Hypoactive sexual desire disorder HSDD
Posted by dkwinter

Causes include

  • Mental health concerns (e.g. stress, anxiety, past sexual abuse)
  • Relationship conflict
  • Inadequate stimulation
  • Behavioral factors such as alcohol and smoking
  • HPA dysfunction (see investigations, below)
  • Drug side effects
    • SSRIs (see below)
    • Antihistamines
    • Anticholinergics
    • Antihypertensives
  • Underlying medical conditions/chronic illness particularly involving vascular and neurologic systems (e.g. diabetes, MS)
  • Postpartum period
  • Menopause
  • Vulvovaginal atrophy


Hypothalamic/pituitary axis investigations:

  • TSH
  • Estrogen
  • Progesterone
  • FSH
  • LH
  • PRL
  • Testosterone


Often the side-effect of SSRIs

  • With the exception of Viibryd (vilazodone)
  • Any drug with mostly serotonin-enhancing effects will have worse sexual dysfunction.
  • Alternative drugs that are multi-modal are better
    • Better alternatives include:
      • SNRIs, particularly duloxetine (Cymblata) or Levomilnacipran (Fetzima)
      • Mirtazepine (Remeron)
      • Addition of Bupropion (Wellbutrin)
      • Trintellix (Vortioxetine)



  • Optimize everything
    • Medication review/substitution
  • Combine things
    • Many women will need topical estrogen + moisturizer + lubricant
  • Consider pharmacotherapy
    • HRT
    • Testosterone
    • PDE-5i doesn't work unless diabetic with neuropathy
  • Daily moisturizer with RepaGyn (or Replens, Gynatrof, HLA, coconut oil or other alternatives-if preferred) is strongly encouraged
  • Generous use of lubricant with sexual activity (silicone or water-based, both are fine). Encourage patient to explore options and "see what works best".
  • Topic conjucated estrogen trial (cream, ring, pill)
    • If using premarin vaginal cream specifically, treatment can be applied both externally and internally. Application daily for 14 days then twice weekly adjusted depending on response.
  • Topical anesthetic if the problem is pain only in order to initiate intercourse in order to "get things started"/"get over the hump"
    • EMLA, Lidocaine 2-10%
  • Other topicals for pain
    • Diclofenac 10-15%
    • Gabapentin 3-6%
    • Ketoprofen 5-10%
    • Baclofen 2%
    • Amitriptyline 2-4%
  • Clobetasol ointment if lichen sclerosis
  • Trial of self-stimulation
  • Trial of dilatory therapy -- slow and progressive especially in combination with treatment of atrophic urogenital tissue


If post-menopausal female who previously had a functional libido:

  • HRT (E+P)
  • If no improvement then consider adding (must be on HRT if uterus is intact):
    • Supplemental testosterone (off-label; consider a half-pump of Androgel every 2nd day)
    • "Testosterone is effective in menopausal women with low sexual desire, causing distress, with administration via non-oral routes.. because of [their] neutral lipid profile."
      • Side effects can include:
        • Acne
        • Virilization (e.g. lower voice, hair growth)
        • Nothing serious in one meta analysis
    • Can follow with serial Total testosterone levels



  • Calm, Cool, Disgruntedly Collected: Female sexual interest / arousal disorder -- Presented by Ted Jablonski, FMF 2022