What are the potential causes and treatment options for decreased libido in females, particularly in postmenopausal women?

Decreased Libido in Females: Causes and Treatment

For decreased libido in females, start with non-hormonal vaginal lubricants and moisturizers for any concurrent vaginal symptoms, followed by cognitive behavioral therapy or psychosexual counseling, and consider FDA-approved flibanserin for premenopausal women or bremelanotide as needed before sexual activity when first-line approaches fail. 1

Initial Assessment: Identify Reversible Contributing Factors

Screen systematically for the following modifiable causes:

• Medications: SSRIs, narcotics, hormonal therapies (especially aromatase inhibitors in breast cancer survivors), spironolactone, and beta-blockers are the most common culprits 1, 2
• Psychological factors: Depression, anxiety, chronic stress, body image concerns, relationship conflicts, and partner sexual dysfunction 1, 2
• Vaginal symptoms: Dryness, dyspareunia, atrophy (affects ~50% of postmenopausal women) 2
• Medical comorbidities: Cardiovascular disease, diabetes, obesity, chronic liver disease, cancer and its treatments 1, 2
• Lifestyle factors: Smoking, excessive alcohol use, sedentary behavior 1
• Hormonal: Loss of estrogens and androgens, elevated prolactin 3

Critical point: Cancer survivors, particularly those who received chemotherapy or hormonal therapies, have significantly increased risk—sexual dysfunction affects at least 50% of cancer survivors and is frequently overlooked 2. Chemotherapy-induced menopause is a major contributor in breast cancer survivors 4.

Treatment Algorithm

Step 1: Address Vaginal Symptoms First (if present)

• First-line: Water-, oil-, or silicone-based vaginal lubricants and moisturizers 1, 2

  • Silicone-based products last longer than water-based or glycerin-based options 1, 2
  • This addresses the physical barrier to sexual activity that drives avoidance behavior 2

• For postmenopausal women: Vaginal estrogen (pills, rings, creams) is the most effective treatment for vaginal dryness leading to sexual dysfunction 1

  • Exception: Avoid in women with estrogen-sensitive cancers 1
  • Consider vaginal DHEA (prasterone) in cancer survivors—shows significant improvements in desire, arousal, pain, and overall function 1
  • Ospemifene may be used for dyspareunia in survivors of non-hormonally sensitive cancers 1

• Pelvic floor physical therapy: Improves sexual pain, arousal, lubrication, orgasm, and satisfaction 4, 1

Step 2: Non-Pharmacological Interventions

• Cognitive behavioral therapy (CBT): Demonstrated effectiveness for improving sexual functioning, particularly in breast cancer survivors 4, 1

• Psychosexual counseling: Achieves success in 50-80% of patients 2

  • Address anxiety, stress, mood changes, relationship distress 2
  • Include partner in therapy when relationship factors are present 2

• Lifestyle modifications: Increased physical activity, smoking cessation, weight loss if overweight, limiting alcohol 1

Step 3: Pharmacological Options for Low Desire

For premenopausal women:

• Flibanserin (FDA-approved): Results in approximately one additional satisfying sexual event every two months 1

  • Indicated for acquired, generalized hypoactive sexual desire disorder 1

• Bremelanotide (FDA-approved alternative): Subcutaneous injection administered as needed before anticipated sexual activity 1

• Second-line off-label options (limited data):

  • Bupropion 4, 1
  • Buspirone 4, 1

For postmenopausal women:

• Menopausal hormone therapy can improve sexual function when symptoms are menopause-related 4
• Androgens may be discussed as an option despite limited safety and efficacy data 4, 1

Special Populations and Critical Pitfalls

Cancer Survivors

• Do NOT prescribe: Hormonal contraception to breast cancer survivors—use barrier methods, copper IUDs, or male contraception instead 4
• Do NOT use: Hormonal therapies in women on aromatase inhibitors 1
• Caution with vaginal hormones: Low-dose vaginal estrogens (10-mg estradiol tablet, 4-mg estrogen insert) may be considered with careful discussion about lack of long-term safety data during concurrent aromatase inhibitor use 4
• CO2 laser therapy has observational data but lacks randomized trial evidence and FDA approval—use with caution 4

What NOT to Use

• PDE5 inhibitors (sildenafil): Not recommended for female sexual dysfunction due to contradictory results and lack of effectiveness data 1
• Vaginal laser therapy: Not currently recommended due to limited safety data and lack of FDA approval 1

Common Pitfalls to Avoid

• Failing to screen for medication side effects: Antidepressants and hormonal therapies profoundly impact desire and arousal 2
• Ignoring vaginal symptoms: Dyspareunia and dryness drive sexual avoidance and must be treated first 1, 2
• Not addressing psychological and relationship factors: These are often primary contributors and require direct intervention 1
• Assuming decline is "normal aging": Open, directed inquiry provides opportunity for patients to disclose dysfunction they may not volunteer 2
• Overlooking partner factors: Partner sexual dysfunction and dissatisfaction significantly impact treatment success 2
• Prescribing hormones without cancer history review: Especially critical in estrogen-sensitive cancers 1

Sexual dysfunction is multifactorial and requires a systematic approach addressing physiologic, psychological, and interpersonal factors simultaneously 4. The most recent NCCN guidelines (2024) emphasize that treatment requires a multidimensional plan tailored to underlying causes 4.