What are the treatment options for hypoactive sexual desire disorder (HSDD) in women with low sex drive?

Treatment of Low Sex Drive in Women (HSDD)

For premenopausal women with hypoactive sexual desire disorder (HSDD), flibanserin 100 mg daily at bedtime is the FDA-approved first-line pharmacologic treatment, though its efficacy is modest—resulting in approximately one additional satisfying sexual event every two months compared to placebo. 1, 2

Initial Assessment and Diagnosis

Before initiating treatment, identify contributing factors that must be addressed:

• Screen for medications that impair sexual desire: SSRIs, SNRIs, beta blockers, narcotics, and hormonal contraceptives 3, 4
• Evaluate medical conditions: cardiovascular disease, diabetes, obesity, hypertension, and menopausal status 3
• Assess psychological factors: depression, anxiety, body image concerns, relationship dissatisfaction, and history of physical or sexual abuse 4, 5
• Use validated screening tools: Brief Sexual Symptom Checklist or Female Sexual Function Index to quantify dysfunction 3, 4

The diagnosis requires that low desire causes marked personal distress, occurs regardless of partner or situation, and is not better explained by another medical/psychiatric condition, relationship problems, or medication effects 2, 5.

Treatment Algorithm

First-Line Pharmacologic Options (Premenopausal Women)

Flibanserin (Addyi):

• Dose: 100 mg once daily at bedtime only 1, 2
• Critical safety warnings: Absolutely no alcohol consumption from bedtime dosing until the following day due to severe hypotension and syncope risk 2
• Contraindicated with moderate/strong CYP3A4 inhibitors (azole antifungals, macrolide antibiotics, HIV protease inhibitors, diltiazem, verapamil) and in patients with liver disease 2
• FDA-approved only for acquired, generalized HSDD in premenopausal women 2

Bremelanotide:

• Alternative FDA-approved option for premenopausal women with HSDD 1, 4
• Administered as subcutaneous injection as needed (melanocortin receptor agonist mechanism) 1

Second-Line/Off-Label Pharmacologic Options

When first-line agents are contraindicated or ineffective:

• Bupropion: Off-label use with limited but supportive data, particularly helpful if concurrent depression or SSRI-induced sexual dysfunction 3, 1, 4, 6
• Buspirone: Off-label option with limited evidence but considered by expert panels 1, 4
• DHEA (prasterone): 10-50 mg daily has shown improvements in sexual desire, arousal, and pain, with FDA approval for vaginal symptoms 4

Non-Pharmacologic Interventions (Essential Components)

These should be implemented alongside or before pharmacotherapy:

For vaginal symptoms contributing to low desire:

• Water-, oil-, or silicone-based lubricants and moisturizers for vaginal dryness and dyspareunia 3, 4
• Vaginal estrogen (creams, rings, tablets) for postmenopausal vaginal atrophy—estriol-containing preparations preferred in breast cancer survivors over estradiol 3
• Ospemifene for postmenopausal dyspareunia (contraindicated in hormone-sensitive cancer history) 1, 4, 6

Physical therapy and mechanical interventions:

• Pelvic floor muscle training improves arousal, lubrication, orgasm, and satisfaction 3, 1, 4
• Vibrators or clitoral stimulatory devices for orgasmic difficulties 1, 4
• Vaginal dilators for vaginismus, stenosis, or scarring 3, 4

Psychotherapy:

• Cognitive behavioral therapy (CBT) has demonstrated efficacy, particularly in cancer survivors 3, 4
• Sexual/couples counseling for relationship factors 3

Lifestyle modifications:

• Regular exercise, stress reduction, adequate sleep, and healthy diet 4
• Address alcohol use, smoking, and obesity 3, 4

Special Population Considerations

Postmenopausal women:

• Flibanserin is not FDA-approved but may be used off-label 1
• Testosterone therapy shows efficacy but lacks FDA approval and long-term safety data 4, 6
• Address vaginal atrophy with local estrogen or ospemifene if no hormone-sensitive cancer history 3, 1, 4

Cancer survivors:

• Avoid hormonal treatments in hormone-sensitive cancer survivors 3, 4
• Estriol-containing vaginal preparations preferred over estradiol in aromatase inhibitor users 3
• Treatment selection must consider cancer type and prior treatments 1, 4

Common Pitfalls and Contraindications

Do NOT use:

• PDE5 inhibitors (sildenafil): Not recommended due to contradictory trial results and lack of efficacy data in women 3, 1, 4
• Flibanserin with any alcohol consumption or CYP3A4 inhibitors 2
• Hormonal therapies in women with hormone-sensitive cancer history without careful risk-benefit discussion 3, 4

Critical safety considerations:

• Flibanserin must be taken only at bedtime; daytime dosing increases hypotension, syncope, and CNS depression risk 2
• If lightheadedness or dizziness occurs with flibanserin, patient must lie down immediately and seek emergency care if symptoms persist 2
• Discontinue SSRIs/SNRIs if they are contributing to sexual dysfunction 3

Setting Realistic Expectations

Counsel patients that current pharmacologic treatments have limited efficacy—flibanserin produces approximately one additional satisfying sexual event every two months 1. A combined approach addressing biological, psychological, and relationship factors yields better outcomes than pharmacotherapy alone 3, 4.