Management of Decreased Libido in Females
Begin with a comprehensive assessment for menopausal symptoms (vaginal dryness, dyspareunia), psychological factors (depression, anxiety, body image concerns), and medication side effects, then treat vaginal symptoms with non-hormonal lubricants as first-line therapy, consider flibanserin for premenopausal women with hypoactive sexual desire disorder, and offer psychosexual therapy which achieves success in 50-80% of patients. 1
Initial Assessment
Screen for Contributing Factors
Evaluate for menopausal symptoms including vaginal dryness, dyspareunia, and other vaginal issues that directly contribute to decreased sexual desire 1
Assess psychological concerns including distress, anxiety, depression, body image concerns, and relationship issues, as these are common contributors to sexual dysfunction 1
Review all medications, particularly antidepressants, which commonly impair libido as a side effect 1
In cancer survivors, sexual dysfunction affects at least 50% of women and is often multifactorial, involving treatment effects, body image changes, and psychosocial trauma 2
Common Pitfalls in Assessment
The most critical error is failing to ask about sexual function at regular intervals. Use validated screening instruments like the Brief Sexual Symptom Checklist for Women, which includes a final question asking whether the patient would like to discuss sexual function with a healthcare professional 2
Treatment Algorithm
First-Line: Address Vaginal Symptoms
Vaginal moisturizers, lubricants, and gels are the recommended first-choice treatments for vaginal dryness and dyspareunia that contribute to low libido 1
These non-hormonal options are particularly important for breast cancer survivors, where hormonal contraception is generally contraindicated 1
Atrophic vaginitis affects approximately 50% of postmenopausal women and, unlike hot flashes, symptoms persist indefinitely without treatment 2
Second-Line: Psychosexual Therapy
Psychosexual therapy demonstrates successful outcomes in 50-80% of patients and can be used alone or combined with physical therapies 1
This approach is particularly valuable given that sexual dysfunction in women is often complex, involving the diagnosis itself, body image changes, psychosocial trauma, and relationship factors 2
Pharmacologic Options
For Premenopausal Women
Flibanserin (ADDYI) is FDA-approved for acquired, generalized hypoactive sexual desire disorder in premenopausal women 1, 3
Critical contraindications: Do not prescribe if the patient takes moderate or strong CYP3A4 inhibitors (including certain HIV medications, antifungals, antibiotics, or calcium channel blockers), has liver problems, or consumes alcohol 3
Dosing: One 100 mg tablet taken only at bedtime; taking at any other time increases risk of hypotension, syncope, and CNS depression 3
Alcohol warning: Patients must avoid alcohol from the time of dosing until the following day due to severe risk of hypotension and syncope 3
Important limitation: Flibanserin is not indicated for postmenopausal women or for improving sexual performance 3
For Postmenopausal Women
DHEA supplementation (10-50 mg daily) can be considered for persistent lack of libido and/or low energy levels in postmenopausal women 1
The biological basis involves loss of estrogens and particularly androgens, which deprives female libido of major biological fuel, affecting the central nervous system, sensory organs, and quality of sexual response 4
Special Populations
Cancer Survivors
Sexual health should be included in survivorship care plans, as this is frequently overlooked 1
For breast cancer survivors on aromatase inhibitors, vaginal dryness is significantly more common (18%) compared to tamoxifen (8%), and symptoms can markedly affect quality of life and treatment compliance 2
Young women who undergo bilateral oophorectomy for breast cancer treatment commonly experience severe and long-lasting menopausal symptoms, including sexual dysfunction 2
Key Clinical Considerations
Avoid These Common Errors
Do not obtain testosterone levels in women in non-research settings, as this is not recommended 2
Do not prescribe hormonal contraception to breast cancer survivors; use alternative non-hormonal methods 1
Do not overlook medication-induced sexual dysfunction, particularly from antidepressants and endocrine therapies, which have profound impacts on both desire and arousal 2
When to Refer
Consider referral to a specialist menopause service when symptoms are refractory to initial management or when complex hormonal issues are present 2