What are the treatment options for low libido in females?

Treatment for Low Libido in Females

For premenopausal women with hypoactive sexual desire disorder (HSDD), flibanserin 100 mg daily at bedtime is the FDA-approved first-line pharmacological option, though it provides modest benefit of approximately one additional satisfying sexual event every two months, and should be combined with addressing underlying psychological, relationship, and vaginal symptoms. 1, 2

Initial Assessment and Contributing Factors

Before initiating treatment, identify and address reversible causes:

• Screen for medications that impair libido, particularly SSRIs, narcotics, and hormonal therapies 3, 4
• Evaluate for psychological factors including anxiety, depression, relationship distress, body image concerns, and partner sexual dysfunction 3, 1, 4
• Assess for vaginal symptoms such as dryness, dyspareunia, or atrophy that may lead to sexual avoidance 3, 1, 4
• Review traditional risk factors including cardiovascular disease, diabetes, obesity, smoking, and alcohol abuse 3, 4
• Consider cancer treatment effects if applicable, as chemotherapy and hormonal therapies significantly impact sexual desire 3, 1

Use the Brief Sexual Symptom Checklist for Women as a primary screening tool, with the Female Sexual Function Index for more comprehensive evaluation 3, 4

Non-Pharmacological First-Line Approaches

These should be initiated alongside or before pharmacological options:

• Cognitive behavioral therapy (CBT) has demonstrated effectiveness for improving sexual functioning in women with low libido 3, 5
• Mindfulness-based interventions show excellent evidence for improving low sexual desire 5
• Psychoeducation and sexual/couples counseling address relationship issues and psychological factors contributing to decreased libido 1, 5
• Lifestyle modifications including increased physical activity, smoking cessation, weight loss if overweight, and limiting alcohol consumption can improve sexual function 1, 6

For Concurrent Vaginal Symptoms

• Vaginal moisturizers, lubricants, and gels (water-, oil-, or silicone-based) are first-choice treatments for vaginal dryness and dyspareunia; silicone-based products last longer 3, 1, 4
• Pelvic floor physical therapy can improve sexual pain, arousal, lubrication, orgasm, and satisfaction 3, 1
• Vaginal estrogen (pills, rings, or creams) is the most effective treatment for vaginal dryness leading to sexual dysfunction in postmenopausal women 3

Pharmacological Treatment Options

For Premenopausal Women

First-line FDA-approved medications:

• Flibanserin (Addyi) 100 mg daily at bedtime is FDA-approved for acquired, generalized HSDD in premenopausal women 1, 7, 2

  • Results in approximately 1 additional satisfying sexual event every 2 months compared to placebo 1, 7
  • Critical safety warnings: Absolutely no alcohol consumption from the time of dosing until the following day due to severe risk of hypotension and syncope 2
  • Contraindicated with moderate or strong CYP3A4 inhibitors (including certain HIV medications, oral antifungals, antibiotics like ciprofloxacin and erythromycin, diltiazem, verapamil) 2
  • Contraindicated in liver disease 2
  • Must be taken only at bedtime; daytime dosing increases risk of hypotension, syncope, and accidents 2

• Bremelanotide (subcutaneous injection) is an alternative FDA-approved option administered as needed before anticipated sexual activity 3, 1, 7

Second-line off-label options (when first-line options are contraindicated or ineffective):

• Bupropion may be considered despite limited safety and efficacy data 3, 1, 7
• Buspirone may be considered despite limited data 3, 1, 7
• Androgens may be discussed, though not FDA-approved for HSDD 3, 7

For Postmenopausal Women

• Transdermal testosterone has evidence supporting its use for low desire in postmenopausal women 5, 8
• Vaginal DHEA (prasterone) has shown significant improvements in sexual desire, arousal, pain, and overall sexual function 1
• Ospemifene may be considered for concurrent dyspareunia in women without history of estrogen-dependent cancers 1, 7
• Off-label flibanserin may be considered, though most efficacy data is in premenopausal women 7

For Orgasm Difficulties

• Mechanical devices including vibrators or clitoral stimulatory devices with referral to appropriate specialists 3, 1, 7
• Pelvic physical therapy can help with orgasm difficulties 3, 7

What NOT to Use

• Phosphodiesterase type 5 inhibitors (PDE5i) such as sildenafil are NOT recommended for female sexual dysfunction due to contradictory results and lack of effectiveness data in women 1, 7
• Vaginal laser therapy is not recommended due to limited safety and effectiveness data and lack of FDA approval 1

Special Considerations for Cancer Survivors

• Treatment selection requires careful consideration of cancer type, particularly avoiding hormonal therapies in women with estrogen-sensitive cancers 1, 7, 4
• Hormonal therapies are contraindicated in patients with estrogen-dependent cancers 1
• Hormonal contraception is generally contraindicated in breast cancer survivors; use alternative non-hormonal methods 4

Common Pitfalls to Avoid

• Failing to address psychological and relationship factors that may be primary contributors will hinder treatment effectiveness 1
• Prescribing hormonal therapies without considering cancer history, especially estrogen-sensitive cancers, is dangerous 1
• Setting unrealistic expectations: Current pharmacological treatments show limited effectiveness, with flibanserin resulting in only about one additional satisfying sexual event every two months 1, 7
• Ignoring medication side effects: Many commonly prescribed medications (SSRIs, narcotics) significantly impair libido and should be reviewed 3, 4
• Not screening for vaginal symptoms: Dyspareunia and vaginal dryness often contribute to sexual avoidance and must be addressed concurrently 3, 1, 4