Management of Hypoactive Sexual Desire Disorder

Introduction

• Hypoactive sexual desire disorder (HSDD) is a condition characterized by a lack of sexual desire, causing distress in women, and can be treated with a multidimensional approach, including non-pharmacological and pharmacological interventions, as recommended by the American College of Obstetricians and Gynecologists 1, 2, 3

Pharmacological Options

• The American College of Obstetricians and Gynecologists recommends flibanserin and bremelanotide as the most effective pharmacological options for increasing libido in women with HSDD, with off-label options including bupropion and buspirone as alternatives 2
• Flibanserin results in approximately 1 additional satisfying sexual event every 2 months in premenopausal women with acquired, generalized HSDD 2
• Bremelanotide significantly increases sexual desire and reduces distress related to low sexual desire in premenopausal women with HSDD 2
• Bupropion can be considered for HSDD, with a recommended starting dose of 150 mg daily, and can be increased to 150 mg twice daily if needed, with situational dosing also an option 1
• The FDA has approved bupropion for acquired, generalized HSDD in premenopausal women, with a dosing regimen of 100 mg daily at bedtime, although efficacy data is limited to approximately 1 additional satisfying sexual event every 2 months 1
• Flibanserin is approved for premenopausal women with acquired, generalized HSDD, with a dosing regimen of 100 mg daily at bedtime, and has shown efficacy in increasing sexual desire and reducing distress related to low sexual desire 2, 3, 4
• Bremelanotide is approved for premenopausal women with HSDD, with self-administered subcutaneous injections as needed, and has shown efficacy in increasing sexual desire and reducing distress related to low sexual desire 2, 3, 4
• The following medications are approved or considered for HSDD treatment:

2, 3, 4, 1, 5, 6

Hormonal Therapies

• Prasterone (DHEA) can improve sexual desire, arousal, pain, and overall sexual function in women with vaginal dryness and pain with sexual activity, but should be used carefully in patients on aromatase inhibitor therapy as it increases circulating androgens 2, 1
• Ospemifene is recommended for moderate to severe dyspareunia in postmenopausal women, but is contraindicated in women with a history of breast cancer 2, 1
• Vaginal estrogen (pills, rings, or creams) effectively treats vaginal dryness, itching, discomfort, and painful intercourse, but should be avoided in patients with a history of hormone-sensitive cancers 6
• Testosterone therapy may be considered for loss of desire in postmenopausal women, but has limited long-term safety data available 2, 3, 4

Non-Pharmacological Options

• Regular physical exercise, stress reduction techniques (yoga, meditation), and addressing relationship issues through open communication can be beneficial for women with HSDD 2, 3, 1
• Pelvic floor physical therapy may improve sexual pain, arousal, lubrication, orgasm, and satisfaction, particularly in women with concurrent pelvic floor dysfunction 6, 2, 3
• Cognitive behavioral therapy has shown efficacy in improving sexual function in women with low libido, including survivors of breast, endometrial, and cervical cancer 6, 4, 1
• Vaginal moisturizers and lubricants (water-, oil-, or silicone-based) can improve vaginal dryness and dyspareunia 5, 6, 2, 3, 1
• Topical vaginal therapies, such as gels, oils, topical vitamin D or E, may also be considered for alleviating symptoms 3, 1

Assessment and Monitoring

• The National Comprehensive Cancer Network recommends using validated screening tools, such as the Brief Sexual Symptom Checklist for women, to assess sexual dysfunction in women with cancer 3
• HSDD can be assessed using validated tools like Female Sexual Function Index (FSFI) or Arizona Sexual Experiences Scale (ASEX) 2
• A thorough evaluation is essential before initiating treatment, including screening for underlying medical conditions, medications that affect sexual function, psychosocial factors, and traditional risk factors, such as cardiovascular disease, diabetes, obesity, smoking, and alcohol use 7, 6, 1
• Response to treatment should be assessed after 4-8 weeks, with monitoring for common side effects of bupropion, including insomnia, headache, dry mouth, nausea, and rare but serious seizures 1
• Regular follow-up is essential to monitor treatment efficacy and side effects, and to evaluate the risk/benefit of hormonal treatments in women with a history of hormone-sensitive cancers 7, 6, 1

Special Considerations

• Cancer treatments, especially pelvic radiation and hormonal therapy, can significantly impact sexual function, and the treatment approach should consider cancer history and risk of recurrence 6
• A medication review should be conducted to consider switching from medications known to cause sexual dysfunction, with first-line pharmacotherapy being bupropion 150 mg daily, increasing to 150 mg twice daily if needed 1
• Ospemifene can be considered for dyspareunia in survivors of non-hormone sensitive cancers, while estrogen-containing products should be avoided in patients with a history of hormone-sensitive cancers 1, 8, 9