How can I address a lack of libido while on hormone replacement therapy (HRT)?

Addressing Low Libido While on Hormone Replacement Therapy

For women experiencing low libido while on HRT, adding testosterone therapy or FDA-approved medications like flibanserin or bremelanotide should be considered to restore sexual desire while maintaining the benefits of HRT for vaginal symptoms.

Understanding the Problem

Your situation is common among women on HRT. While your hormone therapy has successfully addressed vaginal dryness and pain during intercourse, you're experiencing hypoactive sexual desire disorder (HSDD) - characterized by low libido, lack of arousal, and inability to reach orgasm despite having resolved the physical discomfort.

Treatment Options for Low Libido

First-Line Options:

1. FDA-Approved Medications:

   • Flibanserin (Addyi):

     • Specifically approved for premenopausal women with HSDD 1
     • Take one tablet at bedtime 2
     • Results in approximately one additional satisfying sexual event every two months 1
     • Some evidence suggests it may be effective and safe for postmenopausal women as well 1
     • Important safety note: Cannot be taken with alcohol due to risk of severe low blood pressure and fainting 2

   • Bremelanotide:

     • FDA-approved for premenopausal women with low sexual desire 1
     • Shown to significantly increase sexual desire and reduce distress related to low desire 1
     • Administered as needed rather than daily

Second-Line Options:

1. Testosterone Therapy:

   • DHEA (prasterone):

     • Can be considered for vaginal dryness and low libido 1
     • Studies show significant improvements in sexual desire, arousal, and overall sexual function 1
     • Available in vaginal formulation
     • Use with caution if you're on aromatase inhibitors 1

   • Testosterone supplementation:

     • Not FDA-approved for women but often used off-label 3
     • Shown to improve components of FSD including sexual desire, arousal, pleasure, and overall satisfaction 3
     • Consider consulting with a specialist about appropriate dosing

2. Off-Label Medications:

   • Bupropion:

     • Antidepressant that may improve sexual desire 1
     • Can be considered despite limited safety and efficacy data 1

   • Buspirone:

     • Anti-anxiety medication that may help with HSDD 1
     • Limited data but considered an option by experts 1

What Not to Try

• PDE5 inhibitors (like Viagra): Not recommended for women due to contradictory results in clinical trials 1
• Vaginal laser therapy: Currently not recommended due to limited safety and effectiveness data 1

Important Considerations

1. Hormonal Balance:

   • Your current HRT regimen may need adjustment - sometimes the balance between estrogen and progesterone affects libido
   • Feminizing hormone therapy can decrease libido as a known side effect 1

2. Psychological Factors:

   • Sexual desire has both physical and psychological components
   • Consider whether stress, relationship issues, or other psychological factors may be contributing

3. Medical Evaluation:

   • Rule out other medical conditions that might affect libido (thyroid disorders, depression)
   • Review all medications for potential sexual side effects

Next Steps

1. Discuss with your healthcare provider about:

   • Adding flibanserin (if premenopausal) or considering it off-label (if postmenopausal)
   • Exploring testosterone supplementation options
   • Adjusting your current HRT formulation or dosage

2. Be honest with your partner about your experience - maintaining intimacy through open communication can help reduce stress while you work on addressing the physical aspects

3. Consider consulting with a sexual health specialist who can provide comprehensive evaluation and personalized recommendations

Remember that sexual health is an important component of overall quality of life, and effective treatments are available to address low libido while maintaining the benefits of your current HRT for vaginal symptoms.