What medications are recommended for treating sexual arousal disorder in women, specifically hypoactive sexual desire disorder?

Medication Options for Female Sexual Arousal Disorder

For women with hypoactive sexual desire disorder (HSDD), flibanserin is the first-line FDA-approved medication for premenopausal women, while bremelanotide is an alternative FDA-approved option that can be considered when flibanserin is not effective or tolerated. 1, 2

First-Line Pharmacological Options

For Premenopausal Women:

1. Flibanserin (Addyi)

   • FDA-approved specifically for acquired, generalized HSDD in premenopausal women
   • Dosage: 100 mg once daily at bedtime
   • Mechanism: Acts on serotonin receptors in the brain
   • Efficacy: Results in approximately 1 additional satisfying sexual event every 2 months 1
   • Key precautions:
     • Must be taken at bedtime to minimize risk of hypotension and syncope
     • Contraindicated with alcohol consumption (wait until following day after taking)
     • Contraindicated with moderate/strong CYP3A4 inhibitors 2

2. Bremelanotide (Vyleesi)

   • FDA-approved for premenopausal women with HSDD
   • Self-administered as needed via subcutaneous injection
   • Increases sexual desire and reduces distress related to low sexual desire 1

For Postmenopausal Women:

1. Vaginal Estrogen Therapy

   • Effective for vaginal dryness, itching, discomfort, and painful intercourse
   • Available as creams, rings, or tablets
   • Use with caution in women with history of hormone-sensitive cancers 1

2. Ospemifene (Osphena)

   • SERM approved for treating dyspareunia in postmenopausal women
   • Contraindicated in women with history of breast cancer or other estrogen-dependent cancers 1

3. DHEA/Prasterone (Intrarosa)

   • FDA-approved for vaginal dryness/pain
   • Improves sexual desire, arousal, pain, and overall sexual function 1
   • Use with caution in women on aromatase inhibitor therapy 1

Second-Line/Off-Label Options

1. Bupropion

   • Off-label use for HSDD
   • May be beneficial for women with low desire, particularly those with depression 1, 3

2. Buspirone

   • Off-label use for HSDD
   • Limited efficacy data but considered an option for women with low desire 1, 3

Ineffective/Not Recommended Options

Phosphodiesterase type 5 inhibitors (PDE5i) such as sildenafil are NOT recommended for female sexual dysfunction due to contradictory results in clinical trials and lack of data regarding their effectiveness 1.

Treatment Algorithm Based on Presentation

For Premenopausal Women with HSDD:

1. First-line: Flibanserin 100 mg daily at bedtime
2. Alternative: Bremelanotide as needed if flibanserin is ineffective or poorly tolerated
3. Off-label options: Consider bupropion or buspirone if FDA-approved medications are ineffective

For Postmenopausal Women with HSDD:

1. For vaginal symptoms: Start with vaginal estrogen therapy or DHEA/prasterone
2. For dyspareunia: Consider ospemifene (if no history of hormone-sensitive cancers)
3. For desire issues without vaginal symptoms: Consider off-label use of flibanserin (though not FDA-approved for postmenopausal women), bupropion, or buspirone

Important Clinical Considerations

• Screening: Use validated tools like the Female Sexual Function Index (FSFI) or Brief Sexual Symptom Checklist to properly diagnose HSDD 3
• Medication interactions: Be vigilant about drug interactions, particularly with flibanserin, which has numerous contraindications 2
• Monitoring: Regular follow-up is essential to assess efficacy and side effects
• Combination approach: Pharmacotherapy is often more effective when combined with psychosexual counseling 3

Common Pitfalls to Avoid

1. Ignoring underlying conditions: Rule out medical conditions (thyroid disorders, diabetes) and medications (SSRIs, antihypertensives) that can cause sexual dysfunction
2. Overlooking relationship factors: Sexual desire problems often have relational components that medication alone cannot address
3. Prescribing PDE5 inhibitors: Despite theoretical benefits, these medications have shown contradictory results in women and are not recommended 1
4. Using hormonal treatments without proper screening: In women with history of hormone-sensitive cancers, hormonal treatments require careful risk-benefit assessment

Remember that while pharmacological interventions can help manage HSDD, the observed effects of currently available medications are often modest in terms of clinical significance 4. Setting realistic expectations with patients is crucial for treatment satisfaction.