Treatment for low sexual desire includes office-based counseling, psychological therapy, and medications. Office-based counseling can be facilitated using an approach based on the PLISSIT model employed in sex therapy. (The letters of the model’s name refer to the four different levels of intervention that a sex therapist can use: permission [P], limited information [LI], specific suggestions [SS], and intensive therapy [IT].) In addition to sex therapy, intensive psychological therapy may include cognitive-behavioral training and mindfulness-based stress reduction training (see Chapter e4-06).
Based on the understanding of sexual excitatory and inhibitory pathways, medications that increase dopamine or decrease serotonin release or binding may be effective in increasing sexual desire. Flibanserin, which is a full agonist of the 5-HT1A receptor and, with lower affinity, an antagonist of the 5-HT2A receptor, is currently the only FDA-approved medication for the treatment of low sexual desire in premenopausal women. A 2016 systematic review evaluated the efficacy of flibanserin in 5914 premenopausal and postmenopausal women. Compared to women taking placebo, women who were taking flibanserin had a small increase in the number of satisfying sexual events and sexual desire intensity but were four times more likely to experience the side effects of dizziness and somnolence.
Flibanserin is prescribed in a single daily oral dose of 100 mg, to be administered at bedtime. Consumption of alcohol with this medication is contraindicated due to the potential for adverse effects, including syncope and hypotension. Additionally, prescribing clinicians are required to complete a knowledge certification and enrollment process before prescribing this medication.
Several studies have investigated the efficacy of testosterone for the management of hypoactive sexual desire disorder. The results of a systematic review of seven randomized trials involving more than 3000 menopausal women showed that the testosterone patch, compared to placebo, resulted in a significant increase in the number of sexually satisfying encounters and sexual activity as well as sexual desire and orgasms. Side effects included increased acne and hair growth, although there was no significant difference in serious adverse events. However, the lack of FDA-approved testosterone formulations for women with sexual dysfunction (because of insufficient long-term safety data) limits off-label use of this medication for treatment.
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et al.. The International Society for the Study of Women's Sexual Health process of care for management of hypoactive sexual desire disorder in women. Mayo Clin Proc. 2018 Apr;93(4):467–87.
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