What are the treatment options for low libido in women?

Treatment of Low Libido in Women

For premenopausal women with hypoactive sexual desire disorder (HSDD), flibanserin 100 mg daily at bedtime or bremelanotide subcutaneous injection as needed before sexual activity are the FDA-approved first-line pharmacological options, though their efficacy is modest—adding approximately one additional satisfying sexual event every two months. 1, 2, 3, 4

Initial Assessment: Identify Reversible Contributing Factors

Before initiating treatment, systematically screen for modifiable causes:

Medication Review:

• SSRIs, narcotics, and hormonal therapies commonly impair libido and should be evaluated for discontinuation or switching 1
• Antidepressants are particularly problematic contributors 5

Medical Conditions to Evaluate:

• Cardiovascular disease, diabetes, obesity, thyroid disorders, and liver disease 1, 5
• Morning testosterone testing (free testosterone or androgen index preferred) if hypogonadism suspected 5
• TSH and free T4 if thyroid dysfunction suspected 5
• Prolactin level if low testosterone with loss of libido 5

Psychological and Relationship Factors:

• Anxiety, depression, body image concerns, relationship distress, and partner sexual dysfunction 1, 5
• These psychological factors often contribute significantly and require addressing 2

Vaginal Symptoms:

• Dryness, dyspareunia (painful intercourse), or atrophy may lead to sexual avoidance 1, 5

Lifestyle Risk Factors:

• Smoking, alcohol abuse, and sedentary lifestyle 1

Treatment Algorithm

Step 1: Non-Pharmacological First-Line Approaches

Cognitive Behavioral Therapy (CBT):

• Demonstrates effectiveness for sexual functioning with 50-80% success rates 1, 5
• Can be used alone or combined with physical therapies 5

Address Vaginal Symptoms (if present):

• Vaginal moisturizers and lubricants (water-, oil-, or silicone-based) are first-choice treatments, with silicone-based products lasting longer 1, 5
• Vaginal estrogen (pills, rings, or creams) is the most effective treatment for postmenopausal vaginal dryness leading to sexual dysfunction 1
• Pelvic floor physical therapy improves sexual pain, arousal, lubrication, orgasm, and satisfaction 1

Lifestyle Modifications:

• Increased physical activity, smoking cessation, weight loss if overweight, and limiting alcohol consumption 1, 6
• Mindfulness and yoga can enhance sexual satisfaction 6

Psychosexual Therapy:

• Individual or couples therapy to address relationship issues 1, 5

Step 2: FDA-Approved Pharmacological Options for Premenopausal Women

Flibanserin (ADDYI):

• Dosing: 100 mg daily at bedtime only 1, 2, 4
• Efficacy: Approximately 1 additional satisfying sexual event every 2 months compared to placebo 1, 2
• Critical Safety Warnings:
  • Contraindicated with alcohol—do not drink alcohol close to bedtime dose or until the following day due to severe hypotension and syncope risk 4
  • Contraindicated with moderate/strong CYP3A4 inhibitors (certain HIV medications, antifungals, antibiotics, hepatitis C drugs, calcium channel blockers) 4
  • Must be taken at bedtime only; daytime dosing increases risk of hypotension, syncope, and CNS depression 4
  • Avoid activities requiring alertness for at least 6 hours after dose 4

Bremelanotide (VYLEESI):

• Dosing: Subcutaneous injection as needed at least 45 minutes before anticipated sexual activity 1, 2, 3
• Limitations: Maximum 1 dose per 24 hours, no more than 8 doses per month 3
• Side Effects: Transient increase in blood pressure and decrease in heart rate (usually resolves within 12 hours), nausea (most common with first injection), focal hyperpigmentation (may not fully resolve after discontinuation) 3
• Contraindications: Uncontrolled hypertension, known cardiovascular disease 3

Step 3: Second-Line/Off-Label Options

Bupropion:

• Off-label option with limited safety and efficacy data but considered by expert panels 1, 2

Buspirone:

• Off-label option with limited data but considered by expert panels 1, 2

Vaginal DHEA (Prasterone):

• Significant improvements in sexual desire, arousal, pain, and overall function in breast or gynecologic cancer survivors 1

DHEA Supplementation:

• 10-50 mg daily for persistent lack of libido and/or low energy in postmenopausal women 5

Step 4: Special Populations

Postmenopausal Women:

• Ospemifene may be considered for concurrent dyspareunia in women without estrogen-dependent cancer history 1, 2
• Off-label use of flibanserin can be considered, though data in postmenopausal women is limited 2

Cancer Survivors:

• Treatment selection requires careful consideration based on cancer type, particularly for hormone-sensitive cancers 1, 2
• Hormonal therapies contraindicated in estrogen-dependent cancers 1
• Sexual health should be included in survivorship care plans 5

What NOT to Use

Phosphodiesterase Type 5 Inhibitors (PDE5i):

• Not recommended for female sexual dysfunction due to contradictory results and lack of effectiveness data in women 1, 2

Vaginal Laser Therapy:

• Not recommended due to limited safety and effectiveness data and lack of FDA approval 1

Hormonal Therapies in Specific Contexts:

• Avoid in women with estrogen-dependent cancers 1
• Not recommended for women on aromatase inhibitors 1

Common Pitfalls to Avoid

• Ignoring psychological and relationship factors that may be primary contributors hinders effective treatment 1
• Not screening for vaginal symptoms (dyspareunia, dryness) can perpetuate sexual avoidance 1
• Failing to review medications (especially SSRIs, narcotics, hormonal therapies) that impair libido 1
• Unrealistic expectations: Current pharmacological treatments show limited effectiveness—flibanserin results in only about one additional satisfying sexual event every two months 2
• Prescribing hormonal therapies without considering cancer history is contraindicated in estrogen-sensitive cancers 1

Validated Assessment Tools

• Brief Sexual Symptom Checklist for Women for primary screening 5
• Female Sexual Function Index (FSFI) for comprehensive evaluation 5

When to Reassess or Refer

• If symptoms have not improved after 8 weeks of treatment with FDA-approved medications, reassess the diagnosis and contributing factors 3
• Refer to appropriate specialists when multiple endocrine abnormalities identified or when initial screening reveals important abnormalities requiring specialized evaluation 5