Cindy Eckert first learned about hypoactive sexual desire disorder (HSDD)—the most common type of sexual dysfunction in women—while attending a conference as a cofounder of Slate Pharmaceuticals, a male-hormone company. (At the time, Slate’s main drug was a testosterone treatment.)
During a presentation, scientists showed brain scan images comparing how women with normal desire and women with HSDD reacted to erotic materials. The condition is described by the American Sexual Health Association as “the absence of sexual fantasies and thoughts, and/or desire for or receptivity to, sexual activity that causes the person distress or difficulties.” Cindy compares HSDD to a light switch in the brain that can essentially shut off libido.
The proof was in the pictures: Women with the condition had very little to no activation in the pleasure centers of the brain compared to women with normal desire. “Here it was in black-and-white, but everyone sat there looking at their phones,” Cindy says. She glanced around at the group and wondered, Well, who’s doing something about this? As the old adage goes, if you want something done right—or, in the case of women’s sexual health, at all—you gotta do it yourself.
A self-proclaimed science nerd, Cindy was drawn to the field of sexual health because it was a relatively new concept, ripe for discovery. Despite the “taboo” nature of her work, she loved that the findings made a real difference in people’s lives. “From the moment I stepped into the male sexual health space, my fascination was: This matters in someone’s overall life experience,” she says. “Sex is an integral part of the human experience, and when you can improve that for somebody, it’s the highest reward.” But seeing those images at the conference—and realizing that no one else seemed to care—spurred Cindy to ask the “obvious,” she says: How can we have as many as 26 FDA-approved medications for men to lead a more satisfying sex life and not a single one for women? “I knew, based on the data, more women than men actually struggle” with sexual dysfunction.
About half of women—40 to 50 percent—will, at some point in their life, suffer from at least one of the four main types of sexual dysfunction: desire disorders, arousal disorders, orgasm disorders, and pain disorders. The most prevalent is HSDD, affecting about 10 percent of women, predominantly those age 45 and older. In fact, nearly 42 percent of women report a drop in sexual desire during perimenopause. Meanwhile, erectile dysfunction—the main type of sexual dysfunction in men—affects up to 14 percent of men under age 40, increasing to about 52 percent between ages 40 and 70.
For Cindy, the issue was also personal. She’d struggled with symptoms of HSDD, as well as with the (lack of) treatment options. “Here I was, running a company for men to lead more satisfying sex lives and missing out on having one of my own,” she says. “I wanted that part of myself back, but I was dismissed when I brought up the concern to my ob-gyn.” She was told it was a psychological problem and the solution was to light candles, practice mindfulness—just relax. HSDD took a toll on her relationship, which ended, and on her self-confidence as well. “I’d accepted that dim reality,” she says. But when she saw the numbers and the science on that screen, “lightning struck.”
Cindy spent the next year working with the “best sexual medicine doctors in the world” and listening to female patients share their experiences. “They came from all walks of life, but every person’s story at some point was exactly the same,” she recalls. “I thought, That’s me. I’m them. This is the same struggle.” Despite being in happy relationships, these women had little to no sexual desire. When they were intimate with their partners, it often took the form of “mercy sex,” because they loved their partner and wanted them to feel pleasure, even though the women weren’t experiencing any themselves. The worst part: They didn’t know why they felt this way—and all of the so-called solutions (date nights, relaxing bubble baths, etc.) didn’t work.
Those real-talk conversations were Cindy’s secret fuel as she sold Slate Pharmaceuticals, founded Sprout Pharmaceuticals, and began the grueling six-year FDA approval process for Addyi, the first medication designed to treat HSDD in premenopausal women. She was determined that she and all those other women would be taken seriously for what they knew was happening to them biologically—not psychologically.
HSDD is believed to be caused by a chemical imbalance in the brain (not unlike anxiety and depression), and flibanserin—the active ingredient in Addyi—impacts mood. “That’s how it was first discovered: It was a mood drug that had an interesting side effect in that it made you think about sex,” Cindy says. The way that flibanserin works in the brain is not fully understood, but it’s believed to interact with serotonin receptors, increasing the release of dopamine and norepinephrine, both of which play a role in sexual response and behavior. “I am a firm believer that women’s biggest sex organ is here,” she says, pointing to her temple.
Many antidepressants and antianxiety medications, such as Lexapro, Zoloft, and Prozac, are selective serotonin reuptake inhibitors (SSRIs), which primarily work by increasing serotonin but can also have an indirect effect on dopamine. That one-two punch is known to decrease sex drive (one of the common side effects of SSRIs), so the theory goes that because flibanserin appears to act on those neurotransmitters in the opposite way, it would have the opposite effect.
As Cindy and her team began developing Addyi, which she dubbed “the little pink pill,” the hyperfeminine hue also became her armor. Challenging the status quo was not easy, even with a track record. “I’d built a successful company in men’s [sexual] health, yet everyone would pat me on the shoulder and almost in a singsong voice say, ‘Oh, the little pink pill, that’s cute,’” she says. “It was so obvious what was embedded in that—making it trivial, the perceived weakness of femininity.”
Her “unapologetically pink” outlook began to form, almost turning into a battle cry. She started wearing pink every day, and the shade became brighter and bolder with each subsequent FDA hearing for Addyi. She didn’t care if they didn’t take her seriously at first. She would no longer be ignored.
Now, when she wears pink, she feels as if she’s “suiting up to go on mission.” That mission? To empower women. “It’s you getting to live your life on your own terms with complete agency over your pleasure,” Cindy says.
That proud pink stance wasn’t her natural inclination. Like many women, Cindy had “absolutely no sex education” growing up, she says. Her father worked for the State Department, and she moved so much that she was in a different school every year from fourth grade through high school. “No chance I was getting clear messaging on sex,” she says, other than the societal narrative that “pleasure is a man’s to receive and a woman’s to deliver.”
She sees firsthand the lasting effects of this notion. Whenever she meets someone new—say, at a cocktail party—and they ask what she does, she watches their reaction carefully as she explains her work with Addyi. “If it’s a male-female couple, the woman kind of shuts down, like, ‘Oh yeah, okay, I don’t need that,’ and the man leans forward and goes, ‘Can I take it?’” she says. “You see societal conditioning in a snapshot: The woman’s like, ‘I’m not supposed to talk about this,’ and the man’s like, ‘I am entitled to this.’” That might explain why, although Addyi received FDA approval and came on the market in 2015, you haven’t heard much about it. “It tells you how deeply embedded this is culturally—the daring to talk about women’s sexual pleasure.”
Addyi was immediately dubbed “the female Viagra,” and for better or worse (mostly for worse, per Cindy), the moniker stuck. “In a way, you think [the comparison] is amazing: This can be as transformative for women’s health as Viagra was for men’s. But it also sets up the wrong notion of how desire works for women,” Cindy says. “Sex, for women, is not the performative act. It’s about being in the headspace of feeling sexy, being interested, responding to your partner or to [other] cues. We’re brain flow, not blood flow.”
The comparison to Viagra also epitomizes the double standard that Cindy has spent a decade trying to dismantle. “The atrocity of women’s health is that we’re not taken seriously, and it shows up in so many ways,” she says. “First, it shows up in the regulatory queue, where there’s a double standard to get to an approval.” Viagra was “deemed to meet such an important unmet medical need” that the FDA fast-tracked the review process and approved it in less than six months. Despite having “three times as many patients’ worth of data” proving the efficacy of Addyi, Cindy says, it spent six years in the regulatory queue waiting for approval.
That double standard also shows up in advertising guidelines: Hypoactive sexual desire disorder contains the word sex (the horror!), whereas erectile dysfunction does not. “When we first put up ads, they were all taken down,” Cindy says. Even now, you’ll find Addyi commercials mostly on podcasts with a female-leaning audience, not on national TV, in clear contrast to the onslaught of ads for mail-order generic Viagra.
Cindy considers her pink clothes a battle suit of sorts, arming her to advocate.
Last but certainly not least, the double standard shows up in the medical establishment. Perimenopausal women are the largest demographic using Addyi—a patient group that has been, until recently, largely ignored, undermined, and misdiagnosed. (Right now, Addyi is FDA-approved only to treat premenopausal women, but Cindy just received word that it’s been “fast-tracked” for approval in postmenopausal women in the U.S., which is a promising sign.)
Whether officially diagnosed with HSDD or not, women in perimenopause tend to face the same struggles: mood imbalances, libido shifts, weight gain, and sleep disturbances. “Addyi works on every single one of those things,” Cindy says, adding that it does so without hormones. For women who can’t use vaginal estrogen or hormone replacement therapy for other medical reasons, Addyi can be a boon, but the comparison to Viagra has “almost allowed the medical community to not understand how Addyi works,” she says. “Sometimes I’ll sit in a room with physicians and say, ‘Tell me how it works.’ They don’t know that it’s brain chemistry.”
To be clear, progress has been made. Today, you can’t pass a board exam to be an ob-gyn or urologist without answering a question about Addyi. Still, Cindy dreams of the day when doctors ask about sexual satisfaction as a routine part of a woman’s annual checkup. The longer-term goal is changing what the medical establishment prioritizes, from the top down.
Cindy views the advocacy work she’s done with Addyi as part of a larger health care revolution. “Women are now like, ‘I’m gonna demand the care I deserve,’” she says. “The female population is challenging the medical establishment. It’s finally happening. Medicine’s following their lead, not the other way around.” At the front of that invigorated pack? Cindy, their pink-suited entrepreneurial leader, who’ll never stop talking about a woman’s right to understand that better sex and true desire are part of her overall wellness.
Lindsay Geller is the lifestyle director at Women’s Health, where she oversees the Sex & Love, Relationships, and Life sections and manages Women’s Health+ content. She has 10 years of experience covering sex, relationships, health, fitness, and general lifestyle topics for print and digital publications. She currently lives in New Jersey with her husband and loves going on runs around her local park with her rescue dog.
