What are the diagnosis and treatment options for a woman with low libido?

Low Libido in Women: Diagnosis and Treatment

Initial Assessment

Screen systematically for reversible contributing factors before initiating treatment, as multiple biological, psychological, and relationship factors commonly contribute to decreased libido. 1, 2

Key History Elements to Obtain

• Medication review: Specifically assess for SSRIs, narcotics, hormonal therapies (including aromatase inhibitors), and spironolactone, which commonly impair libido 3, 1, 2
• Psychological factors: Screen for anxiety, depression, relationship distress, body image concerns, and partner sexual dysfunction 1, 2
• Vaginal symptoms: Ask about dryness, dyspareunia, or atrophy, as these contribute to sexual avoidance 1, 2
• Medical comorbidities: Evaluate for cardiovascular disease, diabetes, obesity, smoking, and alcohol abuse 1, 2
• Cancer history: Determine if patient has history of estrogen-sensitive cancers, as this significantly impacts treatment options 3, 1

Laboratory Evaluation

• Testosterone levels: Measure free testosterone or androgen index if hypogonadism suspected, though only mandatory if clinical evidence present 3
• Prolactin: Check if testosterone low or loss of libido present 3
• Thyroid function: Include in workup 3

Treatment Algorithm

First-Line: Non-Pharmacological Approaches

Begin with cognitive behavioral therapy (CBT) and address modifiable factors, as these interventions show 50-80% success rates and avoid medication risks. 1, 2

• Psychosexual therapy: CBT demonstrates effectiveness for improving sexual functioning in women with low libido 1, 2
• Couples therapy: Address relationship issues and communication problems 1
• Lifestyle modifications: Recommend increased physical activity, smoking cessation, weight loss if overweight, and limiting alcohol consumption 1

Treatment of Concurrent Vaginal Symptoms

Address vaginal dryness and dyspareunia aggressively, as these symptoms frequently drive sexual avoidance and worsen libido. 1, 2

• Vaginal lubricants and moisturizers: Use water-, oil-, or silicone-based products as first-choice treatment; silicone-based products last longer than water-based or glycerin-based options 1, 2
• Vaginal estrogen (pills, rings, or creams): Most effective treatment for vaginal dryness in postmenopausal women, effectively treating itching, discomfort, and painful intercourse 2
• Pelvic floor physical therapy: Improves sexual pain, arousal, lubrication, orgasm, and satisfaction 1, 2
• Vaginal DHEA (prasterone): Shows significant improvements in sexual desire, arousal, pain, and overall sexual function, particularly in breast or gynecologic cancer survivors 1, 2

Pharmacological Treatment Options

For Premenopausal Women

Flibanserin (100 mg once daily at bedtime) is the FDA-approved first-line pharmacological option for premenopausal women with hypoactive sexual desire disorder (HSDD), resulting in approximately one additional satisfying sexual event every two months. 1, 2, 4

Flibanserin Key Prescribing Information:

• Dosing: 100 mg orally once daily at bedtime 4
• Critical contraindications: Alcohol use within 2 hours of dosing, moderate or strong CYP3A4 inhibitors, hepatic impairment 4
• Alcohol warning: Patients must wait at least 2 hours after consuming 1-2 standard drinks before taking flibanserin; skip dose if consumed 3+ drinks that evening 4
• Discontinuation: Stop after 8 weeks if no symptom improvement 4
• Common side effects: Dizziness, somnolence, nausea, and fatigue 3

Alternative FDA-Approved Option:

• Bremelanotide: Subcutaneous injection administered as needed before anticipated sexual activity; demonstrated statistically significant increases in sexual desire and reductions in distress in phase III trials 1, 2

Second-Line Off-Label Options

Consider bupropion or buspirone as second-line options when FDA-approved medications are contraindicated or ineffective, though evidence is limited. 1, 2

• Bupropion: Small studies suggest improvement in sexual function, particularly in breast cancer survivors 2
• Buspirone: May be considered despite limited data 1, 2

For Postmenopausal Women

Testosterone therapy demonstrates efficacy in postmenopausal women with low desire, though not FDA-approved for this indication, and may not be effective without adequate circulating estrogen. 2

Special Population: Cancer Survivors

Exercise extreme caution with hormonal therapies in cancer survivors, particularly those with estrogen-sensitive cancers, where hormonal treatments are contraindicated. 3, 1

• Avoid: Hormonal therapies in patients with estrogen-dependent cancers 1
• Ospemifene: May be considered for dyspareunia in survivors of cancers that are not hormonally sensitive, though contraindicated in estrogen-dependent cancers 3, 1
• Vaginal DHEA: Preferred hormonal option showing significant improvements in sexual desire, arousal, pain, and overall sexual function in breast or gynecologic cancer survivors 1, 2

Special Population: Advanced Liver Disease

In women with advanced liver disease, altered estrogen metabolism and disruption of the hypothalamic-pituitary axis commonly cause anovulation, amenorrhea, and decreased libido. 3

• Evaluation: Check sex hormone levels and thyroid function 3
• Referral: Refer to appropriate specialists for evaluation and management 3
• Differential diagnosis: Consider psychogenic causes, alcohol use, medication effects (especially spironolactone and beta-blockers), and autonomic dysfunction 3

What NOT to Use

Do not prescribe PDE5 inhibitors (such as sildenafil) for female sexual dysfunction, as they lack effectiveness data in women. 1

Avoid vaginal laser therapy, as it lacks FDA approval for this indication and has limited safety and effectiveness data. 1

Common Pitfalls to Avoid

• Failing to screen for medication side effects: SSRIs, narcotics, and hormonal therapies commonly impair libido and should be identified early 1, 2
• Ignoring vaginal symptoms: Not addressing dyspareunia and vaginal dryness contributes to sexual avoidance and worsens libido 1
• Prescribing hormonal therapies without cancer history: Always determine if patient has estrogen-sensitive cancer history before considering hormonal options 1
• Overlooking relationship and psychological factors: These are frequently primary contributors and require direct intervention 1, 2
• Automatic attribution to "normal aging": Low libido in older women should not be dismissed; many contributing factors are addressable 5