Management of low libido in females

Offer an opportunity to discuss management options; this gives permission for questions that the individual may have been reticent to ask. Information about the high prevalence of low libido in the general population may reassure them that their symptoms are not necessarily pathological, provided they are not distressing. Some changes are normal after menopause, such as a switch from spontaneous desire to responsive desire (triggered by stimulation). If the individual is distressed by their symptoms, offer education about the many factors that can interact to reduce libido. See patient information from:

• the Australian Menopause Society
• the Jean Hailes website.

Consider altering medications that may suppress libido (and other aspects of sexual function) such as¹:

• depression and anxiety medications, especially selective serotonin reuptake inhibitors
• pain medication, such as opioids
• other classes of medications, including antiandrogens, tamoxifen and aromatase inhibitors.

Address other underlying conditions (for examples, see History taking for a person with sexual difficulties), in particular, concurrent sexual symptoms such as sexual pain or orgasm difficulties. Weight loss can improve libido in people with obesity.

In peri- and postmenopausal females, intravaginal estrogen therapy alleviates symptoms of vulvovaginal atrophy and may improve sexual health. Systemic menopausal hormone therapy improves menopausal symptoms and wellbeing. Tibolone improved desire and arousal in one small clinical trial². For patient information on tibolone, see the Australian Menopause Society website.

Drug therapy options to increase libido in females are limited; sildenafil has not been shown to increase sexual satisfaction (measured by frequency of sexual events) so is not recommended for use in general practice.

Data on efficacy of testosterone therapy in premenopausal individuals are insufficient to recommend the use of testosterone.

Testosterone is effective in postmenopausal individuals with low libido associated with distress persisting for 6 months or more (hypoactive sexual desire disorder [HSDD]). The effects of transdermal testosterone in postmenopausal individuals include an increase in sexual desire, arousal, orgasmic function, pleasure and reduced sexual concerns, with an average increase of one satisfying sexual event per month. Testosterone therapy does not benefit mood, cognition, bone mineral density, muscle strength or body composition. Increasing the serum testosterone concentration in postmenopausal individuals into the physiological premenopausal range causes increases in body and facial hair and acne, but does not alter voice, cardiometabolic parameters or breast density. Individuals at high cardiometabolic risk, or a history of breast cancer have been excluded from trials. There are no safety data beyond 2 years.

Do not measure serum testosterone concentration to determine whether testosterone therapy is appropriate. Studies of premenopausal and postmenopausal individuals did not show a correlation between sexual interest and function and serum testosterone concentration. Testosterone production declines throughout adult life in females, but this decline does not accelerate at menopause.

Testosterone formulations made for males and compounded formulations are not safe to use in females due to unpredictable effects, including the risk of supraphysiological serum testosterone concentrations. A low-dose transdermal formulation is approved by the Australian Therapeutic Goods Administration (TGA) for use in postmenopausal females with HSDD.

Psychological therapies offer benefit in treating low libido. Referral for couple therapy may be appropriate if relationship issues are contributing to distress or low libido. Stressors related to work, finances and family issues may benefit from referral to a psychologist or social worker. Cognitive behavioural therapy that challenges unrealistic beliefs can reduce symptom severity, and, to a lesser extent, improve sexual satisfaction. Mindfulness training may be helpful. Consider referral to an accredited therapist with a specialist interest in sexual health practice, such as a sexual medicine specialist, sexologist, general practitioner, nurse, psychologist, other sexual health counsellor or sexual health physician. The Society of Australian Sexologists and the Australian Psychological Society set national accreditation standards for quality and safety of practice and list accredited members.