What are the treatment options for hypoactive sexual desire disorder (HSDD) in females with low libido?

Treatment Options for Hypoactive Sexual Desire Disorder (HSDD) in Females

FDA-approved medications such as flibanserin and bremelanotide are the first-line pharmacological treatments for premenopausal women with hypoactive sexual desire disorder, while off-label options including bupropion and buspirone may be considered for both pre- and postmenopausal women when FDA-approved treatments are ineffective or contraindicated. 1, 2

Diagnostic Criteria

• HSDD is characterized by low sexual desire causing marked distress or interpersonal difficulty
• Not due to coexisting medical/psychiatric conditions, relationship problems, or medication effects
• Assessment using validated tools like Female Sexual Function Index (FSFI) or Arizona Sexual Experiences Scale (ASEX)

Treatment Algorithm

First-line Treatments

Non-pharmacological Interventions

1. Lifestyle modifications

   • Regular physical exercise
   • Stress reduction techniques (yoga, meditation)
   • Addressing relationship issues through open communication

2. For vaginal dryness/dyspareunia

   • Vaginal moisturizers and lubricants (water-, oil-, or silicone-based)
   • Examples: Replens, Sylk 1, 2

3. Psychological interventions

   • Cognitive behavioral therapy
   • Sex therapy
   • Pelvic floor physical therapy (especially with concurrent pain issues)

Pharmacological Options

FDA-Approved Medications

1. Flibanserin (Addyi)

   • Approved for premenopausal women with acquired, generalized HSDD 3
   • Dosing: 100 mg daily at bedtime
   • Efficacy: Approximately 1 additional satisfying sexual event every 2 months 1
   • Side effects: Dizziness, somnolence, nausea, fatigue
   • Contraindication: Alcohol consumption (increased risk of hypotension/syncope)
   • Evidence suggests it may also be effective in postmenopausal women 4

2. Bremelanotide

   • Approved for premenopausal women with HSDD 1
   • Self-administered subcutaneously as needed
   • Increases sexual desire and reduces distress related to low sexual desire
   • Not studied in cancer survivors

For Vaginal Symptoms Contributing to HSDD

1. Prasterone (DHEA)

   • FDA-approved for vaginal dryness and pain
   • Shown to improve sexual desire, arousal, pain, and overall sexual function 1
   • Safe option for cancer survivors without hormone-sensitive cancers

2. Ospemifene

   • FDA-approved for moderate to severe dyspareunia in postmenopausal women
   • Contraindicated in women with history of breast cancer 1
   • Consider for dyspareunia in survivors of non-hormone-sensitive cancers

Off-label Pharmacological Options

1. Bupropion

   • May improve sexual function in women with and without depression 5, 6
   • Option for women with HSDD, including cancer survivors 1

2. Buspirone

   • Limited evidence but may be considered for HSDD 1, 6

3. Testosterone therapy

   • Demonstrated efficacy for loss of desire in postmenopausal women 5
   • Not FDA-approved for women
   • Limited long-term safety data
   • Safety concerns in women with history of hormone-sensitive cancers 1

Special Considerations

Cancer Survivors

• Carefully evaluate risk/benefit ratio of hormonal treatments
• Consider non-hormonal options first
• Avoid estrogen and tibolone in women with history of hormone-sensitive cancers 1
• Vaginal DHEA may be appropriate for some cancer survivors 1

Medication Review

• Consider stopping or switching medications that may contribute to sexual dysfunction
• SSRIs/SNRIs commonly impact sexual desire and function

Treatment Pitfalls to Avoid

1. Not addressing underlying causes: Always evaluate for medical conditions, medication effects, and relationship factors before initiating treatment
2. Inappropriate use of PDE5 inhibitors: Not recommended for female sexual dysfunction due to contradictory results in clinical trials 1, 2
3. Using estrogen without consideration of cancer risk: Vaginal estrogen requires careful risk assessment, especially in women with history of hormone-sensitive cancers
4. Neglecting psychological factors: HSDD often has multifactorial etiology requiring both psychological and pharmacological approaches 7
5. Using flibanserin with alcohol: Significantly increases risk of hypotension and syncope

By following this structured approach to HSDD treatment, clinicians can effectively address this common condition that significantly impacts women's quality of life and relationships.