What treatment options are available for a female patient with low libido and an inability to orgasm?

Treatment of Low Libido and Anorgasmia in Women

For a premenopausal woman presenting with low libido and difficulty achieving orgasm, flibanserin 100 mg daily at bedtime is the first-line FDA-approved pharmacological option, though its efficacy is modest (approximately one additional satisfying sexual event every 2 months), and should be combined with non-pharmacological approaches including pelvic physical therapy for orgasm difficulties and mechanical devices such as vibrators. 1, 2, 3

Initial Assessment and Contributing Factors

Before initiating treatment, screen for reversible causes:

• Medications: Review all current medications, particularly SSRIs, antihypertensives, and hormonal contraceptives that may suppress sexual desire 2
• Medical conditions: Evaluate for cardiovascular disease, diabetes, obesity, thyroid dysfunction, and depression 2
• Relationship factors: Assess for relationship distress, communication issues, and partner sexual dysfunction 4, 2
• Hormonal status: Determine menopausal status, as treatment recommendations differ significantly between pre- and postmenopausal women 1, 3
• Vaginal symptoms: Evaluate for vaginal dryness or dyspareunia that may be contributing to sexual avoidance 4, 2

First-Line Treatment Options

Pharmacological Therapy for Low Libido

Flibanserin (Addyi) is FDA-approved specifically for acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women 1, 3:

• Dosing: 100 mg once daily at bedtime only 3
• Efficacy: Results in approximately 1 additional satisfying sexual event every 2 months compared to placebo 1, 2
• Critical contraindications:
  • Absolute contraindication with alcohol consumption (must avoid alcohol from time of dose until the following day due to severe hypotension and syncope risk) 3
  • Contraindicated with moderate or strong CYP3A4 inhibitors (including fluconazole, erythromycin, ciprofloxacin, diltiazem, verapamil, and grapefruit juice) 3
  • Contraindicated in patients with liver problems 3
• Common side effects: Dizziness, somnolence, nausea, and fatigue 3

Bremelanotide is an alternative FDA-approved option for premenopausal women with HSDD 1, 2:

• Administered as a subcutaneous injection as needed before anticipated sexual activity 1
• Acts as a melanocortin receptor agonist 1

Non-Pharmacological Approaches for Orgasm Difficulties

Mechanical devices and pelvic therapy are recommended first-line treatments for anorgasmia 4, 1:

• Vibrators or clitoral stimulatory devices: Discuss mechanical options with referral to appropriate specialists 1
• Pelvic physical therapy: Can improve orgasm difficulties and overall sexual function 4, 1, 2
• Vibratory therapy: Specifically recommended for orgasm problems 4

Second-Line and Off-Label Options

When first-line treatments are contraindicated, ineffective, or not tolerated:

• Bupropion: Off-label option for HSDD despite limited safety and efficacy data 1, 2
• Buspirone: Off-label option with limited data but considered by expert panels 1
• Androgens: May be discussed for low desire, though not FDA-approved for HSDD 1

Psychosocial Interventions

Psychological and relationship factors must be addressed concurrently 4, 2:

• Cognitive behavioral therapy: Has shown efficacy for sexual desire issues 2
• Sex therapy or couples counseling: Address relationship issues and communication patterns 2
• Psychoeducational support: Provide education about normal sexual response and expectations 2

Lifestyle Modifications

Evidence-based lifestyle changes that can improve sexual function 2:

• Increased physical activity
• Smoking cessation
• Weight loss if overweight
• Limiting alcohol consumption
• Stress reduction techniques

What NOT to Use

Phosphodiesterase type 5 inhibitors (PDE5i) such as sildenafil are NOT recommended for female sexual dysfunction due to contradictory results in clinical trials and lack of effectiveness data in women 4, 1, 2. This is a critical distinction from male sexual dysfunction treatment.

Vaginal laser therapy is not currently recommended due to limited safety and effectiveness data, and lack of FDA approval for this indication 4.

Special Considerations

Cancer Survivors

For women with history of cancer, treatment selection requires careful consideration 4, 2:

• Hormone-sensitive cancers: Avoid hormonal therapies in patients with estrogen-dependent cancers 4, 2
• Aromatase inhibitor users: Hormonal therapies are not recommended 2
• Vaginal DHEA (prasterone): Has shown improvements in sexual desire, arousal, and pain in breast or gynecologic cancer survivors 2

Postmenopausal Women

Flibanserin is FDA-approved only for premenopausal women 3. For postmenopausal women:

• Off-label use of flibanserin may be considered 1
• Ospemifene: May be considered for concurrent dyspareunia in women without hormone-sensitive cancer history 1, 2

Common Pitfalls to Avoid

• Do not prescribe flibanserin without counseling about absolute alcohol prohibition - this combination causes severe hypotension and syncope 3
• Do not check drug interactions - flibanserin has numerous contraindicated medications via CYP3A4 inhibition 3
• Do not use PDE5 inhibitors in women expecting similar results to men - the evidence does not support this 4, 1, 2
• Do not ignore psychological factors - failing to address relationship and mental health issues will undermine treatment success 2
• Do not prescribe testosterone to women actively trying to conceive - it suppresses fertility 4
• Set realistic expectations - current pharmacological treatments have modest efficacy at best 1, 2

Treatment Algorithm

1. Screen for and address reversible causes (medications, medical conditions, relationship issues) 2
2. For premenopausal women with low libido: Offer flibanserin 100 mg at bedtime (if no contraindications) OR bremelanotide as needed 1, 3
3. For orgasm difficulties: Recommend vibrators/clitoral devices and pelvic physical therapy 4, 1
4. Concurrent psychological intervention: Refer for sex therapy or couples counseling 2
5. If first-line fails or contraindicated: Consider off-label bupropion or buspirone 1, 2
6. Address vaginal symptoms: Use water-, oil-, or silicone-based lubricants and vaginal moisturizers 2