For peri- and postmenopausal women experiencing low sexual desire as a result of biologically compromised natural levels of androgens , testosterone replacement therapy can sometimes be an effective treatment option. There are currently no testosterone products for the treatment of low sexual desire in women that have been approved by the FDA, due in part to lack of long-term safety studies assessing the potential risk for cardiovascular disease and breast cancer. However, many clinicians prescribe “off-label” testosterone, in the form of patches or pills, to women who are distressed by low sexual desire [1]. One estimate suggests that 4.1 million prescriptions for off-label testosterone are made annually in the United States [2]. The use of transdermal testosterone for low sexual desire in women with surgically induced menopause was approved by the European Medicines Agency in 2010 but has yet to be approved by the FDA or Health Canada. In addition, Androfeme, a 1% daily testosterone cream that is only available in Australia, has been shown to increase sexual motivation in women [3].

Estrogen treatment and tibolone therapy are other hormonal therapies for low sexual desire. Estrogen treatment is particularly efficacious for desire problems that stem from vulvovaginal atrophy. Given the established relationship between low levels of estrogen and atrophy, estrogen therapy is the first-line treatment for this particular condition [4]. Tibolone is a 19-nortestosterone derivative and a selective tissue estrogenic activity regulator with estrogenic, progestogenic, and androgenic properties [5]. Available in 90 countries (but not in the United States), tibolone is typically used for the treatment of endometriosis and as hormone therapy for postmenopausal women. It has also been shown to increase sexual desire and lubrication. Nijland and colleagues [6] demonstrated an overall improvement in sexual function in women receiving tibolone. There are some concerns, however, that tibolone may increase the risk of breast cancer recurrence [7] and stroke [8] in older women.

Flibanserin (Addyi) was approved by the FDA in 2015 for the treatment of HSDD in premenopausal women after studies showed that the drug increased self-reports of sexually satisfying events and led to significant increases in desire, as measured by the FSFI [9]. Flibanserin (Addyi), a multifunctional serotonin agonist and antagonist (MSAA), acts on different neurotransmitters in the brain. The drug increases levels of norepinephrine and dopamine while reducing levels of serotonin in the prefrontal cortex, nucleus accumbens, and medial preoptic area, all three of which are brain regions that regulate sexual desire in women.

A recent systematic review and meta-analysis of the effects of flibanserin (Addyi) on sexual desire in women revealed that, on average, treatment with the drug resulted in one-half additional sexually satisfying events per month, and women’s mean global impression of improvement scores indicated minimal improvement to no change [10]. The authors of the review suggested that the overall quality of the current evidence supporting the use of the drug in clinical practice was low.

There is some research on other nonhormonal, centrally acting medications for low desire and arousal problems in women. Bupropion (Wellbutrin) is a norepinephrine-dopamine reuptake inhibitor (NDRI) that has been approved by the FDA as an antidepressant and as a smoking cessation aid (branded as Zyban). When used to treat hypoactive sexual desire among nondepressed premenopausal women, bupropion (Wellbutrin) led to modest improvements in sexual interest and arousal [11]. Buspirone (BuSpar), a serotonin 5-HT1A partial agonist, is typically prescribed for the treatment of generalized anxiety disorder or for relief from acute anxiety symptoms. When administered to counteract the sexual side effects of an SSRI, buspirone (BuSpar) led to a significant increase in sexual function compared to placebo [12]. There is preliminary evidence to suggest that intranasal bremelanotide may also be beneficial for treating low sexual desire in women [5].

Since the success of using PDE-5 inhibitors (e.g., sildenafil (Viagra), tadalafil (Cialis), vardenafil hydrochloride (Levitra)) to treat erectile dysfunction, researchers have attempted to find a comparable drug for women with sexual desire or arousal concerns.

Evidence from limited placebo-controlled studies indicates that sildenafil (Viagra) increases genital engorgement in healthy, premenopausal women [13] and in postmenopausal women with severe levels of genital arousal concerns [14]. Despite reports of increased physiological sexual arousal, studies in general have not found that these drugs positively impact a woman’s psychological experience of sexual arousal. This suggests that, for women, psychological factors such as relationship satisfaction, mood state, and sexual scenarios may play a more important role in facilitating increased sexual arousal than do physiological genital cues. If this is the case, drugs that target increasing vasocongestion are likely to be most effective in women whose primary complaint is decreased genital responding, experienced as decreases in lubrication and/or feelings of vaginal fullness or engorgement. Patients with this primary complaint would most likely be women who are postmenopausal, women who have undergone oophorectomy, or women who suffer from arterial vascular problems. For some women, if a drug increases vaginal engorgement to the extent that the sensations are detected and labeled as sexual feelings, vasodilator drugs may also enhance general, psychological arousal.

Studies on vasodilator drugs for women have revealed a notable placebo effect on women’s sexual arousal. Up to 40% of women in the placebo groups of randomized clinical trials for sildenafil (Viagra) and other pharmacological agents report significant improvements in sexual arousal [15]. It appears that nonspecific factors such as treatment expectancies, having contact with a sexuality professional, and monitoring sexual response can exert a powerful influence on women’s sexual arousal and satisfaction at large.

Lybrido and Lybridos are combination drugs that are currently in development for the treatment of FSIAD. Lybrido is the combination of sublingual testosterone and a PDE-5 inhibitor [16]. Designed for women who have a low sensitivity to sexual cues, Lybrido has been associated with statistically significant increases in sexual satisfaction compared to placebo [17, 18]. Lybridos is the combination of sublingual testosterone and buspirone, a 5-HT_1A receptor agonist [16]. Buspirone is believed to counter the sexual inhibition mechanism, so Lybridos was developed specifically for women who experience sexual inhibition during sexual stimulation or partnered sexual activity. Compared to placebo, the combination of testosterone and buspirone increased sexual satisfaction in sexually dysfunctional women [19].

Though some studies have tested the effects of pharmacological agents on genital arousal, decreased physiological sexual arousal is most commonly treated with topical lubricants. Topical lubricants help mask impairments in vaginal lubrication but do not, however, enhance genital/clitoral blood flow or increase other genital sensations, such as warmth, fullness, and tingling.

Though there are no FDA-approved pharmacological treatments for sexual arousal problems in women, the EROS clitoral therapy device (Urometrics, St. Paul, Minnesota) has been approved by the FDA to address arousal concerns. This small handheld device increases vasocongestion in the clitoral and labial region via a suction mechanism and has been reported to increase vaginal lubrication and sensation [20].

Several herbal supplements , including gingko biloba, ginseng, and maca, have been examined in relation to female sexual arousal and desire. Gingko biloba, a living fossil tree that is typically grown in China, contains glycosides and terpenoids, which have been used in traditional Chinese medicine to stimulate blood flow and improve memory. Despite some initial case studies highlighting of the facilitatory effect of gingko biloba on sexual function, several randomized placebo-controlled trials have found that gingko biloba neither significantly increases sexual arousal or desire in women (e.g., [21]) nor improves antidepressant-induced sexual dysfunction [22, 23]. Ginseng, a slow-growing perennial plant with fleshy roots, is common ingredient in many contemporary Asian medicines. Anecdotal reports suggest that ginseng may increase sexual interest, particularly in women with antidepressant-induced sexual dysfunction. Specifically, ginseng’s phytoestrogen activity may increase libido, but research has yet to verify this hypothesis [24]. Maca is a Peruvian plant that is characterized by its hypocotyl, which can be eaten as a root vegetable or employed as a medicinal herb. Native Andean populations have used dried hypocotyls to enhance sexual function and fertility [25]. The results of one small, placebo-controlled trial suggested that maca decreases symptoms of sexual dysfunction in healthy postmenopausal women [26]. In general, researchers have concluded that, though some herbal supplements may hold promise as treatments for female sexual dysfunction, there is no plant that currently has a strong enough level of evidence to be considered efficacious [27].