What are the management options for decreased libido in females?

Management of Decreased Libido in Females

Begin with a systematic assessment of contributing factors including vaginal symptoms, psychological distress, medication side effects, and hormonal status, then treat with vaginal moisturizers/lubricants as first-line for vaginal dryness, psychosexual therapy for psychological components, and consider flibanserin for premenopausal women with hypoactive sexual desire disorder or DHEA supplementation for postmenopausal women with persistent symptoms. 1

Initial Assessment

Screen for Underlying Contributors

• Evaluate for menopausal symptoms including vaginal dryness, dyspareunia, and other vaginal issues that directly contribute to decreased sexual desire 1

• Assess psychological factors including distress, anxiety, depression, body-image concerns, and relationship issues, as these commonly affect libido 1

• Review all medications, particularly antidepressants, which frequently impair libido as a side effect 1

• Consider hormonal status: Premenopausal versus postmenopausal women require different management approaches 2

Important Caveat on Testosterone Testing

• Do not routinely obtain testosterone levels in women in non-research settings, as this is not recommended even when decreased libido is present 3

Treatment Algorithm

First-Line: Address Vaginal Symptoms

• Use vaginal moisturizers, lubricants, and gels as the initial treatment for vaginal dryness and dyspareunia that contribute to low libido 1

• These non-hormonal options are particularly important for breast cancer survivors and women on aromatase inhibitors, who experience higher rates of vaginal atrophy (18% vs 8% with tamoxifen) 3

Second-Line: Psychosexual Therapy

• Implement psychosexual therapy either alone or combined with physical therapies, which demonstrates successful outcomes in 50-80% of patients 1

• This approach is especially critical when body image concerns, relationship issues, or cancer-related psychological trauma contribute to sexual dysfunction 3

Pharmacologic Options

For Premenopausal Women

• Flibanserin (ADDYI) is FDA-approved specifically for acquired, generalized hypoactive sexual desire disorder in premenopausal women 1, 2

• Critical safety requirements with flibanserin:

  • Take only at bedtime (100 mg once daily) 2
  • Absolutely no alcohol consumption close to bedtime dosing or until the following day, as this significantly increases risk of severe hypotension and syncope 2
  • Contraindicated with moderate or strong CYP3A4 inhibitors (including certain HIV medications, antifungals, antibiotics, and grapefruit juice) 2
  • Contraindicated in women with liver problems 2
  • Not for use during breastfeeding 2

For Postmenopausal Women

• Consider DHEA supplementation (10-50 mg daily) for persistent lack of libido and/or low energy levels in postmenopausal women 1

• This addresses the androgen deficiency that commonly occurs after menopause and contributes to decreased sexual drive 4

Special Populations

Cancer Survivors

• Include sexual health in survivorship care plans, as this is frequently overlooked despite affecting at least 50% of women after breast cancer 3, 1

• Sexual dysfunction in cancer survivors is multifactorial: chemotherapy causes fatigue and decreased desire, endocrine therapy produces profound estrogen deprivation effects, and surgery impacts body image 3

• Avoid hormonal contraception in breast cancer survivors; use alternative non-hormonal methods instead 1

Women on Aromatase Inhibitors

• Aromatase inhibitors cause more severe vaginal dryness (18%) compared to tamoxifen (8%) because they inhibit peripheral androgen-to-estrogen conversion by >95% 3

• These women require aggressive management of vaginal symptoms with non-hormonal moisturizers and lubricants 3, 1

Common Pitfalls to Avoid

• Do not dismiss decreased libido as "normal aging": Both premenopausal and postmenopausal women can have hypoactive sexual desire disorder requiring treatment 5

• Do not prescribe flibanserin without ensuring the patient understands alcohol restrictions: The combination causes severe hypotension and syncope 2

• Do not overlook medication-induced sexual dysfunction: Systematically review all medications, especially antidepressants and hormonal therapies 1

• Do not focus solely on biological factors: The etiology is multifactorial, requiring assessment of psychological, relational, and physical components 4, 5

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