What are the treatment options for women with hypoactive sexual desire disorder (HSDD)?

Treatment Options for Women with Hypoactive Sexual Desire Disorder (HSDD)

Psychosocial and psychosexual counseling should be offered as first-line treatment for women with HSDD, with pharmacologic options like flibanserin considered for premenopausal women when counseling alone is insufficient. 1

Diagnostic Evaluation

A thorough evaluation is essential before initiating treatment:

• Screen for underlying medical conditions, medications, and psychosocial factors contributing to low desire
• Assess for anxiety, depression, relationship issues, body image concerns, and stress factors 2
• Review prescription medications that may affect sexual function (especially hormone therapy, narcotics, and serotonin reuptake inhibitors) 1
• Evaluate traditional risk factors: cardiovascular disease, diabetes, obesity, smoking, alcohol use 1
• Consider using validated assessment tools like the Female Sexual Function Index 1

Treatment Algorithm for HSDD

First-Line Treatments:

1. Psychosocial/Psychosexual Counseling

   • Evidence supports both individual and couples-based interventions 1
   • No specific type of psychosexual counseling has proven superior to others 1
   • Cognitive behavioral therapy has shown efficacy in improving sexual desire 3
   • Mindfulness-based approaches and psychoeducation have excellent evidence supporting their use 3

2. Address Contributing Factors

   • Modify lifestyle factors: physical exercise, stress reduction
   • Treat underlying medical conditions
   • Review and adjust medications that may impact sexual desire
   • Consider pelvic floor physical therapy if there are concurrent pain issues 1

Second-Line Treatments:

1. Pharmacologic Options for Premenopausal Women:

   • Flibanserin (FDA-approved for premenopausal women with acquired, generalized HSDD)
     • Indicated when low sexual desire causes marked distress or interpersonal difficulty 4
     • Not for use when HSDD is due to medical/psychiatric conditions, relationship problems, or medication effects 4
     • Side effects include dizziness, somnolence, nausea, and fatigue 1
     • Risk/benefit ratio remains uncertain, especially in women with cancer history 1

2. Off-label Options to Consider:

   • Bupropion has shown some efficacy for improving desire in women with and without depression 5
   • Buspirone may be considered for hypoactive sexual desire disorder 1

Special Considerations for Postmenopausal Women:

• Flibanserin is not indicated for postmenopausal women 4
• For concurrent vaginal symptoms:
  • Vaginal moisturizers and lubricants for vaginal dryness and pain 1
  • Ospemifene for dyspareunia in women without hormone-sensitive cancer history 1
  • Topical vaginal therapies (gels, oils, topical vitamin D or E) 1

Important Caveats

• Partner involvement should always be the choice of the patient 1
• Regular stimulation (including masturbation) may benefit sexual response regardless of the type of stimulation used 1
• PDE5 inhibitors are not recommended for female sexual dysfunction due to contradictory results in clinical trials 1
• For women with cancer history, special consideration must be given to hormone-based treatments, which may be contraindicated 1
• The etiology of HSDD is complex and often multifactorial, requiring attention to biological, psychological, and social elements 5, 6

Monitoring and Follow-up

• Reassess sexual function at regular intervals
• Adjust treatment based on response and side effects
• Consider referral to sexual health specialists for refractory cases

By following this structured approach to HSDD treatment, clinicians can significantly improve sexual function and quality of life for women experiencing distressing low sexual desire.