How should I evaluate and manage hypoactive sexual desire disorder in a woman?

Evaluation and Management of Female Low Libido (Hypoactive Sexual Desire Disorder)

Begin evaluation with the Brief Sexual Symptom Checklist for Women as your primary screening tool, then systematically address psychological factors, medications, and organic causes before considering pharmacological interventions. 1

Initial Screening and History

• Use the Brief Sexual Symptom Checklist for Women at regular intervals to identify women with sexual concerns 2, 1
• Document baseline sexual function before any changes occurred, current sexual activity patterns, and how symptoms affect intimacy and relationships 2, 1
• Screen specifically for depression, anxiety, body image concerns, and relationship distress—these are major contributors to reduced libido 2, 1
• Assess substance use including alcohol consumption, recreational drugs, and smoking 2, 1
• Inquire about partner's sexual health and relationship quality, as these significantly impact sexual function 2

Medication Review (Critical Step)

Immediately review all medications, as this is often the most reversible cause of low libido. 1

• SSRIs (paroxetine, sertraline, citalopram, fluoxetine) are common culprits that suppress libido 2, 1
• Beta-blockers are strongly associated with sexual dysfunction 2, 1
• Hormonal therapies, particularly aromatase inhibitors and hormonal contraceptives, commonly reduce desire 2, 1
• Opioids, corticosteroids, and H2-receptor antagonists may contribute 1
• Consider switching to alternatives with lower sexual side effect profiles when feasible 1

Physical Examination

• Perform gynecologic examination to assess for vaginal atrophy (mucosal thinning, loss of rugae, tissue friability), anatomic changes, and points of tenderness 2, 1
• Look specifically for signs of menopause and estrogen deprivation 2

Laboratory Workup

Order these specific tests to identify treatable organic causes:

• Morning testosterone (preferably free testosterone or androgen index)—this prevents unnecessary endocrine investigation in up to 50% of cases 1
• TSH and free T4 if thyroid dysfunction suspected 1
• Prolactin levels when there is loss of libido with low testosterone 1
• Fasting glucose or HbA1c to screen for diabetes, which affects sexual function through vascular and neurological mechanisms 2, 1

Validated Assessment Tools for In-Depth Evaluation

• Use the Female Sexual Function Index (FSFI) for comprehensive assessment of desire, arousal, lubrication, orgasm, and satisfaction—this 19-item instrument is validated in multiple populations 2, 1
• The Arizona Sexual Experience Scale (ASEX) is a shorter 5-item alternative covering sexual drive, arousal, lubrication, orgasm ability, and satisfaction 1

Screen for Chronic Medical Conditions

• Cardiovascular disease and hypertension impair sexual function through vascular mechanisms 2, 1
• Diabetes causes dysfunction through both vascular and neurological pathways 2, 1
• Assess for obesity, metabolic syndrome, chronic kidney disease, and liver failure 2, 1
• Review cancer treatment history (chemotherapy, radiation, hormonal therapies) as these commonly suppress libido 2

Treatment Algorithm Based on Symptom Pattern

For Vaginal Dryness and Dyspareunia:

• First-line: Water-, oil-, or silicone-based lubricants and vaginal moisturizers 2
• Second-line: Vaginal estrogen (pills, rings, creams) for postmenopausal women—effective for vaginal dryness, itching, and painful intercourse 2
• Consider: Ospemifene for vaginal atrophy (not approved for breast cancer survivors) 2
• Pelvic floor physical therapy improves sexual pain, arousal, lubrication, orgasm, and satisfaction 2

For Low Desire/Libido Specifically:

Premenopausal women:

• Flibanserin is FDA-approved for premenopausal women with HSDD, though benefits are modest above placebo and side effects (dizziness, somnolence, nausea, fatigue) are substantial 2, 3, 4
• Critical contraindications: Do not prescribe flibanserin with alcohol, certain CYP3A4 inhibitors (HIV medications, azole antifungals, macrolide antibiotics), or in patients with liver problems 3
• Take only at bedtime to reduce risk of severe hypotension and syncope 3

Postmenopausal women:

• Transdermal testosterone has evidence supporting its use for low desire 5
• Consider hormone therapy risks and benefits in women without hormone-sensitive cancers who are prematurely postmenopausal 2

For Orgasm Difficulties:

• Discuss vibrator or clitoral stimulatory devices with referral to appropriate specialist 2
• Pelvic physical therapy 2

Psychotherapy Options

• Cognitive behavioral therapy shows 50-80% success rates for sexual dysfunction 1
• Mindfulness and psychoeducation have excellent evidence for improving low sexual desire 5
• These psychological interventions should be considered first-line or adjunctive to pharmacological treatments 5

Referral Indications

Refer to sexual medicine specialists when:

• Multiple endocrine abnormalities require specialized evaluation 1
• Primary reduced libido persists despite addressing obvious contributing factors 1
• Complex psychological factors require specialized psychosexual therapy 1
• Patient desires specialized sexual health counseling 1

Critical Pitfalls to Avoid

• Do not prescribe flibanserin without explicitly counseling about alcohol avoidance—the combination causes severe hypotension and syncope 3
• Do not assume age alone causes low desire—both pre- and postmenopausal women can have HSDD, and distress often decreases with age even as desire decreases 6, 4
• Do not overlook relationship factors and partner sexual health, which significantly impact treatment success 2
• Recognize that less than half of patients with sexual problems initiate discussions—physicians must proactively screen 4