What medications are available to treat low libido in premenopausal and postmenopausal women with hypoactive sexual desire disorder (HSDD)?

Medications for Low Libido in Women

FDA-Approved Pharmacologic Options

For premenopausal women with hypoactive sexual desire disorder (HSDD), flibanserin (100 mg once daily at bedtime) is the primary FDA-approved medication, resulting in approximately one additional satisfying sexual event every two months. 1, 2, 3

Flibanserin (Addyi)

• Indicated specifically for acquired, generalized HSDD in premenopausal women characterized by low sexual desire causing marked distress or interpersonal difficulty 3
• Dosing: 100 mg once daily at bedtime only 2
• Improves desire scores and reduces sexual distress 2
• Not indicated for postmenopausal women, men, or to enhance sexual performance 3

Bremelanotide

• Alternative FDA-approved option for premenopausal women with HSDD 1, 2
• Administered as subcutaneous injection as needed before anticipated sexual activity 1, 2
• Demonstrated statistically significant increases in sexual desire and reductions in distress in phase III trials 2

Off-Label Pharmacologic Options

Bupropion

• May be considered as second-line off-label treatment despite limited safety and efficacy data 4, 1
• Small studies suggest improvement in sexual function, particularly in breast cancer survivors 4
• Has shown benefit in some women with and without depression 5

Buspirone

• May be considered as second-line off-label option, though data are limited 4, 1

Postmenopausal Women: Special Considerations

Testosterone Therapy

• Has demonstrated efficacy in postmenopausal women with low desire, though not FDA-approved for this indication 2, 5
• Limited long-term safety data exist 2, 5
• May not be effective without adequate circulating estrogen 4
• Cannot be recommended after breast cancer due to safety concerns 4

Vaginal DHEA (Prasterone)

• Shown significant improvements in sexual desire, arousal, pain, and overall sexual function in survivors of breast or gynecologic cancer 1
• Can be considered for vaginal dryness or pain with sexual activity 4

Addressing Concurrent Vaginal Symptoms

Vaginal estrogen (pills, rings, or creams) is the most effective treatment for vaginal dryness leading to sexual dysfunction in postmenopausal women 4, 1, 2

• Effectively treats itching, discomfort, and painful intercourse 4
• Large cohort study of almost 50,000 breast cancer patients showed no evidence of higher breast cancer-specific mortality with vaginal estrogen use 4
• For women on aromatase inhibitors, estriol-containing agents (such as Ovestin) will not increase circulating estradiol, though safety is not fully established 4

Non-Hormonal Vaginal Treatments

• Water-, oil-, or silicone-based lubricants and vaginal moisturizers are first-choice treatments for vaginal dryness 1, 6, 2
• Silicone-based products last longer than water-based or glycerin-based products 1

Ospemifene

• May be considered for dyspareunia in survivors of cancers that are not hormonally sensitive 1
• Selective estrogen receptor modulator that can be used as alternative to vaginal estrogen 5

Non-Pharmacologic Interventions

Psychotherapy

• Cognitive behavioral therapy (CBT) has demonstrated effectiveness for improving sexual functioning 4, 1, 2
• Psychosexual therapy shows successful outcomes in 50-80% of patients 6
• Sexual counseling and couples therapy can address relationship issues 1

Pelvic Floor Physical Therapy

• Can improve sexual pain, arousal, lubrication, orgasm, and satisfaction 4, 1, 2
• Particularly helpful for women with associated pelvic floor dysfunction 4

Mechanical Devices

• Vibrators or clitoral stimulatory devices are recommended first-line treatments for anorgasmia 1

What NOT to Use

Phosphodiesterase type 5 inhibitors (PDE5i) such as sildenafil are not recommended for female sexual dysfunction due to lack of effectiveness data in women 1

• Although animal and human studies showed increases in vaginal blood flow, this has not translated into improved sexual response in placebo-controlled studies 4

Vaginal laser therapy is not currently recommended due to limited safety and effectiveness data and lack of FDA approval for this indication 1

Critical Assessment Steps Before Treatment

Screen for Reversible Contributing Factors

• Medications that impair libido, particularly SSRIs, narcotics, and hormonal therapies 1
• Consider stopping SSRIs/SNRIs as these may reduce libido and cause anorgasmia 4
• Psychological factors: anxiety, depression, relationship distress, body image concerns 1, 6
• Traditional risk factors: cardiovascular disease, diabetes, obesity, smoking, alcohol abuse 1

Use Validated Screening Tools

• Brief Sexual Symptom Checklist for Women as primary screening tool 6
• Female Sexual Function Index (FSFI) for more comprehensive evaluation 6
• Decreased Sexual Desire Screener validated for use in general practice 7, 8

Common Pitfalls to Avoid

• Failing to distinguish between desire, arousal, and pain disorders—treatment must be tailored to the specific dysfunction 2
• Not screening for vaginal symptoms such as dyspareunia and vaginal dryness, which can contribute to sexual avoidance 1
• Prescribing hormonal therapies without considering cancer history, especially estrogen-sensitive cancers 1
• Ignoring relationship issues and depression, which are major contributors requiring concurrent management 2
• Avoiding progestins with anti-androgenic effects in women with iatrogenic premature ovarian insufficiency, as they may worsen hypoandrogenism 2