CLINICAL ACTIONS:

Ascertain if the patient’s primary concern is HSDD (Hypoactive Sexual Desire Disorder, i.e. low desire) and screen for arousal, orgasm or pain issues.

• Determine if the problem is primarily desire and not secondary to arousal, orgasm or pain issues
• Ascertain if the problem is universal rather than situational
  • That is, determine that the lack of desire is persistent in every situation and does not appear to be a response to particular problematic relationship
• Treatment with medication can be extremely effective but simultaneous consultation with a sex therapist can be encouraged

SYNOPSIS:

HSDD is the absence of fantasies and the absence of desire for sexual activity. In order for it to be considered a dysfunction, it must be causing distress or marked interpersonal difficulty. Since HSDD can be secondary to problems with pain, arousal or orgasm, those problems should be screened for as well and treated as appropriate. Treating HSDD successfully, often requires a complex combination of drugs, behavior modification and in some cases psychotherapy.

KEY POINTS:

• Interview with patient should confirm that HSDD is a primary concern and not merely a result of other problems (e.g. problems with arousal, orgasms or pain)
• If the HSDD seems most likely to be a result of other issues, those should be treated first before the low desire is addressed
  • Sometimes when the primary issue is resolved, the lack of desire is resolved as well
• Ascertain if the HSDD is a result of medications that can adversely affect levels of desire
• While many medications can include adverse effects on sexual desire, some of the most common to do so include hormonal birth control and SSRIs
  • If it is likely that HSDD is a result of medications, consider reducing or eliminating those under the guidance of the prescribing clinician
• In the event that patient complains of low desire only within the context of current relationship, consider making a referral to a couple’s therapist
  • This referral does not necessarily require a sex therapist, although a couple’s counselor with expertise in sex therapy would likely be the most effective
• If circumstances lead to treatment for low desire, the following medications have been used:
  • Testosterone (not FDA approved for this use)
    • Topical gel (1%)
    • Pellet – 75 mg pellet (1-2 pellets) administered every three months

• • Flibanserin (FDA approved) – 100 mg tablet, nightly at bedtime
    • Note prescribers need to have completed an online exam in order to prescribe

• • Estrogen therapy (with progesterone, if applicable) if concerns related to menopausal issues
  • Bremelanotide (FDA approved) – injection under the skin of the abdomen or thigh at least 45 minutes before anticipated sexual activity
    • Optimal time to use bremelanotide is based on how they experience the duration of benefit and any side effects, such as nausea
    • Patients should not use more than one dose within 24 hours or more than eight doses per month

• • The patient should be referred for sex therapy while they are being treated
  • While medications can help the patient physiologically, sex therapy can help address and alleviate both bad habits, communication issues and insecurities can continue to affect the sexual relationship

• Diagnosis Codes: DSM-5: 302.72; ICD-10: F522.22

Learn More – Primary Sources:

Female Hypoactive Sexual Desire Disorder: Epidemiology, Diagnosis and Treatment

Flibanserin for Treating Hypoactive Sexual Desire Disorder

Testosterone Therapy in Female Hypoactive Sexual Desire Disorder

Flibanserin for hypoactive sexual desire disorder: place in therapy

ACOG Practice Bulletin 119: Female Sexual Dysfunction

AAFP: Sexual Dysfunction in Women – A Practical Approach

ISSWSH Expert Consensus Panel Review: Hypoactive Sexual Desire Disorder 

FDA approves new treatment for hypoactive sexual desire disorder in premenopausal women

Locate a Sexual Health Professional:

AASECT-Referral Directory 

ISSWSH-Find a Provider 

SSTAR-Find a Therapist

Related ObG Topics:

Prescribing Flibanserin for Low Desire: How, When and Where?

A Patient Complains of Low Sexual Desire – Making an Accurate Diagnosis

Female Sexual Dysfunction Explained 

Asking About Sexual Health

What is Sex Therapy?

Testosterone Therapy for Low Desire – How, When and Where?

A Patient Complains of Anorgasmia – What Next?