What medications can be used to increase libido in women?

Medications for Increasing Libido in Women

For women with hypoactive sexual desire disorder (HSDD), FDA-approved medications like flibanserin and bremelanotide are the most effective pharmacological options for increasing libido, with off-label options including bupropion and buspirone as alternatives. 1, 2

FDA-Approved Medications

First-Line Options:

1. Flibanserin (Addyi)

   • Indication: Acquired, generalized HSDD in premenopausal women
   • Mechanism: 5-HT1A agonist/5-HT2A antagonist that increases dopamine and norepinephrine while decreasing serotonin 3, 4
   • Dosing: 100 mg once daily at bedtime 1, 2
   • Efficacy: Results in approximately 1 additional satisfying sexual event every 2 months 1, 5
   • Side effects: Dizziness, somnolence, nausea, fatigue 6, 3
   • Contraindications: Alcohol consumption (risk of severe hypotension), strong CYP3A4 inhibitors 6
   • Important note: Although not FDA-approved for postmenopausal women, some data suggest effectiveness in this population as well 1

2. Bremelanotide (Vyleesi)

   • Indication: HSDD in premenopausal women
   • Mechanism: Melanocortin receptor agonist
   • Administration: Self-administered subcutaneous injection as needed
   • Efficacy: Significantly increases sexual desire and reduces distress related to low sexual desire 1, 2
   • Not studied in cancer survivors but considered an appropriate option for some with HSDD 1

Off-Label Options:

1. Bupropion

   • Starting dose: 150 mg daily, can increase to 150 mg twice daily if needed 2
   • Mechanism: Dopamine and norepinephrine reuptake inhibitor
   • Advantages: Can be used in both pre- and postmenopausal women
   • Side effects: Insomnia, headache, dry mouth, nausea 2

2. Buspirone

   • Indication: Off-label for HSDD
   • Evidence: Limited data from trials in non-cancer populations 1, 7
   • Can be considered when FDA-approved options are not suitable

Hormonal Options (Use with Caution):

1. Prasterone (DHEA)

   • Indication: Vaginal dryness and pain with sexual activity
   • Benefits: Can improve sexual desire, arousal, pain, and overall sexual function 1, 2
   • Caution: Use carefully in patients on aromatase inhibitor therapy as it increases circulating androgens 1
   • Contraindication: History of breast cancer (FDA warning) 1

2. Ospemifene

   • Indication: Moderate to severe dyspareunia in postmenopausal women
   • Mechanism: Selective estrogen receptor modulator (SERM)
   • Contraindication: Known or suspected breast cancer or history of breast cancer 1
   • Recommendation: Consider for dyspareunia in survivors of non-hormone sensitive cancers 1

3. Testosterone therapy

   • Consideration: May be considered for loss of desire in postmenopausal women
   • Limitation: Limited long-term safety data available 2

Not Recommended:

1. Phosphodiesterase type 5 inhibitors (PDE5i)
   • Not recommended for female sexual dysfunction due to contradictory results in clinical trials 1, 2
   • Despite theoretical benefits of increasing pelvic blood flow, evidence does not support use 1

Treatment Algorithm:

1. For premenopausal women with HSDD:

   • First-line: Flibanserin 100 mg daily at bedtime or bremelanotide as needed
   • Alternative: Bupropion 150 mg daily (can increase to twice daily)

2. For postmenopausal women with HSDD:

   • First-line: Bupropion 150 mg daily (can increase to twice daily)
   • Consider: Flibanserin (off-label) or buspirone if bupropion is ineffective

3. For women with concurrent dyspareunia:

   • Add: Vaginal moisturizers/lubricants
   • Consider: Ospemifene (if no history of hormone-sensitive cancer)
   • Consider: Prasterone (if no history of breast cancer)

Monitoring and Follow-up:

• Assess response to treatment after 4-8 weeks
• Monitor for side effects, particularly dizziness and somnolence with flibanserin
• Evaluate risk/benefit of hormonal treatments in women with history of hormone-sensitive cancers
• Consider referral to specialist if inadequate response to initial therapy

Important Considerations:

• Review current medications that may affect sexual function
• Assess for underlying medical conditions that could contribute to sexual dysfunction
• Consider non-pharmacological approaches (cognitive behavioral therapy, pelvic floor physical therapy) as adjuncts to medication
• Flibanserin requires strict avoidance of alcohol due to risk of severe hypotension 6