Treatment Options for Women with Low Libido and Difficulty Achieving Orgasm

First-Line Treatment Options

The National Comprehensive Cancer Network recommends flibanserin (100 mg daily at bedtime) as a first-line treatment for premenopausal women with hypoactive sexual desire disorder (HSDD), with modest efficacy of approximately 1 additional satisfying sexual event every 2 months compared to placebo 1
Discussion of mechanical options, including vibrators or clitoral stimulatory devices, with referral to appropriate specialists for women with orgasm difficulties is recommended 2
Pelvic physical therapy can help with orgasm difficulties and overall sexual function 2

Bupropion is considered an off-label option for women with HSDD, despite limited safety and efficacy data 1
Androgens may be discussed for women with low desire, though not FDA-approved specifically for HSDD 2

Phosphodiesterase type 5 inhibitors (PDE5i) are NOT recommended for female sexual dysfunction due to contradictory results in clinical trials and lack of data regarding their effectiveness in women 1, 3, 4
Psychological factors often contribute significantly to sexual dysfunction and should be addressed through appropriate referrals for anxiety, depression, or other psychological concerns 2, 5
Lifestyle modifications, including increased physical activity, stress reduction, and addressing relationship issues, can improve sexual function 3

Cancer survivors require careful consideration of treatment options, particularly those with hormone-sensitive cancers 1, 2
Postmenopausal women may benefit from ospemifene for concurrent dyspareunia (painful intercourse), but this is contraindicated in women with a history of estrogen-dependent cancers 1, 2

Current pharmacological treatments show limited effectiveness, with flibanserin resulting in only about one additional satisfying sexual event every two months 1
"Restorative or regenerative" therapies lack robust clinical trial data and FDA approval 3

The American College of Obstetricians and Gynecologists recommends flibanserin as the first-line FDA-approved medication for premenopausal women with HSDD, with bremelanotide as an alternative FDA-approved option 6, 7, 8
Bremelanotide is FDA-approved for premenopausal women with HSDD and is used as a self-administered subcutaneous injection as needed, with a mechanism of action as a melanocortin receptor agonist 6, 8
Flibanserin results in approximately 1 additional satisfying sexual event every 2 months compared to placebo in premenopausal women with HSDD 6, 8

Bupropion is considered an off-label option for premenopausal women with HSDD, with limited safety and efficacy data but considered an option by expert panels 6, 7, 8, 9
Buspirone is considered an off-label option for premenopausal women with HSDD, with limited data but considered an option by expert panels 6, 7, 8, 9, 10

Ospemifene is FDA-approved for dyspareunia in postmenopausal women but is not specifically indicated for HSDD, and may be considered for those with concurrent dyspareunia and no history of estrogen-dependent cancers 8, 9
Phosphodiesterase type 5 inhibitors are not recommended for female sexual dysfunction due to limited and contradictory evidence 8, 9, 10
For cancer survivors with HSDD, treatment options should be carefully selected based on cancer type, particularly for hormone-sensitive cancers 8, 9

For premenopausal women, first-line treatment options include flibanserin 100 mg daily at bedtime or bremelanotide as needed 6, 8
For postmenopausal women, consider off-label use of flibanserin or ospemifene for those with concurrent dyspareunia and no history of estrogen-dependent cancers 8, 9
For patients with contraindications or intolerance to first-line options, consider off-label use of bupropion or buspirone 6, 8, 9

The National Comprehensive Cancer Network notes that data on the efficacy of HSDD treatments in cancer survivors or postmenopausal women is limited, with most studies focusing on premenopausal women 11