Is tadalafil (Cialis) appropriate and safe for treating sexual dysfunction in women?

Tadalafil (Cialis) for Female Sexual Dysfunction

Tadalafil is NOT recommended for treating sexual dysfunction in women due to insufficient evidence of effectiveness, according to the National Comprehensive Cancer Network (NCCN) Survivorship Panel. 1

Why Tadalafil Should Not Be Used in Women

The NCCN explicitly states that oral phosphodiesterase type 5 inhibitors (PDE5i) like tadalafil should not be prescribed for female sexual dysfunction because randomized clinical trials have shown contradictory results in women being treated for sexual arousal disorder. 1 Although tadalafil theoretically increases pelvic blood flow to the clitoris and vagina, multiple expert panels have concluded that more research is needed before it can be recommended. 1

This recommendation stands in stark contrast to the well-established efficacy of tadalafil in men with erectile dysfunction, where it is FDA-approved and highly effective. 2, 3

What SHOULD Be Used Instead

The treatment approach depends on the specific type of sexual dysfunction:

For Premenopausal Women with Low Desire (HSDD)

• Flibanserin (100 mg daily at bedtime): FDA-approved in 2015 for acquired, generalized hypoactive sexual desire disorder in premenopausal women, resulting in approximately 1 additional satisfying sexual event every 2 months. 1, 4
• Bremelanotide: FDA-approved as a self-administered subcutaneous injection taken as needed before anticipated sexual activity. 2, 4
• Bupropion or buspirone: Off-label options with limited data but considered reasonable alternatives. 2, 5

For Postmenopausal Women with Painful Intercourse (Dyspareunia)

• Vaginal estrogen (pills, rings, or creams): Most effective treatment for vaginal dryness leading to sexual dysfunction, treating itching, discomfort, and painful intercourse. 2
• Ospemifene: FDA-approved SERM for moderate to severe dyspareunia in postmenopausal women WITHOUT known or suspected breast cancer. 1, 4
• Prasterone (vaginal DHEA): FDA-approved for dyspareunia, showing significant improvements in sexual desire, arousal, pain, and overall sexual function, though contraindicated in women with a history of breast cancer. 2, 1

For Arousal and Orgasm Difficulties

• Mechanical devices: Vibrators or clitoral stimulatory devices with referral to appropriate specialists. 2, 4
• Pelvic floor physical therapy: Improves sexual pain, arousal, lubrication, orgasm, and satisfaction. 2

For Vaginal Dryness and Pain

• Water-, oil-, or silicone-based lubricants and moisturizers: First-line approach for alleviating vaginal dryness and sexual pain, with silicone-based products lasting longer. 2
• Topical anesthetics (lidocaine): Applied to the vulvar vestibule before penetration to improve dyspareunia. 2
• Vaginal dilators: For vaginismus, sexual aversion disorder, or vaginal stenosis from pelvic surgery or radiation. 2

Non-Pharmacological Approaches (Always Consider First)

• Cognitive behavioral therapy: Has demonstrated effectiveness for improving sexual function. 2, 5
• Sexual/couples counseling: Addresses relationship dynamics that commonly contribute to desire disorders. 2, 5

Critical Assessment Steps Before Treatment

Screen for reversible contributing factors that commonly impair sexual function: 2, 5

• Medications: Hormone therapy, narcotics, SSRIs, and anticholinergics are common iatrogenic causes
• Psychological factors: Anxiety, depression, relationship distress, body image concerns
• Medical conditions: Cardiovascular disease, diabetes, obesity
• Lifestyle factors: Smoking, alcohol abuse
• Menopausal status: Fundamentally guides treatment selection
• Cancer history: Particularly estrogen-sensitive cancers, which contraindicate many hormonal therapies

Common Pitfalls to Avoid

• Do not prescribe tadalafil or other PDE5 inhibitors for women: The evidence does not support their use despite theoretical mechanisms. 1, 5
• Do not overlook medication side effects: SSRIs, narcotics, and hormonal therapies frequently cause sexual dysfunction. 2, 5
• Do not use hormonal therapies in women with estrogen-dependent cancers: This includes vaginal estrogen and ospemifene in women with breast cancer history. 1, 5
• Do not ignore relationship factors: Partner communication and relationship quality significantly impact treatment success. 1
• Do not assume all sexual dysfunction is the same: Treatment must be guided to the specific type of problem (desire, arousal, orgasm, or pain). 2, 1

Limited Research Evidence

While a few small studies have suggested potential benefit of tadalafil in specific female populations (such as type 1 diabetic women with genital arousal disorder 6 or women with antidepressant-induced sexual dysfunction 7), these findings have not been replicated in larger, high-quality trials, and guideline panels have explicitly rejected recommending PDE5 inhibitors based on the totality of evidence. 1