Hypoactive Sexual Desire Disorder (HSDD) in Women

Hypoactive sexual desire disorder at a glance

• Hypoactive sexual desire disorder (HSDD) is a type of mental and physical sexual dysfunction in which women lack motivation or lose desire to have sex for an extended period of time (at least 6 months), causing significant levels of personal distress – an integral part of an HSDD diagnosis.
• Hypoactive sexual desire disorder affects about 10% of women across all age groups. Men can also be affected by low sexual desire.
• Symptoms of HSDD include decreased spontaneous sexual thoughts or fantasies, decreased responsiveness to stimulation, inability to maintain interest through sex, and loss of desire to initiate sex. Women with HSDD may also avoid situations that could lead to sexual activity.
• Treatments include sex therapy and medications. Flibanserin is the only drug currently approved by the Food and Drug Administration (FDA) for HSDD treatment in premenopausal women, however other medications may be prescribed to treat certain HSDD symptoms.

What is HSDD?

Hypoactive sexual desire disorder is a medical term used for various types of diminished sexual desire. Hypoactive means a decrease in behavioral or physical activity.

HSDD is defined as the persistent and recurrent loss of desire in sexual activity, sexual thoughts and sexual stimulation, causing heightened stress in the woman. This clinically significant stress can involve sadness, a sense of grief, and feelings of incompetence, loss and frustration. The significant personal distress caused by HSDD is integral to the diagnosis.

Hypoactive sexual desire disorder is also diagnosed when the woman’s symptoms cannot be attributed to a different type of sexual disorder, medications or medical and psychological conditions. Another facet of an HSDD diagnosis is that these deficiencies of interest and response last for 6 months or longer.

It is a difficult condition to diagnose and treat, in part because there is still little scientific knowledge about the biology of sexual desire. It is also underdiagnosed due to the hesitation of of patients – and even some physicians – to discuss this very private and emotionally troubling condition.

The International Society for the Study of Women’s Sexual Health estimates 10% of women have hypoactive sexual desire disorder, though the actual number is likely considerably higher. One recent survey of 2,207 women found that 26.7% of premenopausal women and 52.4% of menopausal women experience low desire and HSDD. That study estimated that at least 16 million women aged 50 years or older currently experience low desire, and approximately 4 million are distressed by their low desire.

Hypoactive sexual desire disorder vs. low sex drive (libido)

Having a low libido alone does not necessarily mean a woman has hypoactive sexual desire disorder. HSDD also always includes experiencing high levels of stress due to having low sex drive (lack of sexual desire), which is crucial in establishing a diagnosis. However, the two conditions are often related and the terms HSDD, low libido and low sex drive are sometimes used interchangeably.

Women can have low libido, or low sex drive, at various times in their lives and relationships. Low libido is different for each woman, and one’s lack of interest in sex isn’t something that can be readily quantified. It may be the woman’s interest is less than what is normal for her, and what is normal can evolve throughout a woman’s life.

If a woman is concerned that her sex drive is becoming a problem, she should consult with her OB-GYN. Together, they can discuss her risk factors and symptoms (see below), determine the extent of the problem and ways to treat it. This can be a change in medications or lifestyle habits, as well as the treatments below.

Causes & risk factors for HSDD/low libido or sex drive in women

What causes sexuality and desire, or lack of it, is complicated and can change during one’s life. Sexual identity, desire, arousal, orgasm, emotional satisfaction and intention are all involved.

Certain regions and functions in the brain regulate sexual desire. Sexual excitement involves such neurotransmitters as dopamine and melanocortin that help process sexual stimulation. But sexual inhibition systems involving brain opioids and other substances restrict sexual excitement impulses.

While it is not completely known how and why these brain inhibition systems result in hypoactive sexual desire disorder in women, we do know that certain factors put women at risk of developing HSDD. These include:

• Sexual functioning of the partner.
• Medical conditions such as diabetes.
• Medication side effects, such as commonly used antidepressants or blood pressure medications.
• Negative attitudes about sexuality.
• Problems in a relationship, including emotional or physical abuse.
• Psychiatric issues such as anxiety and depression.

Symptoms of HSDD

• Lack or loss of interest to initiate or engage in sexual activity.
• Absence or decrease of spontaneous desire, which is the need to experience sexual arousal.
• Not responding to sexual stimulation or cues, which can be visual or related to other senses.
• Reduced or missing ability to maintain interest or desire in sexual activity for at least 6 months.
• Experiences of high personal stress due to the lack of sexual desire.

Treatment of HSDD/low libido (sex drive) in women

Treatment for hypoactive sexual desire disorder addresses the psychological, social and biological aspects of the condition. Treatment decisions are always customized to each woman to meet her specific situation and needs.

Addressing the suspected underlying contributing factors for HSDD is often the best approach, focusing first on the factors that are particularly stressful to the woman. Our OB-GYNs completely discuss all treatment options with each patient before initiating any form of treatment.

Psychotherapy and sex therapy

Psychotherapy is often beneficial as it can help to resolve unconscious conflicts from early development or current issues in a woman’s life.

Some couples may need marriage/relationship counseling prior to or in addition to specific HSDD therapy. Sex therapy sessions may be recommended, which sometimes may include dual sex therapy involving both partners.

Medications (drug therapy)

The drug flibanserin (brand name Addyi) was approved by the FDA in 2015 for treatment of generalized HSDD in premenopausal women. Flibanserin is a nonhormonal daily medication that increases sexual desire and frequency of satisfying sexual events.

The FDA advises not to drink alcohol within 2 hours of taking flibanserin to prevent low blood pressure or syncope (passing out).

Other drugs can also be used to treat HSDD with off-label use. These include:

• Testosterone, typically used for perimenopausal and postmenopausal women to help balance reproductive hormones, which impact sexual arousal, sex drive and distress. Use of systemic hormones is only recommended for postmenopausal women.
• Bupropion, an antidepressant shown to increase sexual function, arousal and orgasm in women with HSDD. This is a daily medication that is especially helpful in HSDD associated with SSRIs, a type of antidepressant.
• Buspirone, a drug for anxiety disorder that can increase sexual interest. This can be taken prior to sexual activity and is especially helpful in HSDD associated with SSRIs.

All medication options require monitoring of the patient, as risk assessments of these off-label drugs for HSSD patients has not been fully explored.