What are the causes and treatment options for decreased sexual desire in women, particularly those with a history of depression, anxiety, or physical conditions such as thyroid disorders, diabetes, or cardiovascular disease, and who may be peri-menopausal, post-menopausal, or premenopausal with hypoactive sexual desire disorder?

Decreased Sexual Desire in Women

Decreased sexual desire in women requires systematic evaluation for underlying medical, psychiatric, and relationship factors, followed by targeted treatment addressing the specific etiology—with cognitive behavioral therapy and pharmacologic options like flibanserin (for premenopausal women with HSDD) or testosterone (off-label for postmenopausal women) when appropriate.

Epidemiology and Impact

Hypoactive sexual desire disorder (HSDD) affects 8.9% of women ages 18-44,12.3% ages 45-64, and 7.4% over age 65 1. While low desire increases with age, associated distress decreases, keeping HSDD prevalence relatively constant across age groups 1. This condition significantly impairs quality of life, general happiness, satisfaction with partners, and is associated with more frequent negative emotional states 1.

Diagnostic Approach

Essential Screening Elements

• Screen all women at regular intervals about sexual function concerns, distress regarding sexual activity, and impact on relationships 2
• Use the Decreased Sexual Desire Screener (DSDS) for primary care settings—validated for clinicians not specialized in sexual dysfunction 3, 4
• For comprehensive assessment, employ the Female Sexual Function Index 2

Key Historical Components

Depression and anxiety must be assessed before sexual activity engagement, as these conditions have detrimental effects on sexual desire and are strongly associated with sexual disorders 2. Specifically evaluate:

• Psychiatric comorbidities: Depression is a major contributing cause of decreased libido, difficulty with arousal and orgasm 2
• Medications: Serotonin reuptake inhibitors, narcotics, and hormone therapy can suppress desire 2
• Medical conditions: Cardiovascular disease, diabetes, thyroid disorders, and obesity are traditional risk factors 2
• Relationship quality: Dissatisfaction with partner relationship is a major risk factor 5
• Trauma history: Physical or sexual abuse history increases risk 5
• Menopausal status: Chemotherapy-induced menopause particularly affects desire 2

Physical Examination Priorities

Perform gynecologic examination noting:

• Vaginal atrophy
• Points of tenderness
• Anatomic changes from prior treatments or conditions 2

Treatment Algorithm

Step 1: Address Underlying Contributors

Treat coexisting depression and anxiety first, as these psychological conditions directly impair sexual desire and function 2. Consider:

• Switching medications that suppress desire (especially SSRIs) 2
• Optimizing control of cardiovascular disease, diabetes, and thyroid disorders 2
• Addressing relationship issues through couples counseling 2

Step 2: Menopausal Symptom Management

For vaginal dryness, discomfort, or pain:

• Vaginal estrogen therapy for vaginal atrophy and dyspareunia (does not directly improve desire but addresses painful intercourse) 2, 5
• Ospemifene as alternative to vaginal estrogen 2, 5
• Vaginal moisturizers, gels, and oils for symptom relief 2
• Topical lidocaine to vulvar vestibule before penetration for dyspareunia 2

Systemic estrogen therapy is not recommended for desire alone in the absence of vasomotor symptoms 5.

Step 3: Psychotherapeutic Interventions

Cognitive behavioral therapy (CBT) has demonstrated effectiveness in improving sexual functioning, particularly in cancer survivors but applicable broadly 2. Structured sexual counseling using:

• Patient education and therapeutic communication 2
• Cognitive-behavioral techniques addressing fear, anxiety, and body image 2
• Multiple sessions including partners when possible 2

Integrative therapies (yoga, meditation) may help alleviate anxiety that impacts sexual function 2.

Step 4: Pharmacologic Treatment for HSDD

For Premenopausal Women:

Flibanserin (Addyi) is FDA-approved for acquired, generalized HSDD in premenopausal women 6, 1, 4:

• Dosing: 100 mg once daily at bedtime 6
• Critical safety warnings: Contraindicated with moderate/strong CYP3A4 inhibitors and in hepatic impairment; severe hypotension and syncope risk with alcohol—patients must wait 2 hours after 1-2 drinks or skip dose after ≥3 drinks 6
• Discontinue after 8 weeks if no improvement 6
• Common adverse effects: dizziness, somnolence, nausea, fatigue 6

Bremelanotide is also FDA-approved for premenopausal HSDD 4.

Bupropion (off-label) has shown efficacy in improving desire in women with and without depression 5.

For Postmenopausal Women:

Exogenous testosterone has demonstrated efficacy but is not FDA-approved for this indication 5. Counsel patients about:

• Off-label use
• Limited long-term safety data
• Need for monitoring 5

Step 5: Adjunctive Physical Therapies

Pelvic floor physical therapy for associated pelvic floor dysfunction, which can improve sexual pain, arousal, lubrication, orgasm, and satisfaction 2.

Vaginal dilators for pain during sexual activity 2.

Critical Pitfalls to Avoid

• Do not assume age alone causes decreased desire—both pre- and postmenopausal women can have HSDD 3
• Never prescribe flibanserin with moderate/strong CYP3A4 inhibitors (including many antifungals, antibiotics) or in hepatic impairment—this is contraindicated due to severe hypotension/syncope risk 6
• Recognize CYP2C19 poor metabolizers have increased flibanserin exposure and higher risk of adverse effects 6
• Oral contraceptives increase flibanserin exposure and adverse reaction incidence 6
• Patients often will not initiate discussions about sexual concerns due to fear of embarrassing physicians—clinicians must proactively ask 1, 4
• Systemic hormone therapy should not be used solely for desire in absence of vasomotor symptoms 5

Treatment Requires Multidimensional Planning

Sexual dysfunction is multifactorial, requiring plans that address physiologic (menopause, illness), psychologic (anxiety, depression), medication-induced, and interpersonal issues 2. Referrals to sexual health specialists, psychotherapy, or couples counseling should be made when appropriate 2.