What are the treatment options for decreased libido in women?

Treatment of Decreased Libido in Women

Start with non-hormonal vaginal lubricants and moisturizers for any concurrent vaginal symptoms, then proceed to psychosexual therapy (which succeeds in 50-80% of cases), and consider flibanserin for premenopausal women or DHEA for postmenopausal women if first-line approaches are insufficient. 1

Initial Assessment: Identify Reversible Causes

Before initiating treatment, systematically evaluate for modifiable contributors:

Menopausal and Vaginal Symptoms:

• Screen for vaginal dryness, dyspareunia, and atrophic vaginitis, which affects approximately 50% of postmenopausal women and directly impairs sexual desire 1, 2
• Unlike hot flashes, vaginal atrophy symptoms persist indefinitely without treatment 1

Medication Review:

• Antidepressants (particularly SSRIs), narcotics, and hormonal therapies commonly impair libido 1, 2
• This is a frequently overlooked but reversible cause 1

Psychological Factors:

• Assess for anxiety, depression, distress, body image concerns, relationship issues, and partner sexual dysfunction 1, 3, 2
• These psychological factors are common contributors and must be addressed for successful treatment 1

Medical Comorbidities:

• Evaluate for cardiovascular disease, diabetes, obesity, smoking, and alcohol abuse as traditional risk factors 3, 2

Treatment Algorithm

First-Line: Address Vaginal Symptoms

For all women with vaginal dryness or dyspareunia:

• Water-, oil-, or silicone-based vaginal lubricants and moisturizers are the recommended first-choice treatments 1, 3, 2
• Silicone-based products last longer than water-based or glycerin-based alternatives 3
• For postmenopausal women, vaginal estrogen (pills, rings, or creams) is the most effective treatment for vaginal dryness leading to sexual dysfunction 3

Pelvic floor physical therapy:

• Improves sexual pain, arousal, lubrication, orgasm, and satisfaction 3
• Particularly valuable for dyspareunia 3

Second-Line: Psychosexual Therapy

Psychosexual therapy demonstrates successful outcomes in 50-80% of patients and can be used alone or combined with physical therapies. 1, 2

Specific psychological approaches with evidence:

• Cognitive behavioral therapy (CBT) has demonstrated effectiveness for improving sexual functioning in women with low libido 3, 4
• Mindfulness has excellent evidence for improving low sexual desire 4
• Psychoeducational support, sexual counseling, and marital/couples therapy address relationship issues and psychological factors 3

Pharmacological Options

For Premenopausal Women:

Flibanserin (ADDYI):

• FDA-approved for acquired, generalized hypoactive sexual desire disorder in premenopausal women 1, 3, 2
• Results in approximately one additional satisfying sexual event every two months 3
• Critical safety warnings: 5
  • Must be taken only at bedtime (never during waking hours)
  • Absolutely no alcohol consumption close to bedtime dose or until the following day
  • Contraindicated with moderate or strong CYP3A4 inhibitors (including fluconazole, erythromycin, diltiazem, verapamil, and many HIV medications)
  • Contraindicated in liver disease
  • Risk of severe hypotension, syncope, and CNS depression
  • Not for use during breastfeeding

Bremelanotide:

• FDA-approved alternative for premenopausal women with hypoactive sexual desire disorder 3
• Administered as subcutaneous injection as needed before anticipated sexual activity 3

Off-label options with limited evidence:

• Bupropion may be considered as second-line despite limited safety and efficacy data 3
• Buspirone may be considered as second-line despite limited data 3

For Postmenopausal Women:

DHEA supplementation:

• 10-50 mg daily can be considered for persistent lack of libido and/or low energy levels 1, 2
• Vaginal DHEA (prasterone) has shown significant improvements in sexual desire, arousal, pain, and overall sexual function 3

Transdermal testosterone:

• Evidence supports use for low desire in postmenopausal women 4

Special Populations

Cancer Survivors:

• Sexual dysfunction affects at least 50% of women cancer survivors and is multifactorial 1
• Sexual health should be included in survivorship care plans, as this is frequently overlooked 1, 2
• For breast cancer survivors on aromatase inhibitors, vaginal dryness is significantly more common (18%) compared to tamoxifen (8%) 1
• Do not prescribe hormonal contraception to breast cancer survivors; use alternative non-hormonal methods 2
• Ospemifene may be considered for dyspareunia in survivors of cancers that are not hormonally sensitive 3

Critical Pitfalls to Avoid

Do NOT:

• Obtain testosterone levels in women in non-research settings—this is not recommended 1
• Prescribe PDE5 inhibitors (sildenafil) for female sexual dysfunction due to lack of effectiveness data 3
• Use vaginal laser therapy due to limited safety and effectiveness data and lack of FDA approval 3
• Prescribe hormonal therapies to women with estrogen-dependent cancers 3
• Overlook medication-induced sexual dysfunction, particularly from antidepressants and endocrine therapies 1
• Ignore vaginal symptoms, as dyspareunia and vaginal dryness contribute to sexual avoidance 3

When to Refer

Consider referral to a specialist menopause service when symptoms are refractory to initial management or when complex hormonal issues are present 1