Treatment for Female Sexual Desire Dysfunction
Treatment should be tailored to menopausal status: premenopausal women with hypoactive sexual desire disorder (HSDD) should receive flibanserin (FDA-approved) or bremelanotide as first-line pharmacotherapy, while postmenopausal women benefit most from transdermal testosterone therapy. 1, 2, 3, 4
Initial Assessment and Contributing Factors
Before initiating treatment, identify and address modifiable contributors to sexual dysfunction:
- Screen for medications that impair desire, particularly hormone therapy, narcotics, and serotonin reuptake inhibitors, as these are common iatrogenic causes 5
- Evaluate for depression, anxiety, relationship problems, and substance use, as psychosocial factors frequently contribute to or exacerbate desire disorders 5, 6
- Assess traditional cardiovascular risk factors including diabetes, obesity, smoking, and alcohol abuse, which independently affect sexual function 5
- Determine menopausal status, as this fundamentally guides treatment selection 5
Treatment Algorithm by Menopausal Status
Premenopausal Women with HSDD
Pharmacological options:
Flibanserin 100 mg orally once daily at bedtime is FDA-approved for acquired, generalized HSDD in premenopausal women 1, 2
- Must be taken at bedtime to reduce risks of hypotension, syncope, and CNS depression 2
- Critical contraindications: alcohol within 2 hours of dosing, moderate or strong CYP3A4 inhibitors, and hepatic impairment 2
- Discontinue after 8 weeks if no symptom improvement 2
- Expect modest benefits above placebo with potential side effects 3
Bremelanotide (subcutaneous injection as needed) is an FDA-approved alternative for premenopausal HSDD 1
Non-pharmacological approaches:
- Cognitive behavioral therapy with mindfulness focus has excellent evidence for improving low sexual desire 3, 6
- Psychoeducation and office-based counseling provide foundational support 4, 6
- Sexual/couples counseling addresses relationship dynamics that commonly contribute to desire disorders 5
Postmenopausal Women with Low Desire
Pharmacological options:
- Transdermal testosterone has demonstrated efficacy for treating loss of desire in postmenopausal women, though it lacks FDA approval for this indication and has limited long-term safety data 3, 4
- Vaginal estrogen (pills, rings, or creams) effectively treats vaginal dryness, itching, and dyspareunia that may secondarily impair desire 5, 7
Non-pharmacological approaches:
- Water-based or silicone-based lubricants for sexual activity and vaginal moisturizers applied 3-5 times weekly should be first-line therapy 7
- Cognitive behavioral therapy and mindfulness remain effective psychological interventions 3, 6
Special Considerations for Breast Cancer Survivors
- Try non-hormonal options first at higher frequency before considering hormonal therapy 7
- Estriol-containing preparations may be preferable over estradiol for women on aromatase inhibitors, as estriol is a weaker estrogen that cannot be converted to estradiol 7
- Intravaginal testosterone cream has shown safety and efficacy in postmenopausal breast cancer survivors on aromatase inhibitors 7
- Discuss risks and benefits thoroughly if vaginal estrogen is needed, though retrospective studies suggest no adverse effects on breast cancer outcomes 7
Additional Therapeutic Modalities
For concomitant arousal or pain disorders:
- Pelvic floor muscle training improves sexual pain, arousal, lubrication, orgasm, and satisfaction 5, 1
- Vaginal dilators for vaginismus, sexual aversion disorder, or vaginal stenosis, though evidence for effectiveness is limited 5, 1
- Intravaginal DHEA (prasterone) is FDA-approved for vaginal dryness and dyspareunia in postmenopausal women, improving desire, arousal, pain, and overall function (contraindicated in breast cancer history) 7, 1
- Ospemifene (oral SERM) is FDA-approved for moderate to severe dyspareunia in postmenopausal women without breast cancer history 7, 1
What NOT to Use
Phosphodiesterase type 5 inhibitors (sildenafil) are explicitly NOT recommended for female sexual dysfunction due to contradictory results in randomized trials and insufficient evidence of effectiveness 5, 1
Common Pitfalls to Avoid
- Do not prescribe flibanserin without counseling about alcohol restrictions, as concurrent use dramatically increases hypotension and syncope risk 2
- Do not use systemic estrogen therapy solely for low desire in the absence of vasomotor symptoms, as it is not directly associated with desire improvement 4
- Do not overlook relationship factors, as partner communication and relationship quality significantly impact treatment success 5
- Do not assume all sexual dysfunction is desire-related—treatment must be guided to the specific type of problem (desire, arousal, orgasm, or pain) 5