The International Society for the Study of Women's Sexual Health Process of Care for Management of Hypoactive Sexual Desire Disorder in Women Anita H.

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The International Society for the Study of Women's Sexual Health Process of Care for Management of Hypoactive Sexual Desire Disorder in Women Anita H. Clayton, MD, Irwin Goldstein, MD, Noel N. Kim, PhD, Stanley E. Althof, PhD, Stephanie S. Faubion, MD, Brooke M. Faught, WHNP-BC, Sharon J. Parish, MD, James A. Simon, MD, Linda Vignozzi, MD, Kristin Christiansen, MD, Susan R. Davis, MBBS, PhD, Murray A. Freedman, MD, Sheryl A. Kingsberg, PhD, Paraskevi-Sofia Kirana, PhD, Lisa Larkin, MD, Marita McCabe, PhD, Richard Sadovsky, MD Mayo Clinic Proceedings Volume 93, Issue 4, Pages 467-487 (April 2018) DOI: 10.1016/j.mayocp.2017.11.002 Copyright © 2017 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 1 The International Society for the Study of Women's Sexual Health (ISSWSH) process of care for hypoactive sexual desire disorder (HSDD) algorithm begins with asking or having permission to discuss sexual concerns and focuses specifically on women who have concerns with their low sexual desire/interest. Initiation of diagnosis starts with the Decreased Sexual Desire Screener or a sexual history. Women with other sexual dysfunctions or those with lifelong or situational low sexual desire/interest are not specifically addressed in this algorithm. Women with generalized acquired HSDD then undergo a focused medical assessment to identify potentially modifiable biopsychosocial factors. Therapeutic intervention begins with education/modification of recognized modifiable factors. Women whose HSDD persists are categorized by menopausal status, and appropriate therapeutic interventions are then followed/reassessed. CNS = central nervous system. *Women with lifelong low sexual desire/interest without distress/bother may characterize themselves as asexual and should not be considered for treatment. **Women in the late reproductive years. Mayo Clinic Proceedings 2018 93, 467-487DOI: (10.1016/j.mayocp.2017.11.002) Copyright © 2017 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 2 Decreased Sexual Desire Screener. From J Sex Med,32 with permission from Elsevier. Mayo Clinic Proceedings 2018 93, 467-487DOI: (10.1016/j.mayocp.2017.11.002) Copyright © 2017 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 3 Hypothetical impact of treatments for hypoactive sexual desire disorder (HSDD). Although the precise etiology of HSDD remains unknown, the activities of inhibitory brain neurotransmitters (opioids, serotonin, and endocannabinoids) are thought to be greater than the activities of excitatory brain neurotransmitters (dopamine, melanocortin, oxytocin, vasopressin, and norepinephrine) in the presence of sexual cues and stimuli. Although the initial molecular mechanisms may vary, sex therapy, central nervous system agents, or hormonal agents used in treating HSDD may ultimately cause similar underlying changes in brain function and structure within neural circuits that regulate sexual desire such that excitation systems can be activated to a greater extent than inhibitory systems in the presence of cues and stimuli. Mayo Clinic Proceedings 2018 93, 467-487DOI: (10.1016/j.mayocp.2017.11.002) Copyright © 2017 Mayo Foundation for Medical Education and Research Terms and Conditions