Medications to Treat Female Sexual Dysfunction
For premenopausal women with hypoactive sexual desire disorder (HSDD), flibanserin or bremelanotide are FDA-approved first-line pharmacological options, while for postmenopausal women with vaginal dryness, vaginal estrogen is the most effective treatment. 1
Hypoactive Sexual Desire Disorder (HSDD) in Premenopausal Women
FDA-Approved Options
Flibanserin is FDA-approved for acquired, generalized HSDD in premenopausal women and results in approximately 1 additional satisfying sexual event every 2 months 1. While the benefit appears modest, meta-analyses consistently demonstrate efficacy above placebo. The medication has not been extensively studied in women with cancer or those on endocrine therapy, and the risk/benefit ratio remains uncertain in these populations 2. Side effects include dizziness, somnolence, nausea, and fatigue, and it requires daily administration 3.
Bremelanotide is another FDA-approved option for premenopausal HSDD, evaluated in two phase III randomized controlled trials 1. Participants experienced statistically significant increases in sexual desire and reductions in distress related to low desire compared to placebo. This medication has not been studied in cancer survivors but represents an appropriate alternative for women with HSDD 1.
Off-Label Pharmacological Options
Bupropion and buspirone can be considered off-label for HSDD despite limited safety and efficacy data 1. These have been studied in small trials in non-cancer populations and may be reasonable alternatives when FDA-approved options are not suitable 4.
Important caveat: Flibanserin shows some preliminary efficacy in postmenopausal women despite not being FDA-approved for this population 1.
Vaginal Dryness and Dyspareunia in Postmenopausal Women
First-Line Treatment
Vaginal estrogen (pills, rings, or creams) is the most effective treatment for vaginal dryness leading to sexual dysfunction and effectively treats itching, discomfort, and painful intercourse in postmenopausal women 1. A large cohort study of almost 50,000 breast cancer patients followed for up to 20 years showed no evidence of higher breast cancer-specific mortality with vaginal estrogen use 1. However, safety in estrogen-dependent cancers has not been firmly established 1.
Alternative Prescription Options
Vaginal DHEA (prasterone) is FDA-approved and can be considered for vaginal dryness or dyspareunia 1. Multiple studies demonstrate effectiveness in reducing dyspareunia in postmenopausal women, though a 2015 meta-analysis found uncertain evidence for vaginal dryness improvement. A randomized trial of 464 cancer survivors showed significant improvements in sexual desire, arousal, pain, and overall function, though plain moisturizer also improved symptoms 1. Critical warning: Use with caution in women receiving aromatase inhibitor therapy, as vaginal DHEA increases circulating androgens that may impact AI activity 1.
Ospemifene (a selective estrogen receptor modulator) effectively treats vaginal dryness and dyspareunia in large trials of postmenopausal women 1. A prospective study of 52 cervical cancer survivors showed improvements in vaginal health, sexual function, body image, and quality of life. This option is recommended for dyspareunia in survivors without a history of estrogen-dependent cancers 1.
Non-Prescription Options
Before escalating to prescription medications, vaginal moisturizers (used at least twice weekly) and lubricants should be trialed 5. While less effective than vaginal estrogen, they provide a nonhormonal approach. One study showed plain moisturizer improved symptoms in cancer survivors 1.
Additional Therapeutic Considerations
Pelvic floor physical therapy improves sexual pain, arousal, lubrication, orgasm, and satisfaction 1. A study of 34 gynecologic cancer survivors demonstrated significant improvements in sexual function 1.
Psychosocial counseling should be offered to women with sexual dysfunction, particularly when body image issues or relationship concerns are present 2. Evidence supports couples-based interventions when the woman is partnered 2.
Vaginal dilators are options for pain during sexual activity and vaginal stenosis from pelvic radiation, though evidence for effectiveness is limited 1.
What NOT to Use
Do not use oral phosphodiesterase type 5 inhibitors (PDE5i) for female sexual dysfunction due to limited effectiveness data and contradictory trial results 1.
Do not currently recommend vaginal laser therapy for vaginal dryness in postmenopausal women, as the FDA has not approved energy-based devices for menopausal symptoms and safety/effectiveness data in cancer populations are limited 1.
Clinical Algorithm
- Identify the primary complaint: Low desire vs. vaginal dryness/pain
- For HSDD in premenopausal women: Consider flibanserin or bremelanotide as first-line pharmacological options after addressing modifiable factors
- For vaginal dryness in postmenopausal women: Start with vaginal moisturizers/lubricants, then escalate to vaginal estrogen (most effective) or alternatives (DHEA, ospemifene) based on cancer history
- For all patients: Assess for pelvic floor dysfunction and offer physical therapy; consider psychosocial counseling, especially for relationship/body image issues
- Monitor treatment response and adjust accordingly