Treatment of Decreased Libido in Females

Introduction to Treatment Options

The National Comprehensive Cancer Network recommends treatment for decreased libido in females be guided by the specific underlying causes and may include pharmacological options such as flibanserin for premenopausal women, as well as non-pharmacological approaches including psychotherapy, lifestyle modifications, and addressing vaginal symptoms 1, 2

Assessment and Identification of Contributing Factors

The National Comprehensive Cancer Network suggests screening for reversible contributing factors including medications, psychological issues, and lifestyle factors 3
Evaluation of traditional risk factors for sexual dysfunction such as cardiovascular disease, diabetes, obesity, and alcohol abuse is recommended 3
Consideration of the impact of cancer treatments on sexual desire is necessary, as chemotherapy and hormonal therapies can significantly affect sexual desire 4, 5
Assessment for concurrent vaginal symptoms that may contribute to decreased libido is important 6

Non-Pharmacological Approaches

Psychoeducational support, sexual counseling, and marital/couples therapy can address relationship issues and psychological factors contributing to decreased libido 4, 5
Cognitive behavioral therapy has shown efficacy for sexual desire issues, particularly in cancer survivors 3
Lifestyle modifications such as increased physical activity, smoking cessation, weight loss if overweight, and limiting alcohol consumption can improve sexual function 1, 7
Water-, oil-, or silicone-based lubricants and vaginal moisturizers can help with vaginal dryness, and silicone-based products may last longer than water-based or glycerin-based products 5, 6
Pelvic floor physical therapy can help with pain during sexual activity 6, 3

Pharmacological Options

Flibanserin is FDA-approved for acquired, generalized hypoactive sexual desire disorder in premenopausal women and can result in approximately one additional satisfying sexual event every two months 1, 2
Bupropion and buspirone may be considered for hypoactive sexual desire disorder despite limited safety and efficacy data 1, 2
Vaginal DHEA (prasterone) has shown significant improvements in sexual desire, arousal, pain, and overall sexual function in survivors of breast or gynecologic cancer 1

Special Considerations

Cancer survivors, particularly those who received chemotherapy, are at increased risk of sexual dysfunction and require consideration of cancer type and hormonal sensitivity in treatment 4, 6
Ospemifene may be considered for dyspareunia in survivors of cancers that are not hormonally sensitive 1, 2
PDE5 inhibitors are not recommended for female sexual dysfunction due to contradictory results in clinical trials 1, 2, 3
Hormonal therapies for women on aromatase inhibitors are not recommended 5

Treatment Pitfalls to Avoid

Failing to address psychological and relationship factors that may be primary contributors to decreased libido can hinder effective treatment 3
Prescribing hormonal therapies without considering cancer history, especially estrogen-sensitive cancers, is not recommended 4

Treatment of Female Sexual Dysfunction

Initial Assessment and Contributing Factors

The American College of Obstetricians and Gynecologists recommends assessing relationship distress, communication issues, and partner sexual dysfunction in women with low libido and anorgasmia 8
Vaginal symptoms such as dryness or dyspareunia may contribute to sexual avoidance in women with low libido and anorgasmia 8

First-Line Treatment Options

The National Comprehensive Cancer Network recommends bremelanotide as a first-line treatment option for premenopausal women with hypoactive sexual desire disorder (HSDD), administered as a subcutaneous injection as needed before anticipated sexual activity 9
Mechanical devices such as vibrators or clitoral stimulatory devices, and pelvic physical therapy are recommended first-line treatments for anorgasmia in women 9

What NOT to Use

The National Comprehensive Cancer Network does not recommend phosphodiesterase type 5 inhibitors (PDE5i) such as sildenafil for female sexual dysfunction due to lack of effectiveness data in women 10
Vaginal laser therapy is not currently recommended due to limited safety and effectiveness data, and lack of FDA approval for this indication 10

Special Considerations

For women with a history of cancer, treatment selection requires careful consideration, and hormone-sensitive cancers should be avoided with hormonal therapies 8
The American Society of Clinical Oncology recommends avoiding hormonal therapies in patients with estrogen-dependent cancers 8

Treatment for Low Libido in Females

Initial Assessment and Contributing Factors

The National Comprehensive Cancer Network recommends screening for medications that impair libido, particularly SSRIs, narcotics, and hormonal therapies, in women with low libido 11
Evaluation for psychological factors, including anxiety, depression, relationship distress, body image concerns, and partner sexual dysfunction, is crucial in assessing low libido in women 12
Assessing for vaginal symptoms, such as dryness, dyspareunia, or atrophy, is essential in identifying reversible causes of low libido 12
Reviewing traditional risk factors, including cardiovascular disease, diabetes, obesity, smoking, and alcohol abuse, is important in the initial assessment of low libido 11

Non-Pharmacological First-Line Approaches

Cognitive behavioral therapy (CBT) has demonstrated effectiveness for improving sexual functioning in women with low libido, according to the National Comprehensive Cancer Network 12

Pharmacological Treatment Options

Bremelanotide (subcutaneous injection) is an alternative FDA-approved option for premenopausal women with low libido, administered as needed before anticipated sexual activity 12
Bupropion may be considered as a second-line off-label option for low libido in women, despite limited safety and efficacy data 12
Buspirone may be considered as a second-line off-label option for low libido in women, despite limited data 12

Treatment of Concurrent Vaginal Symptoms

Vaginal moisturizers, lubricants, and gels (water-, oil-, or silicone-based) are first-choice treatments for vaginal dryness and dyspareunia, with silicone-based products lasting longer 12
Pelvic floor physical therapy can improve sexual pain, arousal, lubrication, orgasm, and satisfaction in women with low libido 11, 12
Vaginal estrogen (pills, rings, or creams) is the most effective treatment for vaginal dryness leading to sexual dysfunction in postmenopausal women 11, 12

Special Considerations

Ignoring medication side effects, such as those caused by SSRIs, narcotics, and hormonal therapies, can hinder treatment effectiveness for low libido 11
Not screening for vaginal symptoms, such as dyspareunia and vaginal dryness, can contribute to sexual avoidance and decreased libido 12

Low Libido in Women: Diagnosis and Treatment

Initial Assessment

The American College of Obstetricians and Gynecologists recommends screening for reversible contributing factors, including medication review, before initiating treatment for low libido, as multiple biological, psychological, and relationship factors commonly contribute to decreased libido, and medications such as SSRIs, narcotics, hormonal therapies, and spironolactone can impair libido 13
The National Comprehensive Cancer Network recommends evaluating for a history of estrogen-sensitive cancers, as this significantly impacts treatment options for low libido in women 14

Laboratory Evaluation

The British Medical Journal recommends measuring free testosterone or androgen index if hypogonadism is suspected, though only mandatory if clinical evidence is present, and checking prolactin if testosterone is low or loss of libido is present 15
The American Association for the Study of Liver Diseases recommends including thyroid function in the workup for low libido in women with advanced liver disease 13

Special Population: Cancer Survivors

The National Comprehensive Cancer Network recommends exercising extreme caution with hormonal therapies in cancer survivors, particularly those with estrogen-sensitive cancers, where hormonal treatments are contraindicated, and considering vaginal DHEA as a preferred hormonal option for breast or gynecologic cancer survivors 14

Special Population: Advanced Liver Disease

The American Association for the Study of Liver Diseases recommends evaluating sex hormone levels and thyroid function in women with advanced liver disease, as altered estrogen metabolism and disruption of the hypothalamic-pituitary axis commonly cause anovulation, amenorrhea, and decreased libido 13

First‑Line Management of Female Anorgasmia with Vaginal Intercourse

Mechanical Devices and Specialist Referral

The NCCN guidelines recommend that women who cannot achieve orgasm with vaginal intercourse should be offered discussion of vibrators or clitoral stimulatory devices together with referral to a sexual‑health specialist as the first‑line approach. 16

Pelvic‑Floor Physical Therapy

Pelvic‑floor physical therapy, initiated concurrently with device use, improves sexual pain, arousal, lubrication, orgasm frequency, and overall sexual satisfaction in affected women. 16

Pharmacologic Adjuncts for Vaginal Symptoms

Topical lidocaine applied to the vaginal introitus reduces dyspareunia and consequently enhances sexual function. 16
Ospemifene may be considered for treatment‑related dyspareunia in survivors of non‑hormone‑sensitive cancers. 16

Partner Involvement

Inclusion of the sexual partner in therapy sessions is associated with better treatment outcomes for female orgasmic difficulty. 16

Psychosocial and Physical Factors Linked to Orgasmic Difficulty

Mood and Relationship Factors

Depression, negative body‑image concerns, and relationship distress are significantly associated with the presence of orgasmic problems in women. 17

Vaginal Health Factors

Vaginal dryness, dyspareunia, or atrophic changes lead to sexual avoidance and impair the arousal needed for orgasm. 17

General Health Risk Factors

Traditional cardiovascular and metabolic risk factors—including cardiovascular disease, diabetes, obesity, smoking, and alcohol misuse—are linked to increased rates of orgasmic difficulty. 17

Evidence Strength

The NCCN recommendations cited above are based on expert consensus and clinical guideline development; specific levels of evidence are not detailed in the source material.

Management of Low Libido in Women (NCCN Guidelines)

Initial Assessment and Identification of Reversible Causes

Systematically screen for modifiable contributors—including psychological factors (depression, anxiety, relationship distress, body‑image concerns), vaginal symptoms (dryness, dyspareunia, atrophy), and traditional risk factors such as cardiovascular disease, diabetes, obesity, smoking, and alcohol use—before initiating specific therapy. 18
Perform a focused physical and gynecologic examination to identify signs of vaginal atrophy (mucosal thinning, loss of rugae, anatomic changes). 19

Non‑Pharmacological First‑Line Approaches

Offer cognitive‑behavioral therapy (CBT) as a primary intervention; evidence shows it improves sexual functioning in women with low libido. 20
Recommend the use of appropriate lubricants (water‑, oil‑, or silicone‑based) and vaginal moisturizers to alleviate dryness; silicone‑based products provide longer lasting lubrication. [19][20]
Provide pelvic‑floor physical therapy for women experiencing dyspareunia, which can enhance arousal, lubrication, orgasm, and overall sexual satisfaction. [19][18]20

Pharmacological Treatment Options for Premenopausal Women

Flibanserin – the first FDA‑approved medication for acquired, generalized hypoactive sexual desire disorder in premenopausal women; clinical trials demonstrate an average gain of ~1 additional satisfying sexual event per two months. 21
Common adverse effects of flibanserin include dizziness, somnolence, nausea, and fatigue. 21
Flibanserin is not contraindicated in women with a prior history of breast cancer. 21
Bupropion – may be used off‑label; limited data suggest benefit in some women with and without concomitant depression. 21

Treatment of Vaginal Symptoms Contributing to Low Libido

Vaginal estrogen (pills, rings, or creams) is the most effective therapy for postmenopausal vaginal dryness and dyspareunia, leading to measurable improvements in sexual function. [19][18]20
Ospemifene, a selective estrogen‑receptor modulator, is an alternative to vaginal estrogen but is contraindicated in women with estrogen‑sensitive cancers (e.g., breast, endometrial). 21
Topical lidocaine applied to the vulvar vestibule before vaginal penetration can reduce dyspareunia and improve comfort during intercourse. 20