What are the treatment options for hypoactive sexual desire disorder (HSDD) in postmenopausal women?

From the Guidelines

Low sexual desire in postmenopausal women can be effectively treated through a combination of hormonal therapy, non-hormonal medications, and lifestyle modifications, with FDA-approved flibanserin (Addyi) 100mg daily at bedtime or bremelanotide (Vyleesi) 1.75mg injected subcutaneously 45 minutes before sexual activity being non-hormonal options specifically for hypoactive sexual desire disorder, as recommended by the NCCN guidelines 1.

Treatment Options

• Hormone therapy with estrogen (such as estradiol 0.5-1mg daily orally or 0.025-0.05mg patches twice weekly) helps address vaginal dryness and discomfort, while testosterone therapy (though off-label for women) at low doses (1-2% gel applied to skin daily) may improve libido.
• Non-hormonal medications such as flibanserin (Addyi) and bremelanotide (Vyleesi) are specifically approved for hypoactive sexual desire disorder.
• Psychological approaches including cognitive behavioral therapy and mindfulness practices are important components of treatment.
• Regular exercise, stress management, and open communication with partners also play crucial roles.

Lifestyle Modifications

• Vaginal moisturizers and lubricants can help alleviate symptoms of vaginal dryness and discomfort.
• Pelvic physical therapy can help improve sexual function and reduce pain.
• Topical anesthetics can be used to reduce pain during sexual activity.
• Integrative therapies such as yoga and meditation can help reduce stress and improve overall well-being.

Important Considerations

• Treatment should be individualized based on symptoms, preferences, and medical history, with regular follow-up to assess effectiveness and manage side effects.
• The decline in sexual desire often stems from decreasing hormone levels after menopause, particularly estrogen and testosterone, which affect both physical sexual function and psychological aspects of desire.
• The NCCN guidelines recommend a comprehensive approach to addressing sexual function in cancer survivors, including screening, evaluation, and treatment of sexual dysfunction 1.

From the Research

Treatment Options for Low Sexual Desire in Women Post-Menopause

• Hormone replacement therapy (HRT) has been shown to be effective in improving sexual desire in postmenopausal women, particularly when estrogen replacement therapy (ERT) is used 2.
• The addition of androgen to ERT has also been found to be helpful in improving sexual desire in postmenopausal women who do not respond to ERT alone 2.
• Flibanserin, a non-hormonal treatment approved for hypoactive sexual desire disorder (HSDD) in premenopausal women, has also shown efficacy in postmenopausal women, although it is not approved for this population 3, 4.
• Other treatment options, such as cognitive behavioral therapy, mindfulness meditation, pelvic floor therapy, and clitoral stimulators, may also be effective in improving sexual desire in postmenopausal women, although more research is needed to fully understand their efficacy 3.

Efficacy and Safety of Flibanserin

• Flibanserin has been shown to increase the number of satisfying sexual events and improve sexual desire scores in premenopausal women with HSDD, although the evidence is graded as very low quality 5.
• Common side effects of flibanserin include dizziness, somnolence, nausea, and fatigue, and the risk of these side effects is statistically and clinically significantly increased compared to placebo 5.
• The efficacy and safety of flibanserin in postmenopausal women have not been fully established, and more research is needed to determine its potential benefits and risks in this population 3, 4.

Limitations and Future Directions

• More research is needed to fully understand the efficacy and safety of flibanserin in postmenopausal women, as well as to explore other treatment options for low sexual desire in this population 3, 5.
• Studies should include women from diverse populations, particularly those with comorbidities, medication use, and surgical menopause, to better understand the potential benefits and risks of different treatments 5.