What is the treatment for low libido in a generally healthy adult woman (premenopausal or post‑menopausal)?

Treatment of Low Libido in Women

For generally healthy women with low libido, begin with addressing reversible causes (medications, vaginal symptoms, psychological factors), then consider FDA-approved pharmacotherapy—flibanserin for premenopausal women or bremelanotide as an alternative—alongside cognitive behavioral therapy and treatment of concurrent vaginal dryness with lubricants or vaginal estrogen if postmenopausal. 1, 2, 3

Initial Assessment and Identification of Reversible Causes

Before initiating specific treatment, systematically screen for modifiable contributors:

• Review all medications, particularly SSRIs (paroxetine, sertraline, citalopram, fluoxetine), hormonal therapies including aromatase inhibitors and contraceptives, narcotics, and beta-blockers—all of which commonly suppress libido 4, 5
• Screen for psychological factors including depression, anxiety, relationship distress, and body image concerns, as these are major contributors to reduced desire 1, 4
• Assess for vaginal symptoms such as dryness, dyspareunia, or atrophy, which lead to sexual avoidance and decreased libido 1, 2, 4
• Evaluate traditional risk factors including cardiovascular disease, diabetes, obesity, smoking, and alcohol abuse 1, 4

A physical and gynecologic examination should assess for vaginal atrophy, mucosal thinning, loss of rugae, and anatomic changes 1, 4. Laboratory testing has limited value unless indicated by history, though morning testosterone (preferably free testosterone or androgen index) can be considered if hypogonadism is suspected 4, 5.

Non-Pharmacological First-Line Approaches

Cognitive behavioral therapy has demonstrated effectiveness for improving sexual functioning in women with low libido and should be offered as a primary intervention. 1, 2

Additional non-pharmacological strategies include:

• Psychoeducational support and sexual/couples counseling to address relationship issues and psychological factors 2
• Lifestyle modifications such as increased physical activity, smoking cessation, weight loss if overweight, and limiting alcohol consumption 2
• Treatment of concurrent vaginal symptoms with water-, oil-, or silicone-based lubricants and vaginal moisturizers (silicone-based products last longer than water- or glycerin-based options) 1, 2
• Pelvic floor physical therapy for women with concurrent dyspareunia, which can improve arousal, lubrication, orgasm, and satisfaction 1

Pharmacological Treatment Options for Premenopausal Women

Flibanserin is the first FDA-approved medication for acquired, generalized hypoactive sexual desire disorder in premenopausal women, resulting in approximately one additional satisfying sexual event every two months. 1, 2, 3, 6

• Flibanserin is taken daily and works centrally to enhance excitatory pathways while decreasing inhibitory processes 6
• Common side effects include dizziness, somnolence, nausea, and fatigue 1
• It is not contraindicated in patients with breast cancer history 1

Bremelanotide is an alternative FDA-approved option, administered as a subcutaneous injection as needed before anticipated sexual activity. 2, 3

Off-label options with limited but supportive data include:

• Bupropion may be considered despite limited safety and efficacy data, and has shown benefit in some women with and without depression 1, 2, 7
• Buspirone may be considered as a second-line option despite limited data 2

Treatment of Vaginal Symptoms Contributing to Low Libido

When vaginal dryness or dyspareunia contributes to decreased desire:

• Vaginal estrogen (pills, rings, or creams) is the most effective treatment for vaginal dryness and dyspareunia in postmenopausal women, improving sexual function 1, 2
• Ospemifene, a selective estrogen receptor modulator, can be used as an alternative to vaginal estrogen but is contraindicated in women with estrogen-sensitive cancers 1, 2, 7
• Vaginal DHEA (prasterone) has shown significant improvements in sexual desire, arousal, pain, and overall sexual function, particularly in survivors of breast or gynecologic cancer 2
• Topical lidocaine applied to the vulvar vestibule before vaginal penetration can improve dyspareunia 1

Special Considerations and Pitfalls to Avoid

Do not prescribe hormonal therapies to women with estrogen-sensitive cancers (breast, endometrial), as these are contraindicated. 2

Common pitfalls include:

• Failing to address psychological and relationship factors, which may be primary contributors 2
• Not screening for medication side effects, particularly SSRIs, narcotics, and hormonal therapies 2, 4
• Ignoring concurrent vaginal symptoms that lead to sexual avoidance 2
• Prescribing phosphodiesterase type 5 inhibitors (PDE5i) such as sildenafil, which are not effective for female sexual dysfunction 2
• Using vaginal laser therapy, which lacks FDA approval and sufficient safety/effectiveness data for this indication 2

When to Refer to Specialists

Referral to sexual health specialists, gynecologists, or mental health professionals is appropriate when:

• Primary reduced libido persists despite addressing obvious contributing factors 4
• Multiple endocrine abnormalities are identified requiring specialized evaluation 4
• Complex psychological factors require specialized cognitive behavioral therapy or psychosexual therapy (which shows 50-80% success rates) 4, 5
• Partner involvement in therapy is needed, as inclusion of sexual partners is associated with better treatment outcomes 2