Medications to Help Women with Sexual Orgasms
For premenopausal women with difficulty achieving orgasm and low sexual desire, flibanserin (Addyi) 100 mg taken once daily at bedtime is the only FDA-approved medication, though its efficacy is modest—resulting in approximately one additional satisfying sexual event every two months compared to placebo. 1, 2, 3
Understanding the Indication
Flibanserin is specifically FDA-approved for acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women—not directly for orgasmic dysfunction alone. 2 The medication addresses low sexual desire that causes marked distress and is not due to medical/psychiatric conditions, relationship problems, or medication effects. 2
First-Line Treatment Approach
For Women with Low Desire AND Orgasm Difficulties:
Flibanserin 100 mg at bedtime is the primary pharmacological option, working by increasing dopamine and norepinephrine (sexual excitement) while decreasing serotonin (sexual inhibition). 1, 4, 5
Bremelanotide (subcutaneous injection as needed) is an alternative FDA-approved option for premenopausal women with HSDD, administered before anticipated sexual activity. 1, 6
For Orgasm Difficulties Specifically:
Mechanical devices (vibrators, clitoral stimulatory devices) with specialist referral are recommended first-line treatments for anorgasmia. 1, 6
Pelvic floor physical therapy can improve orgasm difficulties, arousal, lubrication, and overall sexual function. 7, 1
What NOT to Use
Phosphodiesterase type 5 inhibitors (PDE5i) such as sildenafil are NOT recommended for female sexual dysfunction due to contradictory clinical trial results and lack of effectiveness data in women. 7, 1, 6 Despite theoretical mechanisms to increase pelvic blood flow, randomized trials have failed to demonstrate benefit. 7
Second-Line/Off-Label Options
Bupropion may be considered off-label for HSDD despite limited safety and efficacy data. 1, 6
Buspirone is another off-label option with limited supporting evidence. 1, 6
To date, no pharmacological trials (including bupropion, granisetron, or sildenafil) have proven beneficial beyond placebo specifically for Female Orgasmic Disorder. 8
Critical Safety Considerations for Flibanserin
Absolute Contraindications:
Alcohol consumption close to bedtime dosing or until the following day—severe risk of hypotension and syncope. 2
Moderate or strong CYP3A4 inhibitors including certain HIV medications, antifungals (fluconazole, ketoconazole), antibiotics (ciprofloxacin, erythromycin, clarithromycin), and cardiac medications (diltiazem, verapamil). 2
Liver problems of any severity. 2
Common Adverse Effects:
Dizziness, somnolence, nausea, and rarely syncope—comparable to other CNS medications. 4, 5, 3
Must be taken only at bedtime; daytime dosing increases risk of hypotension, syncope, and accidental injury. 2
Non-Pharmacological Approaches (Often More Effective)
Cognitive-behavioral therapy has demonstrated effectiveness for orgasmic dysfunction, promoting attitude changes and anxiety reduction through directed masturbation, sensate focus, systematic desensitization, sex education, and communication skills training. 1, 6, 8
Addressing vaginal symptoms with water-, oil-, or silicone-based lubricants and moisturizers (silicone-based products last longer). 1, 6
Vaginal estrogen (pills, rings, creams) is most effective for postmenopausal vaginal dryness contributing to sexual dysfunction. 7, 6
Special Population Considerations
Cancer Survivors:
Treatment selection requires careful consideration of cancer type, particularly avoiding hormonal therapies in estrogen-sensitive cancers. 7, 1, 6
Vaginal DHEA (prasterone) has shown improvements in sexual desire, arousal, pain, and function in breast or gynecologic cancer survivors. 6
Postmenopausal Women:
Flibanserin is not FDA-approved for postmenopausal women, though some efficacy data exists in this population. 1, 2, 5
Ospemifene may be considered for concurrent dyspareunia in women without estrogen-dependent cancer history. 1, 6
Common Pitfalls to Avoid
Prescribing flibanserin without screening for contributing medications (SSRIs, narcotics, hormonal therapies) that impair libido. 6
Ignoring psychological and relationship factors that are often primary contributors requiring psychotherapy or couples counseling. 7, 1, 6
Failing to address concurrent vaginal symptoms (dryness, dyspareunia) that contribute to sexual avoidance. 7, 6
Not counseling about modest efficacy—flibanserin results in only about one additional satisfying sexual event every two months. 1, 3