What are the treatment options for decreased libido in women?

Treatment of Decreased Libido in Women

For premenopausal women with decreased libido, start with non-hormonal vaginal lubricants for any concurrent vaginal dryness, followed by psychosexual counseling (which achieves success in 50-80% of patients), and consider flibanserin 100 mg at bedtime as a pharmacological option if initial approaches fail—though it provides only modest benefit of approximately one additional satisfying sexual event every two months. 1, 2, 3

Initial Assessment: Identify Reversible Contributing Factors

Before initiating treatment, systematically screen for modifiable causes:

• Medication review: Antidepressants (especially SSRIs), narcotics, hormonal therapies, spironolactone, and beta-blockers are the most common culprits for libido impairment 1, 2
• Psychological factors: Depression, anxiety, chronic stress, body image concerns, relationship distress, and partner sexual dysfunction significantly contribute to decreased libido 1, 2
• Vaginal symptoms: Assess for dryness, dyspareunia, or atrophy—these directly impact sexual desire and lead to sexual avoidance 4, 1, 2
• Medical comorbidities: Evaluate cardiovascular disease, diabetes, obesity, smoking, and alcohol abuse as traditional risk factors 1, 2
• Cancer treatment effects: Chemotherapy and hormonal therapies (particularly aromatase inhibitors) significantly affect sexual desire, with aromatase inhibitors causing vaginal dryness in 18% versus 8% with tamoxifen 4, 2

First-Line Non-Pharmacological Treatments

Vaginal Symptom Management

• Non-hormonal lubricants and moisturizers are the primary recommended treatment for vaginal dryness and dyspareunia 4, 1, 2
• Silicone-based products last longer than water-based or glycerin-based options 4, 1
• Combination therapy may provide additional short-term benefit 4, 2

Psychological and Behavioral Interventions

• Psychoeducational support, sexual counseling, and marital/couples therapy achieve successful outcomes in 50-80% of patients 4, 2
• Cognitive behavioral therapy (CBT) has demonstrated effectiveness for improving sexual functioning in women with low libido 1
• Brief psychoeducational interventions addressing anxiety, stress, and mood changes should be offered to all patients with sexual complaints 4, 2

Lifestyle Modifications

• Increased physical activity, smoking cessation, weight loss if overweight, and limiting alcohol consumption can improve sexual function 1
• Pelvic floor physical therapy can help with sexual pain, arousal, lubrication, orgasm, and overall satisfaction 1

Pharmacological Treatment Options

FDA-Approved Medications for Premenopausal Women

Flibanserin (Addyi):

• Dosing: 100 mg once daily at bedtime only 1, 3
• Efficacy: Results in approximately 1 additional satisfying sexual event every 2 months compared to placebo 1, 5, 3
• Critical safety warnings:
  • Absolutely no alcohol consumption close to bedtime dose or until the following day due to severe risk of hypotension and syncope 3
  • Contraindicated with moderate or strong CYP3A4 inhibitors (including fluconazole, erythromycin, ciprofloxacin, diltiazem, verapamil, HIV protease inhibitors) 3
  • Contraindicated in patients with liver problems 3
  • Must be taken only at bedtime—daytime dosing increases risk of hypotension, syncope, and accidental injury 3
• Common side effects: CNS depression, somnolence, sedation—avoid activities requiring full alertness for at least 6 hours after dosing 3

Bremelanotide:

• Administered as subcutaneous injection as needed before anticipated sexual activity 1, 5
• Alternative FDA-approved option for premenopausal women with hypoactive sexual desire disorder 1, 5
• Mechanism: melanocortin receptor agonist 5

Second-Line Off-Label Options

When first-line treatments fail or are contraindicated:

• Bupropion: Off-label option with limited safety and efficacy data but considered by expert panels 1, 5
• Buspirone: Off-label option with limited data but considered by expert panels 1, 5

Postmenopausal Women Considerations

• Vaginal estrogen (pills, rings, or creams) is the most effective treatment for vaginal dryness leading to sexual dysfunction in postmenopausal women, though results take 6-12 weeks 4, 1
• Ospemifene may be considered for dyspareunia in postmenopausal women with no history of estrogen-dependent cancers 1, 5
• Vaginal DHEA (prasterone) has shown significant improvements in sexual desire, arousal, pain, and overall sexual function in survivors of breast or gynecologic cancer 1

Special Population: Cancer Survivors

• Sexual dysfunction affects at least 50% of cancer survivors and is frequently overlooked 2
• Treatment selection requires careful consideration based on cancer type, particularly for hormone-sensitive cancers 1, 5
• Do not prescribe hormonal therapies to women on aromatase inhibitors 4, 1
• The level of estrogen absorption from vaginal preparations is variable, raising concerns in patients with breast cancer history 4

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 1, 5
• Vaginal laser therapy is not currently recommended due to limited safety and effectiveness data and lack of FDA approval for this indication 1
• Hormonal contraception should not be prescribed to breast cancer survivors—use alternative non-hormonal methods 2

Critical Pitfalls to Avoid

• Failing to address psychological and relationship factors that may be primary contributors to decreased libido hinders effective treatment 1
• Not screening for medication-induced dysfunction, particularly from antidepressants and endocrine therapies which profoundly impact desire and arousal 2
• Ignoring vaginal symptoms such as dyspareunia and vaginal dryness contributes to sexual avoidance and decreased libido 1
• Prescribing hormonal therapies without considering cancer history, especially estrogen-sensitive cancers 1
• Assuming libido decline is "normal aging": Open, directed inquiry in clinic provides opportunity for patients to disclose dysfunction that they may not volunteer 2
• Overlooking partner factors: Partner sexual dissatisfaction negatively affects sexual function recovery, and many couples require support to recover sexual intimacy 2

Treatment Algorithm Summary

1. Screen and address reversible factors: medications, psychological issues, vaginal symptoms, medical comorbidities 1, 2
2. First-line: Non-hormonal vaginal lubricants/moisturizers for dryness + psychosexual counseling/CBT 4, 1, 2
3. Lifestyle modifications: Exercise, stress reduction, relationship counseling as appropriate 1
4. Pharmacological (premenopausal): Flibanserin 100 mg at bedtime OR bremelanotide as needed 1, 5, 3
5. Pharmacological (postmenopausal): Vaginal estrogen for dryness, consider ospemifene if no estrogen-dependent cancer history 1
6. Second-line: Bupropion or buspirone if first-line options fail or are contraindicated 1, 5