What are the treatment options for a female patient with hypoactive sexual desire disorder (low libido)?

Treatment Options for Hypoactive Sexual Desire Disorder in Women

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

Evaluation Process

A thorough evaluation is essential before initiating treatment:

1. Screen for underlying factors:

   • Medical conditions
   • Medications that affect sexual function (hormone therapy, narcotics, beta blockers, SSRIs)
   • Psychosocial factors (anxiety, depression, relationship issues, body image concerns)
   • Traditional risk factors (cardiovascular disease, diabetes, obesity, smoking, alcohol use) 2, 1

2. Assessment tools:

   • Consider validated tools like the Female Sexual Function Index (FSFI) 2, 1
   • Brief Sexual Symptom Checklist for Women
   • Arizona Sexual Experiences Scale (ASEX) 2

Treatment Algorithm

First-Line: Non-Pharmacological Approaches

1. Psychosexual counseling:

   • Individual or couples-based interventions 1
   • Cognitive behavioral therapy (CBT) - shown to improve sexual functioning in women 2

2. Lifestyle modifications:

   • Physical exercise
   • Stress reduction techniques
   • Regular sexual stimulation, including masturbation 1

3. Integrative therapies:

   • Yoga and meditation may help improve sexual function 2

For Concurrent Vaginal Symptoms

1. Non-hormonal options:

   • Vaginal moisturizers and lubricants (e.g., Replens, Sylk) 2, 1
   • Topical vitamin D or E 2, 1
   • Topical anesthetics for pain (e.g., lidocaine applied to vulvar vestibule before penetration) 2

2. Physical therapy options:

   • Pelvic floor muscle training - improves sexual pain, arousal, lubrication, orgasm, and satisfaction 2, 1
   • Vaginal dilators for pain during sexual activity 2

Pharmacological Options

1. For premenopausal women with HSDD:

   • Flibanserin - FDA-approved for premenopausal women with acquired, generalized HSDD 1, 3
     • Side effects: dizziness, somnolence, nausea, fatigue
     • Limitations: Not indicated for postmenopausal women or to enhance sexual performance 3

2. Off-label options:

   • Bupropion - antidepressant shown to improve desire in some women with and without depression 1, 4
   • Buspirone - may be considered for HSDD 1

3. Hormone therapy considerations:

   • DHEA (prasterone) - FDA-approved for vaginal dryness/pain; may help with sexual function 2
   • Testosterone therapy - has shown efficacy for loss of desire in postmenopausal women, but not FDA-approved and has limited long-term safety data 2, 4
   • Vaginal estrogen (pills, rings, creams) - for vaginal dryness, itching, discomfort, and painful intercourse in postmenopausal women 2
     • In women taking aromatase inhibitors, estriol-containing preparations may be preferable to estradiol 2

Special Considerations

1. For women with cancer history:

   • Risk/benefit ratio of hormonal treatments must be carefully evaluated 1
   • Following breast cancer, current guidelines recommend avoiding estrogen and tibolone 2
   • For severe menopausal symptoms, the decision to use estrogen should be made by a fully informed patient 2

2. Medication adjustments:

   • Consider stopping or switching SSRIs/SNRIs if they're contributing to sexual dysfunction 2
   • Review and adjust medications that may impact sexual desire 1

3. Not recommended:

   • PDE5 inhibitors (e.g., sildenafil) are not recommended for female sexual dysfunction due to contradictory results in clinical trials 2, 1

Treatment Pitfalls to Avoid

• Failing to address underlying psychological factors before initiating pharmacological treatment
• Not considering the impact of current medications on sexual function
• Overlooking the importance of partner involvement (when appropriate for the patient)
• Assuming that treatments effective for men will work for women
• Neglecting to follow up on treatment effectiveness and making necessary adjustments

By following this structured approach, clinicians can effectively address HSDD in women, improving quality of life and relationship satisfaction.