What treatment options are available for a postmenopausal woman with hypoactive sexual desire disorder (Low Libido)?

Treatment for Low Libido in Postmenopausal Women

For a postmenopausal woman with low sexual desire, start with off-label flibanserin 100 mg daily at bedtime combined with mindfulness-based cognitive behavioral therapy, while simultaneously addressing any vaginal dryness with water- or silicone-based lubricants. 1

Initial Assessment

Before initiating treatment, screen for reversible contributing factors that commonly impair libido:

• Medications: Review for SSRIs, narcotics, hormonal therapies, and spironolactone, all of which can significantly reduce sexual desire 2
• Psychological factors: Assess for depression, anxiety, relationship distress, body image concerns, and partner sexual dysfunction 2
• Vaginal symptoms: Evaluate for dryness, dyspareunia, or atrophy, as these often lead to sexual avoidance 2
• Medical comorbidities: Check for cardiovascular disease, diabetes, obesity, smoking, and alcohol abuse 2

Laboratory testing is of limited value unless clinically indicated by history or physical examination. 3

First-Line Treatment Approach

Pharmacological Options

Flibanserin is the primary pharmacological option, though it must be used off-label in postmenopausal women:

• Dose: 100 mg daily at bedtime 1
• Expected benefit: Approximately 1 additional satisfying sexual event every 2 months compared to placebo 1
• Critical caveat: Set realistic expectations—even the most effective treatments yield only modest improvements 1

Transdermal testosterone may be considered if the patient is not taking estrogen therapy, particularly in surgically menopausal women with low free testosterone levels. 1, 4 However, this is not FDA-approved for this indication in the United States and has limited long-term safety data. 3

Psychological Intervention (Essential Component)

Mindfulness-based cognitive behavioral therapy has excellent evidence for improving low sexual desire and should be offered concurrently with any pharmacological treatment. 1 Standard CBT and psychoeducation also show benefit. 1 Sexual dysfunction is multifactorial, and medication alone is rarely sufficient. 1

Addressing Concurrent Vaginal Symptoms

Many postmenopausal women have vaginal dryness contributing to sexual avoidance:

• First step: Use vaginal lubricants for sexual activity and vaginal moisturizers for daily comfort 1
• Silicone-based products last longer than water-based or glycerin-based options 5, 2
• Most effective treatment for vaginal atrophy: Vaginal estrogen therapy (tablets, rings, or creams) 1, 2
• Alternative to vaginal estrogen: Ospemifene (FDA-approved SERM for dyspareunia in postmenopausal women) 5, 3

Important safety consideration: For women with a history of estrogen-dependent cancers (particularly breast cancer), vaginal estrogen and ospemifene are contraindicated. 1 In these cases, vaginal DHEA (prasterone) may be considered, as it has shown improvements in sexual desire, arousal, pain, and overall sexual function in cancer survivors. 5, 2

Second-Line Off-Label Options

If flibanserin is ineffective or not tolerated:

• Bupropion: Off-label option with limited safety and efficacy data in postmenopausal women 1, 2
• Buspirone: Off-label option with limited data 1, 2

Additional Supportive Interventions

• Pelvic physical therapy: Can improve sexual pain, arousal, lubrication, orgasm, and satisfaction, particularly if pelvic floor dysfunction is present 5, 2
• Mechanical devices: Vibrators or clitoral stimulatory devices with referral to appropriate specialists 5
• Lifestyle modifications: Increased physical activity, weight loss if overweight, smoking cessation, and limiting alcohol consumption 2

What NOT to Do

Do not prescribe phosphodiesterase type 5 inhibitors (like sildenafil) for female sexual dysfunction—they show contradictory results in clinical trials and lack evidence of effectiveness in women. 1, 2

Do not use vaginal laser therapy—the FDA has not cleared these devices for menopausal symptoms, and safety/effectiveness data are insufficient. 1

Do not prescribe hormonal therapies for women on aromatase inhibitors or those with a history of hormone-sensitive cancers. 5, 1

Treatment Algorithm Summary

1. Screen for and address reversible factors (medications, psychological issues, vaginal symptoms) 2
2. Initiate mindfulness-based CBT or psychoeducation 1
3. Start flibanserin 100 mg at bedtime (off-label in postmenopausal women) 1
4. Add vaginal lubricants/moisturizers for any vaginal dryness 1
5. Consider vaginal estrogen if significant vaginal atrophy is present (unless contraindicated) 1
6. If inadequate response, consider bupropion or buspirone as alternatives 1
7. Add pelvic physical therapy if pelvic floor dysfunction is suspected 5

Critical Pitfalls to Avoid

• Ignoring psychological factors: Sexual dysfunction is multifactorial; medication alone rarely suffices 1
• Failing to address vaginal symptoms: Dyspareunia and dryness lead to sexual avoidance and worsen desire 2
• Expecting dramatic results: Current treatments show limited effectiveness; counsel patients about realistic expectations 1
• Using hormonal therapies in cancer survivors without considering cancer type: Hormone-sensitive cancers are absolute contraindications to systemic hormone therapy 1