What are the treatment options for female hypoactive sexual desire disorder (HSDD) with low libido?

Treatment of Female Hypoactive Sexual Desire Disorder (HSDD)

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

Initial Assessment

Before initiating treatment, identify and address reversible causes:

• Medication review: SSRIs/SNRIs, beta blockers, and narcotics commonly reduce libido and should be discontinued or switched if possible 3, 4
• Medical conditions: Screen for cardiovascular disease, diabetes, obesity, hypothyroidism, and depression 3, 4
• Menopausal status: Vaginal dryness and hormonal changes significantly impact desire 3, 4
• Relationship factors: Psychological distress, body image concerns, and partner issues must be evaluated 3, 4

Pharmacological Treatment Algorithm

First-Line Options (FDA-Approved)

Premenopausal women:

• Flibanserin: 100 mg orally at bedtime daily for acquired, generalized HSDD 1, 2
• Bremelanotide: Subcutaneous injection as needed (alternative to flibanserin) 2

Second-Line Options (Off-Label)

When first-line treatments fail or are contraindicated:

• Bupropion: Limited data but considered by expert panels for HSDD 2, 3
• Buspirone: Off-label option with limited evidence 2
• DHEA (prasterone): 10-50 mg daily has shown improvements in desire, arousal, and pain 4

Postmenopausal Women

• Testosterone therapy: Supported by the American College of Obstetricians and Gynecologists for low desire, though not FDA-approved for this indication 4
• Ospemifene: Only for concurrent dyspareunia in women without hormone-sensitive cancer history 2

Critical caveat: Flibanserin is NOT indicated for postmenopausal women or to enhance sexual performance 1

Non-Pharmacological Interventions (Essential Adjuncts)

Highly Effective Options

• Cognitive behavioral therapy (CBT): Strong evidence for improving sexual function, particularly in cancer survivors 4, 3
• Pelvic floor muscle training: Improves arousal, lubrication, orgasm, and satisfaction 3, 4, 2
• Vaginal moisturizers and lubricants: Water-, oil-, or silicone-based products for vaginal dryness 3, 4

Additional Interventions

• Vaginal dilators: For vaginismus, sexual aversion, or vaginal stenosis from surgery/radiation 3, 4
• Clitoral stimulatory devices/vibrators: For orgasmic difficulties 4, 2
• Sexual/couples counseling: Address relationship dynamics and communication 3

What NOT to Use

Phosphodiesterase type 5 inhibitors (sildenafil, etc.) are NOT recommended due to contradictory clinical trial results and lack of effectiveness data in women, despite increasing pelvic blood flow 3, 2

Special Population: Cancer Survivors

• Avoid estrogen and tibolone in breast cancer survivors due to recurrence risk 3
• Vaginal estrogen may be considered for severe vaginal dryness, though safety is not established in those taking aromatase inhibitors 3
• Testosterone cannot be recommended after breast cancer due to lack of safety/efficacy data 3
• Consider stopping SSRIs/SNRIs as they worsen sexual dysfunction 3

Critical Pitfalls to Avoid

• Do not use hormonal treatments in survivors of hormone-sensitive cancers without careful risk-benefit discussion 4, 2
• Testosterone may not work without adequate circulating estrogen 3
• Avoid progestins with anti-androgenic effects in women with iatrogenic premature ovarian insufficiency, as they worsen hypoandrogenism 3
• Set realistic expectations: Current pharmacological treatments show limited effectiveness 2

Practical Treatment Approach

1. Address reversible causes first: Stop offending medications, treat depression, optimize medical conditions 3, 4
2. Start non-pharmacological interventions immediately: Lubricants, CBT, pelvic floor therapy 3, 4
3. Add pharmacotherapy if distress persists: Flibanserin for premenopausal women 1, 2
4. Combine medical and psychological approaches: Evidence strongly supports this mixed approach 5
5. Continue treatment until natural menopause age (45-55 years) for hormone replacement in premature ovarian insufficiency 3