Julia K. Warnock

Female hypoactive sexual desire disorder: epidemiology, diagnosis and treatment.

Female hypoactive sexual desire disorder (HSDD) may occur in up to one-third of adult women in the US. The essential feature of female HSDD is a deficiency or absence of sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty.The evaluation of female HSDD generally requires careful and thoughtful consideration of the patient and the multitude of factors that impact on the various components of adult female sexual desire. Several female reproductive life experiences may uniquely affect sexual desire. These events include menstrual cycles, hormonal contraceptives, postpartum states and lactation, oophorectomy and hysterectomy, and perimenopausal and postmenopausal states. Sexual dysfunctions in women have strong positive associations with low feelings of physical and emotional satisfaction and low feelings of happiness. Thus, female HSDD can greatly impact on quality of life.In this article, treatment options are discussed with special attention to significant reproductive life events that may impact on sexual desire in adult women. Depending on the particular phase of reproductive life that a woman is experiencing, different recommendations are made. Various options in the treatment of HSDD in women include lifestyle changes, treatment of coexisting medical or psychiatric disorders, switching or discontinuing medications that could impact on sexual desire, hormone therapy and marital therapy. Clinical trials are presently underway to assess medications that may potentially benefit female patients with HSDD.

Depressive symptoms associated with gonadotropin‐releasing hormone agonists

The gonadotropin‐releasing hormone (GnRH) agonists are a relatively new class of drugs that are potentially effective in treating disorders that are aggravated either by estrogen or testosterone. GnRH agonists are effective in the treatment of endometriosis, as well as other disorders, such as advanced prostrate cancer, precocious puberty and uterine leiomyomata. While the GnRH agonists reduce the extent of the endometrial lesions and the occurrence of pelvic pain associated with endometriosis, these agents are associated with physical and psychiatric side effects. The adverse effects of these agents are consistent with the physiological effects of ovarian suppression, such as vasomotor instability, vaginal dryness, and headaches. Preliminary results of a prospective, double‐blind placebo‐controlled study and an open label trial indicates that depressive mood symptoms increase in women treated with GnRH agonist therapy for endometriosis. Additional evidence suggest that sertraline effectively manages depressive mood symptoms associated with GnRH agonist therapy. The reason for the decline in mood on GnRH agonists is postulated to be associated with the decline in estrogen levels. Effective treatment strategies for depressive mood symptoms in women on GnRH agonists therapy may offer insight into the mechanisms of action of estrogen on mood. Depression and Anxiety 7:171–177, 1998.

Adverse Cutaneous Reactions to Antipsychotics

Antipsychotic agents are known to cause adverse cutaneous reactions in approximately 5% of the individuals for whom they are prescribed. The majority of adverse cutaneous events are benign and easily treated, and do not place the patient at a serious health risk. However, these adverse events may impact on compliance so discussing strategies with the patient to avoid potential adverse cutaneous effects will improve compliance. The most frequently reported cutaneous adverse effects of antipsychotic medications include: exanthematous eruptions, skin pigmentation changes, photosensitivity, urticaria and pruritus. Only a small percentage of adverse cutaneous reactions are life threatening. The most important step in minimizing morbidity is prompt recognition of severe drug reactions with withdrawal of the causative medication. If a skin eruption occurs in an outpatient setting, it is generally advisable to discontinue the drug and to consider switching to another class of agent. If the reaction is mild, and the therapeutic benefits far exceed the risks of the symptomatic treatment, then the antipsychotic agent may be continued.

Adverse cutaneous reactions to mood stabilizers.

Of all the psychotropic medications currently available, the mood-stabilizing agents have the highest incidence of severe and life-threatening adverse cutaneous drug reactions (ACDRs).An exanthematous eruption in a patient treated with a mood-stabilizing agent should be viewed as possibly being the initial symptom of a severe and life-threatening ACDR, such as a hypersensitivity reaction, Stevens- Johnson syndrome, or toxic epidermal necrolysis. The combination of mood-stabilizing agents may increase the risk of such reactions. The mood-stabilizing agents addressed in this article are carbamazepine, lithium carbonate, valproic acid, topiramate, lamotrigine, gabapentin, and oxcarbazepine.Prior to the initiation of a mood stabilizer, the potential benefits, risks, and adverse effects should be communicated to the patient. If possible, slow dose escalation should be attempted by the physician. Patients should also be advised to seek medical attention if they suspect a drug-induced skin reaction. If the physician suspects a severe ACDR, the offending agent should be removed immediately.

Adverse cutaneous reactions to antidepressants

Antidepressants are among the most widely prescribed medications in the United States. Adverse cutaneous drug reactions (ACDRs) associated with drugs are common, with possibly higher rates associated with psychotropic medications. While the vast majority of ACDRs are benign and easily treated, serious and life-threatening ACDRs, such as those associated with antidepressants, do rarely occur. ACDRs to antidepressants are diagnosed primarily on the basis of the patient’s history. A clinician who is aware of these common and potentially serious adverse events will help avoid their continuation or recurrence. There are certain characteristics that place an individual at higher risk for an ACDR such as female gender, increasing age, African- American ethnicity, use of multiple medications and presence of a serious illness.If a cutaneous reaction occurs in an outpatient setting, it is advisable to discontinue the offending antidepressant and substitute it with one from another class. Treatment of the ACDR should be symptomatic if the patient shows no other significant signs of reaction. If other signs are present, however, a dermatology consultation should be obtained. Since the diagnosis of ACDRs is often tentative, and the exanthema is likely to be benign, the physician treating a patient with a mood or anxiety disorder must weigh the risk of developing these potential problems against the possibility of relapse of the psychiatric disorder should the medication be discontinued.

Chronic episodic disorders in women

Chronic episodic disorders, such as depressive disorders, IBS, migraine, and FMS, have important commonalities, including cormorbidities, an absence of classic anatomic pathology in the tissues, a lack of objective findings on physical examination, and a lack of abnormal findings by routine laboratory and radiologic tests. These CED are more prevalent in women (perhaps due to changes in estrogen levels), are generally worsened by stress (with resultant hyperactivity of the HPA axis), and often improve with aerobic exercise and common classes of medications affecting serotonin function, such as antidepressants. Thus, an increased understanding of the CED may result in improved treatment and functioning of many patients.

Depressive mood symptoms associated with ovarian suppression

OBJECTIVE To determine if sertraline is helpful in the management of depressive symptoms associated with ovarian suppression during GnRH agonist therapy as compared with a placebo-controlled group. DESIGN Double-blind placebo-controlled prospective study design. SETTING An obstetrics/gynecological office specializing in infertility in an academic environment. PATIENT(S) Premenstrual women with laparoscopically diagnosed endometriosis who required GnRH agonist therapy for treatment and did not have significant depressive or premenstrual mood symptoms at baseline. INTERVENTION(S) Participants were randomly assigned to either the sertraline treatment group or to the placebo group for the 3-month duration of the GnRH agonist therapy. MAIN OUTCOME MEASURE(S) The 21-item Hamilton Rating Scale for Depression (HRSD), which is an instrument designed to assess depressive symptomatology. RESULT(S) A Hotellings T(2) test for repeated measure analysis indicated a statistically significant (P<.05) between-group difference across time for the HRSD (T(2) = 13.3; F[3, 28] = 4.1; P=.02) with the sertraline treatment group manifesting significantly fewer depressive symptoms than the control group. CONCLUSION(S) The results indicate that sertraline is an effective option in the management of depressive mood symptoms associated with ovarian suppression during GnRH agonist therapy.

Psychiatric medications: Adverse cutaneous drug reactions

Psychiatric medications are among the most widely prescribed medications in the United States. Adverse cutaneous drug reactions are associated with psychiatric medications in approximately 2% to 5% of the individuals for whom they are prescribed. Although most adverse cutaneous drug reactions associated with psychotropic medications are benign and easily treated, some can be disfiguring or life-threatening, particularly those associated with the mood stabilizers. Adverse cutaneous drug reactions associated with antidepressants, antipsychotics, and mood stabilizers are reviewed, and important issues that are of concern for the dermatologist who must consider when and how to safely discontinue a psychotropic medication in their patients are presented.

Female hypoactive sexual disorder: Case studies of physiologic androgen replacement

Menopause, surgical or naturally occurring, with reduced or deficient ovarian functioning has a major impact on morbidity and mortality in mid- to late life. A growing body of literature notes the role of androgens in maintaining womens health and emotional well-being. The administration of physiologic levels of testosterone replacement therapy as an adjunct to estrogen replacement requires further investigation. The Sexual Energy Scale was used to measure the patients subjective experience of vitality or sexual energy with androgen replacement therapy. Three cases of women who had undergone a total abdominal hysterectomy with bilateral oophorectomy with complaints consistent with female hypoactive sexual desire disorder and free testosterone levels of < 2.0 pg/ml are presented. Physiologic androgen replacement is helpful in increasing sexual desire for some women.

Self-Injurious Behavior in Elderly Patients With Dementia: Four Case Reports

Self-injurious behavior (SIB) is a polymorphous and poorly understood phenomenon, probably representing the final common pathway arising from a variety of etiologies. SIB is a clinical problem that affects elderly patients, but has received little attention. Although the specific prevalence rates of SIB in elderly patients with dementia is unknown, the lack of data is striking, considering the frequency with which geriatric psychiatrists may be consulted for these and related behavioral problems. The authors present four cases of elderly patients with SIB and dementia who responded favorably to psychopharmacologic treatment.