What are the treatment options for a 60-year-old female with hypoactive sexual desire disorder (low libido)?

Treatment Options for Low Libido in a 60-Year-Old Female

A multidimensional treatment approach including psychosexual counseling, lifestyle modifications, and pharmacological interventions is recommended for a 60-year-old female with hypoactive sexual desire disorder (HSDD). 1

Initial Assessment

• Conduct thorough evaluation for underlying causes:
  • Medical conditions affecting sexual function
  • Medications that may decrease libido (SSRIs, narcotics)
  • Psychosocial factors (relationship issues, stress, body image)
  • Hormonal status (postmenopausal changes)
  • Use validated tools like Female Sexual Function Index (FSFI) 1

First-Line Treatments

Non-Pharmacological Approaches

1. Psychosexual counseling/therapy

   • Cognitive behavioral therapy has shown effectiveness for improving sexual function 1
   • Individual or couples-based interventions depending on patient preference
   • Focus on addressing relationship issues, body image concerns, and stress factors

2. Lifestyle modifications

   • Increased physical activity
   • Stress reduction techniques (yoga, meditation)
   • Smoking cessation and limiting alcohol consumption 1

3. Vaginal moisturizers and lubricants

   • For addressing vaginal dryness and discomfort
   • Options include Replens, Sylk, and other over-the-counter products 1

Pharmacological Options

Hormonal Treatments

1. Vaginal estrogen therapy

   • Effective for vaginal dryness, itching, and painful intercourse
   • Available as creams, rings, or tablets 1
   • Monitor for adverse effects, especially with history of hormone-sensitive cancers

2. Testosterone therapy

   • Has shown efficacy for loss of desire in postmenopausal women
   • Not FDA-approved for women but may be used off-label
   • Limited long-term safety data available 1, 2
   • Monitor for androgenic side effects (acne, hirsutism, voice changes)

Non-Hormonal Medications

1. Flibanserin

   • FDA-approved for premenopausal women with acquired, generalized HSDD
   • Limited evidence in postmenopausal women
   • Side effects include dizziness, somnolence, nausea, and fatigue 3, 1

2. Bupropion

   • Antidepressant shown to improve desire in some women
   • Can be used off-label for HSDD 2
   • May be particularly helpful if depression is a contributing factor

3. Buspirone

   • May be considered for HSDD 1
   • Can help with anxiety that may contribute to sexual dysfunction

Additional Considerations

• Pelvic floor physical therapy

  • Particularly helpful if pain or pelvic floor dysfunction is present 1

• DHEA (prasterone)

  • FDA-approved for vaginal dryness/pain
  • May help with overall sexual function 1

• Ospemifene

  • Selective estrogen receptor modulator
  • For dyspareunia in women without hormone-sensitive cancer history 1

Treatment Algorithm

1. Start with non-pharmacological approaches (counseling, lifestyle modifications)
2. Address any vaginal symptoms with moisturizers/lubricants
3. Consider hormonal therapy if no contraindications:
   • Vaginal estrogen for local symptoms
   • Testosterone (off-label) for desire issues
4. If insufficient response, consider non-hormonal medications:
   • Bupropion if depression is present
   • Buspirone if anxiety is a factor
   • Flibanserin (with awareness of limitations in postmenopausal women)

Important Cautions

• PDE5 inhibitors (sildenafil) are not recommended for female sexual dysfunction due to contradictory results in clinical trials 3, 1
• Review all current medications that may impact sexual desire
• For women with history of hormone-sensitive cancers, carefully evaluate risk/benefit of hormonal treatments 1
• Regular follow-up is essential to monitor treatment efficacy and side effects

Low libido in older women should not be automatically attributed to "normal" aging or menopause, as many contributing factors are addressable with appropriate intervention 4.