Low sexual desire--is it all in her head? Pathophysiology, diagnosis, and treatment of hypoactive sexual desire disorder.

Hypoactive sexual desire disorder (HSDD) is thought to be the most prevalent form of female sexual dysfunction (FSD), affecting up to 1 in 10 US women. Hypoactive sexual desire disorder is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) as persistent or recurrent deficiency or absence of sexual fantasies and thoughts, and/or desire for, or receptivity to, sexual activity, which causes personal distress or interpersonal difficulties and is not caused by a medical condition or drug. This definition has recently received criticism and recommendations for changes encompass the inclusion of duration, intensity, and frequency, and the elimination of distress as a diagnostic criterion. More recently, it has been suggested that arousal and desire be combined into one disorder for the upcoming DSM-V. Causes of low desire include chronic medical conditions, medications, surgeries, and psychosocial factors, but not necessarily increased age; both pre- and postmenopausal women can have HSDD, although the frequency appears to vary by age. Sexual function requires the complex interaction of multiple neurotransmitters and hormones, both centrally and peripherally, and sexual desire is considered the result of a complex balance between inhibitory and excitatory pathways in the brain. For example, dopamine, estrogen, progesterone, and testosterone play an excitatory role, whereas serotonin and prolactin are inhibitory. Thus, decreased sexual desire could be due to a reduced level of excitatory activity, an increased level of inhibitory activity, or both. A number of validated self-report and clinician-administered instruments are available for assessing female sexual function; however, most have been used primarily in clinical research trials. The Decreased Sexual Desire Screener (DSDS) was developed for practicing clinicians who are neither trained nor specialized in FSD to assist in making an accurate diagnosis of generalized acquired HSDD. As our understanding of the pathophysiology of HSDD increases, it may become easier for physicians to identify and treat women with low sexual desire.