Sexual desire/interest disorder is absence of or a decrease in sexual interest, desire, sexual thoughts, and fantasies and absence of responsive desire.
In sexual desire/interest disorder, motivations to become sexually aroused are scarce or absent. The decrease is greater than what might be expected based on a woman's age and the relationship duration.
Causes often involve primarily psychologic factors (eg, depression, anxiety, stress, relationship problems). Use of certain drugs (particularly SSRIs), anticonvulsants, chemotherapy drugs, β-blockers, and oral contraceptives, can reduce sexual desire, as can drinking excessive amounts of alcohol. Fluctuations in hormone levels (eg, at menopause, during pregnancy, with the menstrual cycle) can affect sexual desire.
Women with sexual desire/interest disorder tend to be anxious, to have a low self-image, and to have mood lability even if they do not have a clinical mood disorder.
Diagnosis is clinical (see Sexual Dysfunction in Women: Diagnosis).
If factors that limit trust, respect, attraction, and emotional intimacy between partners are the cause, the couple should be counseled that emotional intimacy is a normal requirement for female sexual response and needs to be enhanced with or without professional help. Education about sufficient and appropriate stimuli may help; women may need to remind their partner of their need for nonphysical, physical nongenital, and nonpenetrative genital stimulation. Recommendations for more intensely erotic stimuli and fantasies may help eliminate distractions; practical suggestions to improve privacy and a sense of security can help when fear of unwanted outcomes (eg, discovery, pregnancy, sexually transmitted diseases) inhibits arousability.
For patient-specific psychologic factors, psychologic therapies (eg, cognitive-behavioral therapy) may be required, although simple awareness of the importance of these factors may be sufficient for women to change patterns of thinking and behavior.
Hormonal causes require targeted treatment—eg, topical estrogen for atrophic vaginitis and bromocriptine for hyperprolactinemia.
Systemic estrogen therapy:
Systemic estrogen therapy (see Menopause: Hormone therapy) initiated at menopause or within the next few years may improve mood and help maintain skin and genital sexual sensitivity and vaginal lubrication. These benefits may enhance sexual desire and arousal despite decreasing free androgen levels. Transdermal preparations of estrogen are usually preferred after menopause, but no studies identify which preparations available in the US are the most beneficial sexually. Progestins or progesterone are also given to women who have not had a hysterectomy. If oral contraceptives or estrogen therapy appears to contribute to sexual desire/interest disorder, substituting another drug (eg, transdermal estrogen or barrier methods for oral contraceptives) may be indicated to increase free androgens.
Benefits and risks of testosterone supplementation are under study. When no interpersonal, contextual, and intrapersonal factors are evident, some experienced clinicians consider supplementation (eg, with methyltestosterone 1.5 mg po once/day or transdermal testosterone 300 μg daily); preparations formulated for men are used.
Benefit has been shown mostly in women who are taking estrogen and who have had bilateral oophorectomy, but benefit is expected in some women who are taking estrogen and who have premature ovarian failure due to other conditions (eg, adrenal or pituitary dysfunction, chemotherapy, idiopathic). Benefit has been modest, but studies included only relatively sexually healthy women (with 2 to 3 sexually satisfying experiences/mo at baseline). Among postmenopausal women who are taking estrogen therapy and who can no longer be aroused by previously effective stimuli and contexts, benefit is conceivable; however, this group has not been studied.
However, testosterone therapy is not approved for women in the US. Also, the American Endocrine Society currently recommends against its use. Too little is known about long-term safety; in most studies, safety as well as efficacy data are limited to 6 mo. If testosterone is prescribed, full explanation of lack of long-term safety data and careful follow-up are essential. Periodically, the free testosterone level should be calculated or the bioavailable testosterone level should be measured (see Male Reproductive Endocrinology and Related Disorders: Diagnosis of primary and secondary hypogonadism), and women should be checked for signs of hirsutism and for hyperlipidemia and impaired glucose tolerance.
Last full review/revision January 2009 by Rosemary Basson, MD, FRCP(UK)
Content last modified February 2012