Sildenafil for Female Anorgasmia
Sildenafil is not recommended for female anorgasmia due to lack of evidence supporting its effectiveness in women with sexual dysfunction. The NCCN guidelines explicitly state that oral phosphodiesterase type 5 inhibitors (PDE5i) should not be used for female sexual dysfunction because randomized clinical trials have shown contradictory results 1.
Why This Recommendation
The guideline evidence is clear and consistent: while sildenafil theoretically increases pelvic blood flow to the clitoris and vagina, clinical trials in women with sexual arousal disorder have produced conflicting and ultimately negative results 1. This is the authoritative position from NCCN (2014), which represents expert consensus based on available trial data.
What the Research Shows
The research evidence presents a mixed picture, but ultimately supports the guideline recommendation:
Negative findings: A 1999 study of 33 postmenopausal women found that only 18% had significant therapeutic response, with overall sexual function not improving significantly 2. A 2003 study showed efficacy only in the highly selected subgroup of women with FSAD without concomitant hypoactive sexual desire disorder 3.
Limited positive findings: Small studies showed some improvements in specific populations (postmenopausal women with orgasmic dysfunction 4, antidepressant-induced dysfunction 5, and healthy volunteers 6), but these were either open-label, very small sample sizes, or studied asymptomatic women—none of which provide strong evidence for clinical use.
A 2016 meta-analysis acknowledged that while some studies showed improvements, the evidence was inconsistent and most data could not be pooled due to methodological differences 7.
Important Safety Considerations
The FDA labeling for Viagra makes no mention of female sexual dysfunction as an indication 8. This is an off-label use. Adverse events in women include:
- Headache, flushing, rhinitis (most common)
- Clitoral discomfort and hypersensitivity (21% in one study) 2
- Visual changes
- Dizziness and nausea
What to Do Instead
For female anorgasmia, evidence-based alternatives include:
- Pelvic floor muscle training: May improve orgasm, arousal, and satisfaction 1
- Psychotherapy/cognitive behavioral therapy: Has some evidence of efficacy, particularly for cancer survivors 1
- Sexual/couples counseling: Recommended with ongoing partner communication 1
- Address underlying causes: Evaluate for relationship issues, emotional factors, history of abuse, hormonal deficiencies, or medication side effects (particularly antidepressants)
Clinical Pitfall
Do not prescribe sildenafil simply because it works in men or because of theoretical mechanisms. The female sexual response is more complex than vascular engorgement alone, and desire disorders (which commonly coexist with anorgasmia) do not respond to PDE5 inhibitors 3. Women with significant emotional, relationship, or abuse-related contributions to sexual dysfunction are particularly unlikely to benefit.