Recognising HSDD in a ten-minute consultation

Why it doesn't get diagnosed

A systematic review of UK qualitative studies found that most healthcare professionals do not proactively discuss sexual issues; the barriers named were time, training and the fear of "opening a can of worms" (Dyer & das Nair, 2013). Patients, meanwhile, are markedly more likely to seek help if a doctor has asked about sexual function at a routine visit in the previous three years (Hinchliff & Gott, 2011). The condition is common — around one in ten adult women — and the conversation is rarer than the condition.

The condition, defined

Hypoactive sexual desire disorder (HSDD) is the persistent or recurrent deficiency or absence of sexual thoughts, fantasies and desire for sexual activity, causing marked personal distress or interpersonal difficulty, and not better accounted for by another psychiatric disorder, a substance or medication, a medical condition, or the circumstances of the relationship. DSM-5 folded desire and arousal together as Female Sexual Interest/Arousal Disorder with a six-month duration criterion; ICD-11 retains hypoactive sexual desire dysfunction as its own entity. In practice the ISSWSH process of care (Clayton et al., 2018) uses the HSDD construct, and it is the one most clinicians find usable.

Two qualifiers change everything:

• Generalised vs situational. Generalised: absent across partners, contexts and solo activity. Situational: present with one partner or context and not another — usually a relationship or contextual problem, not a desire disorder.
• Acquired vs lifelong. Acquired: she used to want sex and now doesn't. Lifelong: she never did. The pathway on this site is for generalised, acquired HSDD.

Distress is the hinge

Low desire without distress is not a disorder — it is a fact about a person. The diagnosis lives in the gap between what she wants to feel and what she does feel. Ask about it directly: "Does this bother you?" If it bothers her partner but not her, the referral is to couples work, not to us.

Two questions that open it

1. "Many women notice a change in their sex drive at some point — has that happened to you?"
2. "Is that something you'd want help with?"

Normalise, then offer. Neither question commits you to managing it.

What looks like HSDD and isn't

• Pain on penetration (genitourinary syndrome of menopause, vulvodynia, vaginismus) — nobody wants what hurts. Treat the pain first.
• A new or recent SSRI/SNRI, combined hormonal contraception, antipsychotic, opioid or beta-blocker — timing is the clue.
• Untreated depression or anxiety — loss of libido is a symptom of both.
• Hypothyroidism, hyperprolactinaemia, iron deficiency, poorly controlled diabetes.
• Relationship breakdown, recent bereavement, a new baby, exhaustion.
• Menopause transition and the years after — falling oestrogen and testosterone lower desire in a proportion of women; this is a cause to assess, not a diagnosis to stop at.

The next two pages give you the screener and the biopsychosocial checklist that separate these.

Reflective learning

1. When did you last ask a woman about sexual function unprompted? What made it easier or harder?
2. Which of the mimics above do you most often see, and what is your routine for excluding it?
3. What would it take to make the two opening questions routine in your menopause or contraception reviews?

References

• Clayton AH et al. The ISSWSH Process of Care for Management of HSDD in Women. Mayo Clin Proc 2018;93:467–87. doi:10.1016/j.mayocp.2017.11.002
• Dyer K, das Nair R. Why don't healthcare professionals talk about sex? J Sex Med 2013;10:2658–70. doi:10.1111/j.1743-6109.2012.02856.x
• Hinchliff S, Gott M. Seeking and receiving help for sexual problems: the role of the GP. J Sex Res 2011;48:106–17. doi:10.1080/00224499.2010.548610