Pink Pill or Blue Pill?

Robyn MacQuarrie explains why she will continue to prescribe Viagra instead of Addyi to treat some women’s sexual dysfunction.


I am a physician who often sees women who complain that sex isn’t fun. There are many reasons why women complain of dissatisfaction with their sex lives, one of which is decreased libido, or hypoactive sexual desire disorder. For those women, when I have ruled out other causes, I sometimes prescribe Viagra. This is an off-label use of Viagra.

Recently, a new drug—Addyi, or “pink Viagra,”—has been approved by the United States Food and Drug Administration to treat hypoactive sexual desire disorder. This drug has not yet been approved in Canada, but even if it were, it wouldn’t result in a change of practice for me.

Sexual dysfunction is a term used to describe a large group of disorders and conditions, all of which impact a woman’s sexual satisfaction. These include: decreased libido, difficulty with arousal, inability to achieve orgasm, pain with intercourse, and pain following intercourse. These problems often occur in combination with one another, have various potential causes, and aren’t always the result of an organic medical problem. For years, treating female sexual dysfunction was difficult for health care providers, as we had little to offer. Now that a new drug exists with an indication for hypoactive sexual desire disorder, I worry that health care providers will treat all causes of sexual dysfunction with a magic pink pill. There is no ONE simple cause of sexual dysfunction, and likewise there is not one simple solution.

pink and blue flowerSetting aside the above concern that Addyi may be inappropriately used as a one-size-fits-all solution to sexual dysfunction, I would like to focus here on a case for which Addyi is clearly indicated. Consider, for example, a woman that presents complaining of decreased libido, despite being happy in her relationship, interested and attracted to her partner, having adequate lubrication, and absent any organic findings preventing satisfying sexual interactions. This woman does exist, and I have met her many times in my office. This is also a woman that, according to indications, should be treated with Addyi. What is a gynecologist to do?

Some would argue that hypoactive sexual desire disorder does not (or ought not) exist, and that women are being forced into feeling that they should be more sexually interested than they are. While this may be the case for some women, many others present as being personally dissatisfied with their own libido. They may be retired, kids grown and gone, not worried about pregnancy, and interested in sexuality far more than they have been in recent years, but are simply dissatisfied with their bodies’ response to sex. In my view, telling these women that their experience isn’t valid; that they are being coerced into believing they are suffering from a disorder that does not or should not exist is paternalistic. However, it does not follow that Addyi is the best solution for these women.

Addyi carries with it the possibility of dangerous side effects—including severe hypotension—that I do not think are outweighed by the modest improvement in satisfactory sexual events. Additionally, Addyi needs to be taken daily, and its side effects are further exacerbated by alcohol. Addyi lobbyists have claimed that Addyi levels the playing field by providing a treatment specifically for female sexual dysfunction just as Viagra did for men. But if we really were to level the playing field for women and men, we would provide women with a similar treatment to that offered to men, one that can be used at a desirable time and that doesn’t require daily administration.

When Viagra was first released, people began to turn to it as a solution to decreased libido in women. What likely prevented the same roaring success in treating women with Viagra to that in treating men is the complexity of the condition being treated. For the most part, erectile dysfunction is a “plumbing “problem. There is an identifiable organic problem.For women, sexual dysfunction is multifaceted. However, while there is limited evidence that Viagra works for women, in some scenarios it does. It allows them to control their sexuality, and only requires them to take a pill when they are interested in sexual activities. Anecdotally (and in a properly selected patient population), I have many patients who are very happy with its success. I meet with these couples, and generally it is the woman pushing for treatment.

So, we now have a new “pink Viagra” approved for hypoactive sexual disorder. Will I be using it? Not a chance. I will stick to my off-label “blue pill.”


Robyn MacQuarrie is a obstetrician/gynaecologist in Amherst, Nova Scotia and a PhD candidate in the Interdisciplinary PhD Program at Dalhousie University @robynmacquarrie

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