Vaginal Sildenafil Is Not Recommended for Female Sexual Dysfunction
The National Comprehensive Cancer Network explicitly does not recommend oral or vaginal phosphodiesterase type 5 inhibitors (PDE5i) like sildenafil for female sexual dysfunction due to insufficient evidence of effectiveness and contradictory results in randomized clinical trials. 1, 2
Why Sildenafil Fails in Women
Although sildenafil theoretically increases pelvic blood flow to the clitoris and vagina, randomized controlled trials in women with sexual arousal disorder have shown contradictory and disappointing results across multiple non-cancer populations. 1, 2 The mechanism that works reliably in men does not translate to effective treatment in women, likely because female sexual dysfunction involves more complex neurohormonal and psychosocial factors beyond simple blood flow enhancement. 3
Evidence-Based Treatment Algorithm for Premenopausal Women
First-Line Non-Pharmacologic Interventions
Start with these proven approaches before considering medications:
Water-, oil-, or silicone-based lubricants and moisturizers address vaginal dryness and sexual pain as foundational treatment. 1, 2, 4 Choose water-based or silicone-based if using latex condoms; oil-based products degrade latex and cause condom failure. 4
Pelvic floor muscle training significantly improves sexual pain, arousal, lubrication, orgasm, and satisfaction. 1, 2 This has demonstrated efficacy in small studies of women with sexual dysfunction. 1
Cognitive behavioral therapy addresses psychological components including anxiety, relationship problems, and prior trauma that commonly contribute to or exacerbate sexual dysfunction. 1, 2, 5
FDA-Approved Pharmacologic Options for Premenopausal Women
If non-pharmacologic approaches are insufficient and the specific diagnosis is hypoactive sexual desire disorder (HSDD):
Flibanserin (FDA-approved 2015) is indicated for acquired, generalized HSDD in premenopausal women. 2 This is the only FDA-approved medication specifically for desire disorders in premenopausal women.
Bremelanotide (FDA-approved as self-administered subcutaneous injection as needed) is an alternative for premenopausal HSDD. 2
Address Contributing Factors
Screen for medications impairing sexual function, particularly hormone therapy, narcotics, and selective serotonin reuptake inhibitors (SSRIs), as these are common iatrogenic causes. 2, 5, 6
Evaluate for depression, anxiety, relationship problems, and substance use, as psychosocial factors frequently contribute to or exacerbate desire disorders. 2, 7, 5
Assess cardiovascular risk factors including diabetes, obesity, smoking, and alcohol abuse, as these independently affect sexual function. 2, 3
Common Pitfalls to Avoid
Do not prescribe sildenafil off-label for female sexual dysfunction. Despite one small open-label study showing benefit in antidepressant-induced sexual dysfunction 8, this contradicts the broader evidence base and guideline recommendations. 1, 2
Treatment must target the specific type of dysfunction (desire, arousal, orgasm, or pain disorders) rather than using a one-size-fits-all approach. 1, 2 Mismatching treatment to the wrong dysfunction type leads to treatment failure.
Do not overlook relationship factors, as partner communication and relationship quality significantly impact treatment success. 2, 7
Distinguish between lubricants and moisturizers, as they serve different purposes—lubricants for immediate use during sexual activity versus moisturizers for ongoing vaginal health. 2, 4
When to Refer
Refer to sexual medicine specialists, gynecologists, or sex therapists when: