100 milligrams at bedtime. I say just put it next to your I nightstand take one right before you go to sleep because it can make you sleepy. For some patients, there was this big to do. When it first came out, it was like 2017 or something. It was big to do about, oh, this big alcohol warning. Most things that work centrally, if you drink too much alcohol on it, you might pass out or drop your blood pressure. That's just a known fact.

But because this was a big female sexual dysfunction medication, there were big black box warnings on it for alcohol, and that was recently removed. But now we say if you consume more than two to three drinks standardly in that night, you should just skip your dose. And don't, don't do twice the dose the next day. Just skip it. Or if you're going to have the one to two standard doses, um, you should wait at least 2 hours before taking the flabanserin at night. You know, who, what kind of, what patients, like, really shouldn't take this are really the ones that have some impairment in their liver, like severe impairment or dysfunction or liver disease, because it is metabolized through the liver. And if you have. If you're on a medication that's metabolized through this pathway called the CYp three a four inhibitors, then, you know, we have to look closely at that as well.

But like I said, 60% of the patients, it works really well for. It works in the peri and post menopause as well. What are some adverse symptoms and side effects? Some people, again, sleepy, some people might get nausea, fatigue, some people get insomnia, but that's a little more rare. I would say anxiety, you know, vertigo, dizziness, very rare, but can happen. These are all, like, listed on their, on their labels, so, you know, something to be aware of. For the most part. My patients say, yeah, they get a little sleepy. You know, maybe if they take it the wrong time, they might get a little dizzy.

But it's pretty rare for some of my patients that I've seen. And so that's some daily medication that's kind of something that you take, you know, every day. And then, you know, we see how you do, and if you respond to it, you continue it. If not, we discontinue it. There are medications that are. I mean, it was actually toted, like as the female viagra when it came out, the pink pill. But, you know, it doesn't work like Viagra. It's not as needed or on demand.

But we do have an on demand medication for HSDD. It's called vileci or bromelainatide, and it's a melanocortin analog. Essentially, when you inject yourself you kind of get a hit of dopamine. So it's an auto injector. It's subcutaneous, like, right under the skin. You just put it. You just inject yourself at least 45 minutes before intended sexual activity. But, you know, the half life is, like, up to 12 hours, so you can really use it, and it works for longer.

You can get a slight increase in blood pressure the first 24 hours. We don't want you to use it for more than eight times a month. If you have uncontrolled hypertension, we're worried about giving it to you as well. But it's a sub q injector, just, like, inject it, and then we feel. See how you feel. Some people do get nausea. I've tried it myself. I think for my patients and myself, sometimes the nausea is a factor, sometimes it's not nausea, you know, if that is what I.

What I like to tell my patients is, hey, let me give you a little bit of zofran tube. Why don't you try it on yourself? We try it, say, like, we say, don't use it more than eight times a month. But most of my patients aren't having intercourse more than eight times a month anyway. So, um, why don't you try it, you know, by yourself, like, you know, plan a night that you're going to be alone, read some erotica, inject yourself, see what your side effects are. Have the Zofran available if the nausea comes, which is, you know, an anti medic or anti nausea medicine, and then let's see what happens. And again, about 60% of my patients really respond well to this. They feel like they have improvements in their desire, libido, and orgasm. So I think it's really an amazing drug, and I think that, you know, we have options now that we didn't have, you know, a decade ago.

So that's great. Otherwise, you know, there's not that much in terms of side effects. You know, technically, again, it's not meant for. It's not. It's not FDA approved for peri and postmenopausal women, but we still use it in those categories off label, like so many things we have to do. Again, what are the biggest precautions? Transient rise in blood pressure. You know, about 1% of patients do report that if they used eight doses or more a month, there was, like, focal areas of hyperpigmentation, really, around the breast or the gums or the face. Again, most patients aren't using it that much, but sometimes in our milan and women of color, like, myself, you know, might experience that.

So we just will discontinue it if that happens. Not sure, based on the studies, you know, if the hyperpigmentation went away for some patients, but again, it was just 1% of the population, so it wasn't an extreme thing, but it's something worth noting then. Nausea, I think, is probably one of the most common ones. Up to 40% of people experience nausea. That's phylece. That's the bremelanotide. One more thing I want to mention, which I mentioned in other podcasts, and we've talked about it with other experts, is the use of testosterone in the midlife woman, the perimenopause post menopausal woman. Testosterone is, per our guidelines and recommendations, very important and a very effective tool for hypoactive sexual desire disorder, HSDD.

What we usually do is we have no FDA approved version of testosterone for women in the United States. The only country that does is Australia. I've mentioned that before. There have been many studies. We just. The FDA won't approve, you know, these medications for reasons that I won't go into, but it's very safe and effective if used in the right way. The way that I use testosterone is I will prescribe male FDA approved testosterone in the form of a gel, because we think transdermal route, or through the skin is the best way to get you to premenopausal levels. So oftentimes I'll check a patient's levels, they're less than three total testosterone.

We'll look at that and say, okay, you know, you do have this low libido with bother. We've treated your general urinary syndrome, menopause. It's not gotten better. Let's try to work at your brain. Remember the brain, the libido is a mood. So a lot of people do reap other benefits. The primary reason we're using it is for HSDD. Sometimes I have patients say all of a sudden they have clarity.

They didn't have their brain fog is improving more, their lean muscle mass, all the things. But again, HSTD is the real reason that we gave it. So we try to give it to the patients. We have them get test in 1% gel. I give them a 30 day supply. These gels come in a tube. These tubes, when a man replaces their testosterone, they use one tube a day. So they get a 30 day supplies.

It lasts them 30 days for us, that one tube should last seven to ten days. So usually patients will use it for ten days. They use a pea size amount. Or you can put it into a five cc syringe, and you can, you should give yourself a half a cc a day, and that will also give you that benefit. And so eventually, you will be able to use that one tube over ten days. So if I give you a 30 day supply, it will last you 300 days or ten months. So you can go to GoodRx and download on the app a coupon and get it for $100. For ten months is not so bad.

So you'll do that test and put it on the back of your thigh or back of your calf or somewhere you don't remind. Getting a little. A little bit of hair growth on the back of your thigh or leg. You know, why I do not usually use pellets or injectables or other things is you can get really supra physiologic testosterone dosing with that. That can be very dangerous for women, causing bleeding issues, causing clitoromegaly, causing deepened voice. Those are not reversible, you know, acne, facial hair, hair loss, all the things when you get to super physiologic testosterone levels. But testosterone is safe. We have plenty of data on it if we're using it in a safe and effective way, which is keeping you at premenopausal levels.

So once we check you at baseline, we'll check you again at four to six weeks, maybe do another check again, you know, and see what happens to you by six months. If by six months, you're, like, no improvement in libido, we try other things. Most of my patients do really like being on testosterone for that reason. And remember, that's the biology, right? We talked about Vilesti, Addi, and testosterone to treat the biological aspects of hypoactive sexual desire disorder. You know, we're treating pain. We're treating all the things from a biologic perspective. But, you know, many patients need sex therapy. I always include that.

I give them a list of my favorite sex therapists in the area. Again, CBT or psychotherapy, cognitive behavioral therapy is sometimes part of it, and couples therapy. So, again, biopsychosocial, you know, this is the information about the biologic component. And, you know, people really, like, they can have much improvement in their sexual function and therefore, improvement in the quality of their life and live happier, better lives. And that's it. You know, guys, that's what I'm here to do now. Like, I'm just here to help you help yourself, right? Because no one's gonna save you, and we have to. I love Smallville, and I love that song at the beginning of Smallville.

Somebody save me. I won't. I'll. I'll spare you the singing, but. But I have to object that nobody's gonna save you. You have to save yourself. So you need to get, you know, all the education you can. Because, you know, as I always say, I'm here to educate so you can advocate.

You can go out there and figure out what's best for you and find a clinician to help you do it. So that's it for now, guys. That's hypoactive sexual desire disorder in a nutshell is very nuanced. It's not a one size fits all thing. Actually, nothing I do is really one size fits all. So, you know, I try not to practice cookie cutter medicine when I can. So that's it for me. This is Doctor Smyrna.

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