What are the treatment options for decreased libido in females?

Treatment Options for Decreased Libido in Females

For women experiencing decreased libido, treatment should be guided by the specific underlying causes and may include pharmacological options such as flibanserin for premenopausal women, as well as non-pharmacological approaches including psychotherapy, lifestyle modifications, and addressing vaginal symptoms. 1

Assessment and Identification of Contributing Factors

• Screen for reversible contributing factors including medications (especially hormone therapy, narcotics, and serotonin reuptake inhibitors), psychological issues (anxiety, depression, relationship problems), and lifestyle factors (alcohol use, smoking) 1
• Evaluate traditional risk factors for sexual dysfunction such as cardiovascular disease, diabetes, obesity, and alcohol abuse 1
• Consider the impact of cancer treatments if relevant, as chemotherapy and hormonal therapies can significantly affect sexual desire 1
• Assess for concurrent vaginal symptoms (dryness, pain with intercourse) that may contribute to decreased libido 1

Treatment Algorithm

Non-Pharmacological Approaches (First-Line)

1. Psychosocial Interventions:

   • Psychoeducational support, sexual counseling, and marital/couples therapy for addressing relationship issues and psychological factors 1
   • Cognitive behavioral therapy has shown efficacy for sexual desire issues, particularly in cancer survivors 1
   • Mindfulness-based approaches have excellent evidence for improving low sexual desire 2

2. Lifestyle Modifications:

   • Increased physical activity, smoking cessation, weight loss if overweight, and limiting alcohol consumption 1
   • These modifications have been shown to improve sexual function, though evidence is stronger in men than women 1

3. For Vaginal Symptoms Contributing to Decreased Desire:

   • Water-, oil-, or silicone-based lubricants and vaginal moisturizers for vaginal dryness 1
   • Silicone-based products may last longer than water-based or glycerin-based products 1
   • Pelvic floor physical therapy for pain with sexual activity 1
   • Vaginal dilators for vaginismus or vaginal stenosis 1

Pharmacological Options

1. For Premenopausal Women:

   • Flibanserin is FDA-approved for acquired, generalized hypoactive sexual desire disorder in premenopausal women 1, 3
   • Mechanism: Increases dopamine and norepinephrine while decreasing serotonin 4
   • Dosing: One tablet daily at bedtime 3
   • Efficacy: Results in approximately one additional satisfying sexual event every two months 1
   • Important precautions: Cannot be taken with alcohol due to risk of severe hypotension and syncope; contraindicated with moderate/strong CYP3A4 inhibitors 3
   • Common side effects: Dizziness, somnolence, nausea, and fatigue 3, 4

2. Other Pharmacological Options:

   • Bupropion and buspirone may be considered for hypoactive sexual desire disorder despite limited safety and efficacy data 1
   • For postmenopausal women, transdermal testosterone has evidence supporting its use for low desire 2

3. For Cancer Survivors:

   • Vaginal DHEA (prasterone) has shown significant improvements in sexual desire, arousal, pain, and overall sexual function in survivors of breast or gynecologic cancer 1
   • However, safety data for androgen-based therapy in survivors of hormonally mediated cancers are limited 1
   • The FDA label for prasterone warns that exogenous estrogens are contraindicated in women with a history of breast cancer 1

Special Considerations

• Postmenopausal Women:

  • Decreased libido is particularly prevalent in this population 5
  • Consider hormonal factors and address concurrent vaginal symptoms 5
  • Transdermal testosterone may be beneficial for low desire 2

• Cancer Survivors:

  • Sexual dysfunction is common in female cancer survivors, particularly those who received chemotherapy 1
  • Treatment should consider cancer type and hormonal sensitivity 1
  • Ospemifene may be considered for dyspareunia in survivors of cancers that are not hormonally sensitive 1

• Not Recommended:

  • PDE5 inhibitors (like sildenafil) are not recommended for female sexual dysfunction due to contradictory results in clinical trials 1
  • Hormonal therapies for women on aromatase inhibitors are not recommended 1

Treatment Pitfalls to Avoid

• Failing to address psychological and relationship factors that may be primary contributors to decreased libido 1
• Using flibanserin with alcohol, which can cause severe hypotension and syncope 3
• Prescribing hormonal therapies without considering cancer history, especially estrogen-sensitive cancers 1
• Focusing only on physical symptoms while neglecting the psychological aspects of sexual desire 2
• Expecting immediate results from pharmacological interventions, as benefits may be modest and take time to manifest 4, 2