What are the treatment options for low female libido (Hyposexual Desire Disorder)?

Treatment of Low Female Libido (Hypoactive Sexual Desire Disorder)

For premenopausal women with HSDD, flibanserin (100 mg at bedtime) is the only FDA-approved first-line treatment, though it provides modest benefit of approximately one additional satisfying sexual event every two months. 1, 2

FDA-Approved Pharmacological Options

Flibanserin (First-Line)

• FDA-approved specifically for premenopausal women with acquired, generalized HSDD that causes marked distress and is NOT due to medical/psychiatric conditions, relationship problems, or medication effects 2
• Dosing: 100 mg once daily at bedtime only—never during waking hours due to increased risk of hypotension and syncope 2
• Absolute contraindications: alcohol consumption (must avoid until the following day after dosing), moderate-to-strong CYP3A4 inhibitors (including common antifungals like fluconazole, HIV medications, certain antibiotics like ciprofloxacin and erythromycin), and liver disease 2
• Expected benefit: approximately 1 additional satisfying sexual event every 2 months compared to placebo 1
• Common side effects: CNS depression, somnolence, hypotension, and syncope—patients must lie down immediately if experiencing lightheadedness 2

Bremelanotide (Alternative FDA-Approved Option)

• FDA-approved melanocortin receptor agonist for premenopausal women with HSDD 1
• Administered as subcutaneous injection on an as-needed basis 1
• Can be considered when flibanserin is contraindicated or not tolerated 1

Off-Label Pharmacological Options

When First-Line Fails or Is Contraindicated

• Bupropion: Off-label option with limited but supportive data, particularly helpful in breast cancer survivors 3, 1
• Buspirone: Off-label option considered by expert panels despite limited evidence 1
• Androgens (testosterone/DHEA): May be discussed for low desire, though not FDA-approved for HSDD 3, 1, 4
  • DHEA (prasterone) 10-50 mg daily has shown improvements in sexual desire, arousal, and pain 4
  • Testosterone therapy lacks long-term safety data and is not FDA-approved for this indication 3, 5

What NOT to Use

• PDE5 inhibitors (sildenafil, etc.) are NOT recommended for female sexual dysfunction due to contradictory trial results and lack of effectiveness data in women 1, 4

Non-Pharmacological Interventions (Often More Effective)

Psychological Approaches

• Cognitive behavioral therapy (CBT) has strong evidence for improving sexual function, particularly in breast cancer survivors 3, 4
• Psychoeducational support, group therapy, sexual counseling, or couples therapy should be offered to all women with sexual complaints 3
• Mindfulness-based therapies show promise 6

Mechanical and Physical Interventions

• Vibrators or clitoral stimulatory devices with specialist referral for orgasm difficulties 3, 1
• Pelvic physical therapy (pelvic floor muscle training) improves sexual pain, arousal, lubrication, orgasm, and satisfaction 3, 4
• Vaginal dilators for pain during sexual activity or vaginal stenosis from pelvic radiation 3

Addressing Vaginal Symptoms

• Non-hormonal water-based lubricants and moisturizers as primary treatment for vaginal dryness 3, 4
• Topical anesthetics (lidocaine) applied to vulvar vestibule before penetration for dyspareunia 3
• Vaginal estrogen is most effective for vaginal dryness but contraindicated in hormone-sensitive breast cancer 3
• Ospemifene for dyspareunia in postmenopausal women without hormone-sensitive cancers 3, 1

Lifestyle Modifications

• Integrative therapies (yoga, meditation) help alleviate anxiety that impacts sexual function 3, 4
• Address modifiable risk factors: smoking cessation, alcohol reduction, obesity management 4
• Regular exercise, stress management, adequate sleep, and healthy diet 4

Critical Assessment Steps

Identify Reversible Contributing Factors

• Medications: SSRIs/SNRIs (cause anorgasmia and reduced libido), beta-blockers, narcotics, hormone therapy 3, 4
• Medical conditions: cardiovascular disease, diabetes, thyroid disorders, depression, anxiety 4
• Menopausal status: vaginal atrophy and dryness significantly impact function 3, 4
• Relationship issues: quality of partner relationship is crucial 3, 5
• History of trauma: physical or sexual abuse 5

Special Population: Cancer Survivors

• Avoid hormonal treatments in hormone-sensitive cancer survivors (breast, endometrial) 1, 4
• For those on aromatase inhibitors, vaginal estrogen may counteract AI efficacy—if needed, use estriol-containing preparations rather than estradiol 3
• Consider stopping SSRIs/SNRIs if contributing to dysfunction 3
• Pelvic physical therapy particularly beneficial for gynecologic cancer survivors 3

Treatment Algorithm

1. Rule out and address reversible causes: medication review, treat depression/anxiety, address relationship issues 3, 4
2. For vaginal dryness/dyspareunia: Start with non-hormonal lubricants/moisturizers; consider vaginal estrogen if no contraindications 3, 4
3. For low desire in premenopausal women: Flibanserin 100 mg at bedtime (if no contraindications) or bremelanotide 1, 2
4. If first-line fails or contraindicated: Consider off-label bupropion or buspirone 1
5. Concurrent psychological intervention: CBT, sexual counseling, or couples therapy for all patients 3, 4
6. For orgasm difficulties: Mechanical devices (vibrators) plus pelvic physical therapy 3, 1

Common Pitfalls to Avoid

• Do not prescribe flibanserin without counseling about absolute alcohol prohibition—combination causes severe hypotension and syncope 2
• Do not use PDE5 inhibitors—they are ineffective in women despite effectiveness in men 1, 4
• Do not prescribe vaginal estrogen to women on aromatase inhibitors without careful consideration—may reverse AI efficacy 3
• Do not expect dramatic pharmacological results—current medications provide modest benefit at best; psychological and mechanical interventions often more effective 1, 6
• Do not overlook partner involvement—sexual dysfunction often has relational components requiring couples therapy 3