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Comment and Controversy

Physical treatment before sexual counseling

September 2002 · Vol. 14, No. 9
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When attempting to help a patient with arousal and/or orgasmic dysfunction, so well described in “Break the silence: discussing sexual dysfunction” [March], by Barbara Levy, MD, my first line of treatment typically involves physical and mechanical measures. For example, if cunnilingus and lubrication during foreplay don’t work, I usually suggest the use of a vibrator. Also, couples can refer to books and training films on sexual techniques. I recommend counseling only when all these practices fail.

With regard to libido, low doses of testosterone usually will help women in committed relationships. One caveat: Testosterone is not absorbed from the gastrointestinal tract. Therefore, I prefer to prescribe sublingual tablets. While there are no good studies with regard to the dosage, I recommend 1.5 to 2 mg to start.


Dr. Levy responds:

I appreciate Dr. Freistadt’s comments regarding arousal and orgasmic dysfunction. Physical and mechanical measures are often useful in enhancing physiological responsiveness. However, in my experience, there are often underlying issues within the relationship that will improve with counseling. It is important to pursue the biological, social, and psychological components of these complex issues in order to help our patients.

I have not had as much success with low-dose testosterone as Dr. Freistadt reports. Natural testosterone is not well absorbed orally, but methyltestosterone is. In addition to sublingual formations, testosterone may be compounded into a cream for transdermal use or an ointment for topical use on the vulva. I have found the genital application of testosterone particularly useful for women who complain of decreased libido associated with diminished genital sensitivity and lubrication. However, once again, I find that the greatest cause of decreased libido among women in committed relationships is an over-committed lifestyle and a lack of focus on sexuality and the relationship.

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