Libido Disorders in Woman: Drug Therapy

Therapeutic target

Restoration of libido

Therapy recommendations

Underlying diseases or known causes (risk factors) should be treated accordingly as a matter of priority. The following agents may be used:

  • Insofar as subnormal testosterone serum levels have been demonstrated several times, substitution therapy with DHEA (dehydroepiandrosterone) is indicated. In postmenopause, for these reasons, DHEA treatment* (oral 5-25-(50) mg/day; for vaginal use of DHEA, a dosage of 6.25 mg/day is recommended) may be indicated if the symptom of postmenopausal androgen deficiency – for example, libido disturbance – can be confirmed. The conversion of DHEA to testosterone and androstenedione in women leads to an effective substitution of the missing testosterone. Serum DHEAS level should reach at least 200 ug/dl under substitution with DHEA.
  • If necessary, also local estrogen therapy of the vagina due todry vagina/urogenital symptoms (complaints) in the climacteric or postmenopausal. Creams or vaginal suppositories containing estrogens – preferably estriol – are used for this purpose. They have mainly only a local effect directly on the vagina (vagina; and no effect on the endometrium / endometrium) and fix symptoms such as burning, itching or hypersensitivity – eg during sexual intercourse.
  • Loss of libido in peri- and postmenopause: testosterone therapy (off-label use) if necessary, if hormone replacement therapy is not effective [S3 guideline].
    • If appropriate, low-dose testosterone therapy to treat sexual dysfunction characterized by lack of sexual fantasies and activity (engl.hypoactive sexual desire disorder (HSDD); dosage: one-tenth of the dosage for men; therapy goal: approximately premenopausal testosterone concentrations.
    • If appropriate, testosterone patch (low dose) + estrogen therapy The Endocrine Society makes suggestions in a practice guideline for a treatment trial of postmenopausal women with sexual dysfunction due to decreased sexual desire for 3-6 months; it also points out that endogenous testosterone levels cannot predict response to therapy.
  • See also under “Other Therapy.”

Further notes

  • DHEA circulates in the blood as DHEA sulfate (DHEAS), so the serum level of DHEA-S is determined.
  • Serum DHEAS levels are elevated in the morning. In principle, DHEAS serum levels should therefore always be determined at the same time – 11:00-12:00 – during course measurements. Furthermore, at least 3-4 hours should have elapsed after the morning DHEA ingestion to obtain reproducible values.
  • FDA reviewers have advocated for the approval of flibanserin for the treatment of female sexual appetence disorder (“hypoactive sexual desire disorder,” HSDD), and approval subsequently followed in 2015
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    • Action: agonist at serotonin receptor 5-HT1A, antagonist at 5-HT2A, and at dopamine receptor D4, flibanserin behaves as a weak partial agonist.
    • Only 10% more women on flibanserin than on placebo reported meaningful improvement in sexual desire and intercourse
    • Indications: female sexual appetite disorder (“hypoactive sexual desire disorder”, HSDD).
    • Contraindications: consumption of alcohol, as well as concomitant treatment with moderate or strong CYP3A4 inhibitors. Patients with impaired liver function.
    • According to the SmPC, flibanserin should not be prescribed if HSDD is caused by medical or psychiatric disorders.
    • Dosage information: Taking in the evening due toblood pressure-lowering effect.
    • Side effects: common (>10%): fatigue, nausea (nausea), and vertigo (dizziness); occasional (1-10%) anxiety, insomnia, dry mouth, abdominal pain, constipation (urination), nocturia (urination at night), palpitations (heart palpitations), and stress. Furthermore, risk of syncope (brief loss of consciousness) may be increased with flibanserin, as well as for accident and injury after taking flibanserin (because of its sedating side effects).
    • One meta-analysis sees little effect of flibanserin: advantage over placebo (which also produced an effect) in 0.5 to 1 additional sexually satisfying experience per month.Side effects such as the risk of blood pressure drops and syncope (brief unconsciousness), which could be dangerous, especially for women with pre-existing conditions, are not acceptable risks in a risk-benefit analysis.
  • In 2019, the FDA approved the active ingredient bremelanotide as Vyleesi. This is an agonist at the melanocortin receptor, which is injected subcutaneously. This is intended to help women with HSDD (“hypoactive sexual desire disorder”) libido disorder achieve a satisfying sex life.
    • Mode of action: Agonist at the melancortin receptor.
    • Dosage: no more than one dose within 24 hours and a maximum of 8 doses per month.
    • Contraindication (contraindications): women with uncontrolled hypertension (high blood pressure) or cardiovascular disease.
    • Side effects: Nausea after the first injection (40% of women), this prompted 13% to take an antiemetic (anti-vomiting agent); headache; skin redness (“flush”); tanning of the gums and parts of the skin, including the face and chest (1% of the percent of women
    • Initial study results are not encouraging: 5% of women in the verum group achieved an increase of 1.2 points or more on a score (1.2-6 points) that captured sexual appetence; with placebo, 17% achieved such an increase.