What are the management options for low libido in women?

Management Options for Low Libido in Women

The management of low libido in women should include a combination of non-hormonal therapies as first-line treatment, with consideration of hormonal options and psychosexual therapy for persistent symptoms, tailored to address the underlying causes of sexual dysfunction. 1, 2

Assessment of Underlying Causes

• Low libido in women is multifactorial, with potential biological, psychological, and relationship factors that should be evaluated 3, 4
• Assess for symptoms of menopause including vaginal dryness, dyspareunia, and other vaginal issues that may contribute to decreased sexual desire 1
• Evaluate for psychological concerns including distress, anxiety, depression, body-image concerns, and relationship issues 1
• Consider medication side effects, particularly from antidepressants, which may negatively impact libido 1

First-Line Treatment Options

Non-Hormonal Therapies

• Vaginal moisturizers, lubricants, and gels are recommended as first-choice treatments for vaginal dryness and dyspareunia that may contribute to low libido 1
• Pelvic physical therapy (pelvic floor muscle training) may improve sexual pain, arousal, lubrication, orgasm, and satisfaction 2
• Lifestyle modifications including regular exercise, mindfulness practices, and yoga can help enhance sexual satisfaction and address low libido 5

Psychosexual Therapy

• Psychosexual therapy has shown successful outcomes in 50-80% of patients and can be used alone or in conjunction with physical therapies 1
• Therapy can address psychological factors affecting libido including anxiety, depression, body image concerns, and relationship issues 1, 6
• Mindfulness, cognitive behavioral therapy, and psychoeducation have excellent evidence for improving low sexual desire in women 6

Pharmacological Options

For Premenopausal Women

• Flibanserin is FDA-approved for acquired, generalized hypoactive sexual desire disorder in premenopausal women 1, 7
• Flibanserin should be taken at bedtime to minimize side effects including dizziness, somnolence, nausea, and fatigue 7
• Important safety considerations include avoiding alcohol consumption and certain medications (particularly CYP3A4 inhibitors) when taking flibanserin 7

For Postmenopausal Women

• DHEA supplementation (10-50 mg daily) can be considered for persistent lack of libido and/or low energy levels 2
• DHEA has shown significant improvements in sexual desire, arousal, pain, and overall sexual function in clinical trials 2
• Treatment efficacy should be guided by monitoring serum DHEA sulphate, androstenedione, and testosterone levels 2
• Transdermal testosterone has evidence supporting its use for low desire in postmenopausal women 6

Special Considerations for Cancer Survivors

• Sexual dysfunction is a major issue with significant impact on quality of life in cancer survivors, particularly those receiving hormonal therapies 1
• First-choice treatments include non-hormonal therapies such as vaginal moisturizers, lubricants, and gels 1
• Low-dose vaginal hormones may be considered in patients where non-hormonal measures are ineffective, though safety data is limited 1
• DHEA should be used with caution in survivors receiving aromatase inhibitor therapy, as vaginal DHEA increases levels of circulating androgens 2

Treatment Algorithm

1. Begin with non-hormonal approaches (lubricants, moisturizers, lifestyle modifications) 1, 5
2. Add psychosexual therapy if psychological or relationship factors are present 1, 6
3. Consider pharmacological options based on menopausal status:
   • Premenopausal: Flibanserin if appropriate 7
   • Postmenopausal: DHEA or testosterone therapy 2, 6
4. For cancer survivors or those with contraindications to hormonal therapy, emphasize non-hormonal approaches and consider specialized referral 1

Pitfalls and Caveats

• Hormonal contraception is generally contraindicated in breast cancer survivors; alternative non-hormonal contraception methods should be used 1
• Long-term effects of DHEA replacement therapy are not fully known, so such regimens should be used with caution 2
• Flibanserin has significant side effects and drug interactions that must be carefully considered before prescribing 7
• Sexual health should be included in survivorship care plans for cancer patients, as this is often overlooked 1