What are the indications for sildenafil (Viagra) in females?

From the Guidelines

Sildenafil is not recommended for female sexual dysfunction due to the lack of data regarding its effectiveness in women. The current evidence base for interventions to treat female sexual dysfunction in survivors is weak, and high-quality studies are needed 1. According to the most recent guidelines, the panel does not recommend the use of oral phosphodiesterase type 5 inhibitors (PDE5i) for female sexual dysfunction due to the lack of data regarding their effectiveness in women 1.

Indications and Usage

Some potential off-label uses of sildenafil in females may include:

• Pulmonary arterial hypertension (PAH), where it's typically dosed at 20 mg three times daily
• Female sexual arousal disorder (FSAD), although evidence for efficacy is mixed compared to its well-established benefits in men

Mechanism of Action and Side Effects

For PAH, sildenafil works by relaxing pulmonary blood vessels, reducing pulmonary vascular resistance and improving exercise capacity. For FSAD, it may increase genital blood flow and enhance sexual response. Patients should be aware of potential side effects including headache, flushing, nasal congestion, and visual disturbances. Sildenafil is contraindicated with nitrate medications due to risk of severe hypotension. Women with cardiovascular disease, retinitis pigmentosa, or severe hepatic impairment should use sildenafil cautiously or avoid it altogether.

Alternative Treatments

Alternative treatments for female sexual dysfunction include:

• Water-, oil-, or silicone-based lubricants and moisturizers to alleviate symptoms such as vaginal dryness and sexual pain 1
• Pelvic floor muscle training to improve sexual pain, arousal, lubrication, orgasm, and satisfaction 1
• Vaginal estrogen (pills, rings, or creams) to treat vaginal dryness, itching, discomfort, and painful intercourse in postmenopausal women 1
• Psychotherapy, such as cognitive behavior therapy, to address sexual dysfunction 1
• Ospemifene for dyspareunia in survivors of cancers that are not hormonally sensitive 1
• Flibanserin for acquired, generalized hypoactive sexual desire disorder in premenopausal women 1

From the Research

Indications for Sildenafil in Females

• Sildenafil citrate has been evaluated for the treatment of female sexual arousal disorder (FSAD) in several studies 2, 3, 4, 5, 6.
• The studies suggest that sildenafil may be effective in improving subjective and physiologic parameters of the female sexual response in women with FSAD 3, 4.
• A double-blind, placebo-controlled study found significant improvements in genital sensation and satisfaction with intercourse in postmenopausal women with FSAD treated with sildenafil 4.
• Sildenafil may also be effective in women with FSAD secondary to multiple sclerosis, diabetes, or antidepressant use, but more trials are needed to confirm these findings 5, 6.
• The efficacy of sildenafil for the treatment of female sexual dysfunction (FSD) has been assessed in several clinical trials, with some studies showing a possible benefit and others showing no significant differences with treatment 6.

Patient Populations

• Sildenafil has been studied in premenopausal and postmenopausal women with FSD, as well as in women with FSD due to concomitant medications and/or disease states 6.
• Postmenopausal women with FSAD without concomitant hypoactive sexual desire disorder (HSDD) may benefit from treatment with sildenafil 4.
• Women with FSAD secondary to multiple sclerosis, diabetes, or antidepressant use may also benefit from treatment with sildenafil, but more research is needed to confirm these findings 5, 6.

Safety and Efficacy

• Sildenafil has been shown to be well-tolerated in women with FSAD, with most adverse events being mild to moderate 2, 4.
• The most common adverse events reported with sildenafil use in women include headache, flushing, rhinitis, nausea, and visual symptoms 2, 4.
• The efficacy and safety of sildenafil for the treatment of FSD should be interpreted cautiously due to the limitations of the available studies, including small sample sizes and nonvalidated assessment tools 6.