How do you treat low libido in a 60-year-old postmenopausal woman?

Treatment of Low Libido in a 60-Year-Old Postmenopausal Woman

For postmenopausal women with low libido, a multidimensional treatment plan addressing both hormonal and non-hormonal factors is recommended, with hormone therapy being the most effective intervention when not contraindicated.

Initial Assessment

• Evaluate for underlying causes:
  • Physiological factors (vaginal atrophy, hormonal changes)
  • Psychological factors (anxiety, depression, body image concerns)
  • Relationship factors (communication issues, partner's health)
  • Medication side effects (SSRIs, beta-blockers, hormone therapies)

Treatment Algorithm

Step 1: Address Vaginal Symptoms (if present)

1. First-line options:

   • Vaginal moisturizers and lubricants for daily comfort and sexual activity 1
   • Water-, oil-, or silicone-based lubricants for sexual activity 1

2. If inadequate response:

   • Low-dose vaginal estrogen (creams, rings, or tablets) for vaginal dryness and dyspareunia 1
   • Vaginal DHEA (prasterone) for vaginal atrophy 1, 2
   • Ospemifene (SERM) for dyspareunia (contraindicated with history of hormone-sensitive cancers) 1, 2

Step 2: Address Low Libido/Desire

1. Non-hormonal approaches:

   • Cognitive behavioral therapy (CBT) - shown to improve sexual functioning 1
   • Pelvic floor physical therapy - improves sexual pain, arousal, lubrication, and orgasm 1
   • Integrative therapies (yoga, meditation) - help alleviate anxiety affecting sexual function 1

2. Pharmacological options:

   • Consider medications such as bupropion or buspirone 1
   • Discuss testosterone therapy if testosterone levels are low (< 300 ng/dL) 2
   • For premenopausal women: flibanserin or bremelanotide (though not specifically studied in women aged 60) 1

Step 3: Address Pain with Sexual Activity

1. For dyspareunia:
   • Topical anesthetics (lidocaine) applied to vulvar vestibule before penetration 1
   • Vaginal dilators for vaginal stenosis or pain 1
   • Pelvic floor physical therapy 1

Special Considerations

• Hormone therapy caution: Systemic hormone therapy is contraindicated in women with history of hormone-sensitive cancers 1
• Partner involvement: Consider couples-based interventions when appropriate, though this should be the patient's choice 1
• Mechanical aids: Discussion of vibrators or clitoral stimulatory devices may be appropriate for orgasmic difficulties 1

Common Pitfalls to Avoid

1. Attributing low libido solely to age: Low libido should not be automatically attributed to "normal aging" 3

2. Overlooking partner factors: Partner's health issues (especially erectile dysfunction) can significantly impact a woman's sexual function 3

3. Ignoring psychological factors: Body image concerns, life stressors, and relationship issues often contribute to low libido 3

4. Medication oversight: Many medications can contribute to sexual dysfunction, including antidepressants, beta-blockers, and hormone therapies 1, 2

5. Inadequate follow-up: Regular assessment of symptom improvement is essential; discontinue treatments that don't show improvement after an adequate trial 2

Monitoring and Follow-up

• Re-evaluate sexual function at regular intervals using validated tools like the Female Sexual Function Index (FSFI) 1, 2
• Adjust treatment based on response and side effects
• Consider referral to specialists (gynecologic care, sexual health specialist) for persistent issues 1

By addressing the physiological, psychological, and relationship factors contributing to low libido in this 60-year-old postmenopausal woman, quality of life and sexual satisfaction can be significantly improved.