What are the treatment options for low libido in women?

Treatment Options for Low Libido in Women

For women with low sexual desire causing distress, a multidimensional approach including both non-pharmacological and pharmacological interventions should be implemented, with FDA-approved medications like flibanserin and bremelanotide as first-line pharmacological treatments for premenopausal women with Hypoactive Sexual Desire Disorder (HSDD). 1

Diagnostic Evaluation

• Use validated screening tools to assess sexual dysfunction:

  • Female Sexual Function Index (FSFI)
  • Arizona Sexual Experiences Scale (ASEX) 1
  • Brief Sexual Symptom Checklist for women 2

• Evaluate for underlying causes:

  • Medical conditions affecting sexual function
  • Medication side effects (particularly SSRIs/SNRIs)
  • Relationship issues
  • Psychological factors (depression, anxiety, stress)
  • Hormonal changes 1

Treatment Algorithm

First-Line: Non-Pharmacological Interventions

1. Lifestyle Modifications:

   • Regular physical exercise
   • Stress reduction techniques (yoga, meditation)
   • Addressing relationship issues through communication 1, 3

2. Psychosexual Interventions:

   • Cognitive behavioral therapy (individual or couples-based)
   • Sex therapy 1

3. For Vaginal Symptoms:

   • Vaginal moisturizers and lubricants (water-, oil-, or silicone-based)
   • Pelvic floor physical therapy for concurrent pelvic floor dysfunction 1

Second-Line: Pharmacological Treatments

For Premenopausal Women with HSDD:

1. Flibanserin (Addyi):

   • FDA-approved for premenopausal women with acquired, generalized HSDD
   • Dosing: 100 mg daily at bedtime
   • Efficacy: Approximately 1 additional satisfying sexual event every 2 months 1, 4

2. Bremelanotide:

   • FDA-approved for premenopausal women with HSDD
   • Self-administered subcutaneously as needed
   • Increases sexual desire and reduces distress 1

For Postmenopausal Women:

1. Vaginal Estrogen (for vaginal symptoms):

   • Available as creams, rings, or tablets
   • Effective for treating vaginal dryness and painful intercourse
   • Requires monitoring, especially in women with history of hormone-sensitive cancers 1

2. Testosterone Therapy (off-label):

   • Has shown efficacy for loss of desire in postmenopausal women
   • Not FDA-approved for women
   • Limited long-term safety data available 1, 5

3. Other Options:

   • Prasterone (DHEA) - FDA-approved for vaginal dryness and pain
   • Ospemifene - for dyspareunia in women without hormone-sensitive cancer history 1, 6

Special Considerations

• Medication Review:

  • Consider stopping or switching medications that contribute to sexual dysfunction
  • Particularly important for SSRIs/SNRIs 1

• Partner Involvement:

  • Include partners in treatment discussions when appropriate
  • Address partner's sexual health issues that may impact the relationship 1

• Cancer Survivors:

  • Surgery, chemotherapy, and endocrine therapy can cause sexual dysfunction
  • Oophorectomy causes acute estrogen deprivation
  • Hysterectomy may change vaginal length and size
  • Endocrine therapy (tamoxifen, aromatase inhibitors) can cause vasomotor symptoms and decreased libido 2

Common Pitfalls and Caveats

1. Failure to address psychological factors:

   • Low libido is often multifactorial, requiring attention to both physical and psychological aspects 7

2. Inappropriate use of hormonal treatments:

   • Carefully evaluate risk/benefit ratio, especially in women with history of hormone-sensitive cancers 1

3. Focusing solely on medications:

   • Most effective approach combines pharmacological and non-pharmacological interventions 1, 6

4. Not addressing relationship issues:

   • Partner dynamics often play a significant role in sexual desire 1, 7

5. Overlooking the distress component:

   • Low desire must cause personal distress to be diagnosed as HSDD requiring treatment 6

Regular follow-up is essential to monitor treatment efficacy and side effects, with adjustments made as needed based on response and tolerability 1.