What is the treatment for hypoactive sexual desire disorder (HSDD) in postmenopausal women?

Treatment for Low Libido in Postmenopausal Women

For postmenopausal women with low libido (HSDD), consider off-label flibanserin 100 mg daily at bedtime as first-line pharmacological treatment, or transdermal testosterone (300 mcg/day patch) if not taking estrogen therapy, while simultaneously addressing psychological factors through mindfulness-based cognitive behavioral therapy. 1, 2, 3, 4

Pharmacological Treatment Options

First-Line: Flibanserin (Off-Label Use)

• Flibanserin 100 mg daily at bedtime is FDA-approved only for premenopausal women but demonstrates efficacy in postmenopausal women with HSDD 5, 1, 2
• The PLUMERIA trial showed statistically significant improvement in desire scores (FSFI-d) in postmenopausal women compared to placebo, though the effect is modest 2
• Expect approximately 1 additional satisfying sexual event every 2 months compared to placebo 5, 1
• Common side effects include insomnia (7.7%), somnolence (6.9%), and dizziness (6.4%) 2
• Flibanserin works by increasing dopamine and norepinephrine while decreasing serotonin, correcting neurotransmitter imbalances affecting sexual desire 6

Alternative: Transdermal Testosterone

• Testosterone patch delivering 300 mcg/day is supported by strong evidence for postmenopausal women not taking estrogen therapy 3, 4
• Results in a mean increase of 2.1 satisfying sexual episodes per 4 weeks versus 0.7 with placebo (P<0.001) 4
• Significantly improves both desire (P<0.001) and reduces distress (P<0.001) 4
• The 150 mcg/day dose showed less consistent efficacy 4
• Key caveat: Androgenic side effects occur in 30% of patients, primarily unwanted hair growth 4
• Critical safety concern: Long-term effects on breast tissue remain uncertain; breast cancer was diagnosed in 4 women receiving testosterone versus none on placebo in trials, though causality is unclear 4

Second-Line Off-Label Options

• Bupropion may be considered despite limited safety and efficacy data in this population 5, 1, 7
• Buspirone is another off-label option with limited supporting evidence 5, 1, 8
• Both medications are recognized by expert panels as reasonable alternatives when first-line options fail or are contraindicated 7

Psychological and Behavioral Interventions

Evidence-Based Psychotherapy

• Mindfulness-based cognitive behavioral therapy has excellent evidence for improving low sexual desire in women 3
• Psychoeducation and standard cognitive behavioral therapy also show benefit 3
• These approaches should be offered concurrently with pharmacological treatment, not as an afterthought 5

Mechanical and Physical Approaches

• Vibrators or clitoral stimulatory devices should be discussed for women with orgasm difficulties 1
• Pelvic floor physical therapy can improve sexual function, arousal, lubrication, and satisfaction 1, 8
• Referral to sexual health specialists or sex therapists when available 5

Addressing Concurrent Vaginal Symptoms

If vaginal dryness or dyspareunia coexists with low libido:

• First step: Vaginal lubricants for sexual activity and vaginal moisturizers for daily comfort 5, 8
• Second step: Vaginal estrogen therapy is the most effective treatment for vaginal atrophy symptoms 5, 8
• Alternative: Vaginal DHEA (prasterone) improves sexual desire, arousal, pain, and overall function 8
• For dyspareunia without hormone-sensitive cancer history: Consider ospemifene, though not specifically indicated for HSDD 1, 8

What NOT to Do

Avoid Ineffective Treatments

• Do not prescribe phosphodiesterase type 5 inhibitors (PDE5i) for female sexual dysfunction—they show contradictory results in clinical trials and lack evidence of effectiveness in women 5, 1, 8
• Do not recommend vaginal laser therapy as the FDA has not cleared these devices for menopausal symptoms, and safety/effectiveness data in this population are insufficient 5

Hormone Therapy Considerations

• Systemic hormone replacement therapy (HRT) for chronic disease prevention is not recommended and carries risks including venous thromboembolism, CHD, stroke, and breast cancer with longer-term use 5
• If HRT is used for menopausal symptoms, use the lowest effective dose for the shortest possible time 5

Special Population: Cancer Survivors

• For postmenopausal cancer survivors with HSDD, treatment selection depends critically on cancer type 5, 1
• Hormone-sensitive breast cancer is an absolute contraindication to systemic hormone therapy 5
• Flibanserin may be appropriate as it is non-hormonal 5, 1
• Preliminary data suggest flibanserin may be effective in breast cancer survivors receiving adjuvant endocrine therapy 5

Treatment Algorithm

1. Screen for contributing factors: Assess for depression, anxiety, relationship issues, and concurrent vaginal symptoms 5
2. Initiate psychological intervention: Begin mindfulness-based CBT or psychoeducation 3
3. Add pharmacological treatment:
   • If not on estrogen therapy and no contraindications: Consider testosterone 300 mcg/day patch 4
   • Otherwise: Flibanserin 100 mg at bedtime (off-label) 2
4. Address vaginal symptoms if present: Lubricants, moisturizers, then vaginal estrogen or DHEA 5, 8
5. If inadequate response: Switch to alternative pharmacological agent (bupropion or buspirone) 1, 7
6. Refer to specialists: Sexual health specialist, sex therapist, or pelvic floor physical therapist as needed 5, 1

Critical Pitfalls to Avoid

• Do not expect dramatic results: Even the most effective treatments yield modest improvements (1-2 additional satisfying sexual events per month) 5, 1, 2
• Do not ignore psychological factors: Sexual dysfunction is multifactorial; medication alone is rarely sufficient 5, 7
• Do not use bremelanotide in postmenopausal women: It is FDA-approved only for premenopausal women and lacks data in the postmenopausal population 5, 9
• Do not overlook medication side effects: Central nervous system effects (dizziness, somnolence, insomnia) are common with flibanserin and may limit tolerability 2