What is the workup and treatment for hypoactive sexual desire disorder (low libido) in women?

Workup and Treatment for Low Libido in Women

Begin with a structured clinical assessment focusing on psychosocial factors, medication review, and physical examination, then treat based on the specific type of sexual dysfunction identified, prioritizing non-hormonal interventions first and considering FDA-approved pharmacotherapy for hypoactive sexual desire disorder (HSDD) in appropriate candidates. 1

Diagnostic Workup

Initial Screening

• Ask directly about sexual function at regular intervals using validated screening tools such as the Brief Sexual Symptom Checklist for Women 1
• Assess sexual functioning before any health changes, current activity level, and impact on distress or interpersonal relationships 1
• Screen for psychosocial contributors: anxiety, depression, relationship issues, body image concerns, drug or alcohol use 1

Comprehensive Evaluation for Symptomatic Patients

• Medication review: Identify prescription and over-the-counter medications that impair libido, particularly hormone therapy, narcotics, beta blockers, and SSRIs 1
• Medical risk factors: Assess cardiovascular disease, diabetes, obesity, smoking, and alcohol abuse 1
• Oncologic and treatment history: If applicable, evaluate for treatment-induced menopause and menopausal symptoms affecting sexual function 1
• Physical and gynecologic examination: Note points of tenderness, vaginal atrophy, and anatomic changes 1
• Consider the Female Sexual Function Index (FSFI) for in-depth evaluation, which has been validated in various populations 1

Laboratory Testing

• Laboratory data are of limited value except when warranted by history or physical examination 2
• Consider morning testosterone levels in women with suspected androgen deficiency, particularly those with diminished libido following oophorectomy or in the context of adrenal insufficiency 1

Treatment Approach

Non-Pharmacologic Interventions (First-Line)

For Vaginal Dryness and Dyspareunia

• Water-, oil-, or silicone-based lubricants and vaginal moisturizers for symptom relief 1
• Vaginal estrogen (pills, rings, or creams) effectively treats vaginal dryness, itching, and painful intercourse in postmenopausal women 1
• Ospemifene (selective estrogen receptor modulator) for dyspareunia in women without estrogen-dependent cancers 1, 2
• Vaginal DHEA (prasterone) can be considered for vaginal dryness or pain with sexual activity 1
• Topical lidocaine for menopausal dyspareunia has shown reduced pain during intercourse and improved sexual function 1

For Sexual Pain and Dysfunction

• Pelvic floor physical therapy may improve sexual pain, arousal, lubrication, orgasm, and satisfaction 1
• Vaginal dilators for vaginismus, sexual aversion disorder, vaginal scarring, or stenosis, though evidence is limited 1

Psychotherapy and Counseling

• Cognitive behavioral therapy (CBT) has demonstrated efficacy in improving sexual functioning 1
• Referrals for psychotherapy, sexual/couples counseling as appropriate 1
• Encourage ongoing partner communication 1

Pharmacologic Interventions

FDA-Approved Medications for HSDD

Flibanserin (Addyi) is the primary FDA-approved option for acquired, generalized HSDD in premenopausal women 3:

• Dosing: 100 mg once daily at bedtime only 3
• Efficacy: Increases satisfying sexual events by approximately 1 additional event every 2 months, improves desire scores, and reduces sexual distress 1, 4
• Critical contraindications: Alcohol consumption (must avoid alcohol from bedtime dose until the following day), moderate or strong CYP3A4 inhibitors, and liver problems 3
• Common side effects: Dizziness, somnolence, nausea, and fatigue 1
• Important caveat: Not FDA-approved for postmenopausal women, though some data suggest potential efficacy 1

Bremelanotide is another FDA-approved option for premenopausal women with HSDD 1:

• Demonstrated statistically significant increases in sexual desire and reductions in distress in phase III trials 1
• Has not been studied in cancer survivors but may be appropriate for some patients 1

Off-Label Pharmacologic Options

For Low Desire/Libido:

• Bupropion: Antidepressant shown to improve desire in women with and without depression 2, 1
• Buspirone: May be considered despite limited data 1
• Testosterone therapy: Demonstrated efficacy in postmenopausal women with low desire, though not FDA-approved for this indication and limited long-term safety data exist 2, 1
  • Consider in women with suspected androgen deficiency, particularly post-oophorectomy 1
  • DHEA replacement is controversial but can be tested and considered in women with low libido who are otherwise well-replaced hormonally 1

For Premature Menopause:

• Hormone replacement therapy (HRT): Consider risks and benefits in women without hormone-sensitive cancers who are prematurely postmenopausal 1
• 17β-estradiol-based formulations preferred over ethinylestradiol 1

Not Currently Recommended

• Oral phosphodiesterase type 5 inhibitors (PDE5i): Contradictory results in clinical trials; insufficient evidence for female sexual dysfunction 1
• Vaginal laser therapy: Limited safety and effectiveness data; not FDA-cleared for menopausal symptoms 1

Common Pitfalls and Caveats

• Do not prescribe flibanserin without counseling about absolute alcohol avoidance and drug interactions—this significantly increases risk of severe hypotension and syncope 3
• Distinguish between desire, arousal, and pain disorders—treatment must be tailored to the specific dysfunction 1
• Screen for relationship issues and depression—these are major contributors that require concurrent management 1
• Avoid progestins with anti-androgenic effects in women with iatrogenic premature ovarian insufficiency, as they may worsen hypoandrogenism 1
• Systemic estrogen is not recommended solely for low desire in the absence of vasomotor symptoms 2