Evaluation and Management of HSDD — Key Recommendations

A recent consensus document synthesizes how hypoactive sexual desire disorder (HSDD) in women is defined, assessed, and managed within a biopsychosocial framework.

The document describes how contemporary classification distinguishes HSDD from related female sexual dysfunction constructs and notes that diagnosis remains a clinical determination that incorporates the patient’s experience of symptoms. It also highlights how validated patient-reported instruments can be used to screen for and quantify symptoms without substituting for clinical assessment.

In its definitions and classification section, the consensus characterizes HSDD as distinct from female sexual arousal dysfunction and notes that it supports keeping these entities separate even as some other nosologies combine desire and arousal constructs. It also reports alignment with ICD-11 terminology and definition for HSDD in women, describing reduced or absent desire or motivation for sexual activity across spontaneous and responsive domains.

On diagnosis, the document notes that HSDD is a clinical diagnosis (and cannot be made by a screening tool) and that when a woman reports low desire, clinicians should assess whether there is distress related to the low desire, which is necessary to diagnose HSDD. In describing evaluation, the consensus reports that assessment includes a focused history and may include a targeted physical examination, with examination performed when clinically indicated by physical complaints, reinforcing the emphasis on clinical assessment and distress.

Validated screening and severity instruments are presented as tools that can support clinical evaluation, particularly for identifying potential HSDD and tracking symptom burden over time. The consensus discusses self-administered questionnaires as standardized inputs to the encounter, describing them as promising and well-validated in some settings while not being sufficient to establish the diagnosis on their own. Examples named include the Brief Profile of Sexual Function and the 5-question Decreased Sexual Desire Screener, which the document references as instruments used for screening or quantifying low desire symptoms. In the consensus narrative, these questionnaires function as structured measures that complement, rather than replace, clinician-led assessment.

For nonpharmacologic management, the document summarizes psychological and behavioral interventions with supportive evidence, including sex therapy, cognitive-behavioral therapy, and mindfulness-based therapy. It describes these approaches as targeting factors that can disrupt sexual response, such as cognitive distraction, rumination, and performance anxiety, and it notes that formats can include individual, couples, or group-based delivery depending on setting considerations. The consensus also describes an expanding literature on internet-delivered interventions, often organized as modular programs that incorporate educational content and at-home exercises aligned with cognitive-behavioral or mindfulness-based rationales. Taken together, the document frames these therapies as part of a biopsychosocial set of options discussed for HSDD.

For pharmacologic and hormonal options with trial evidence summarized in the consensus, the document reports evidence supporting flibanserin in premenopausal women and describes efficacy data in postmenopausal women, and it reports evidence for as-needed bremelanotide in premenopausal women. In menopausal women, the consensus describes randomized-trial and meta-analytic data supporting transdermal testosterone at physiologic dosing ranges for postmenopausal HSDD, while noting that published RCT/meta-analysis data support efficacy and safety up to 24 months and that the recommendations table states serious adverse-event data for physiologic-dose transdermal testosterone are not available beyond 2 months of use, and caution when considering testosterone therapy in women with hormone-sensitive cancer. In the same discussion, the consensus notes that evidence is limited or mixed for many other pharmacologic, hormonal, complementary, or lifestyle approaches reviewed, positioning the overall management landscape as one in which options are described alongside explicit evidence and safety constraints.

Key Takeaways:

• The consensus aligns HSDD terminology with ICD-11 and describes diagnosis as a clinical determination based on low desire accompanied by personal distress.
• Validated instruments (eg, the Decreased Sexual Desire Screener and Brief Profile of Sexual Function) are discussed as tools to support screening and symptom quantification, not as stand-alone diagnostic methods.
• Psychological therapies and selected medications/hormonal options are summarized alongside stated limits in the evidence base and specific safety caveats (including limited long-term testosterone data and caution in hormone-sensitive cancer).

FAQs:

1. How is hypoactive sexual desire disorder (HSDD) in women defined?
The consensus document aligns HSDD terminology with ICD-11 and characterizes the condition as reduced or absent sexual desire or motivation across both spontaneous and responsive domains. Importantly, it distinguishes HSDD from female sexual arousal dysfunction, supporting the conceptual separation of desire and arousal even as some classification systems combine these constructs. Central to the diagnosis is not simply low desire, but low desire accompanied by personal distress. The document underscores that HSDD remains a clinical diagnosis grounded in the patient’s reported experience and its impact, rather than a determination made by questionnaire or laboratory testing alone.

2. What role do screening tools and questionnaires play in diagnosing HSDD?
Validated patient-reported instruments are presented as supportive tools—not substitutes—for clinical assessment. The consensus highlights questionnaires such as the 5-question Decreased Sexual Desire Screener and the Brief Profile of Sexual Function as structured, standardized inputs that can help identify possible HSDD and quantify symptom burden over time. These tools may be especially useful for opening dialogue, tracking changes, and documenting severity. However, they cannot establish the diagnosis independently. Clinicians must assess whether low desire is accompanied by clinically meaningful distress and conduct a focused history, with targeted physical examination when indicated by physical complaints.

3. What nonpharmacologic treatments are recommended for HSDD?
The consensus frames management within a biopsychosocial model and summarizes supportive evidence for psychological and behavioral therapies. These include sex therapy, cognitive-behavioral therapy (CBT), and mindfulness-based approaches, which aim to address contributors such as cognitive distraction, rumination, and performance anxiety that may disrupt sexual response. Delivery formats vary and may include individual, couples, or group-based interventions depending on patient needs and practice setting. The document also notes a growing body of literature supporting internet-delivered programs, often structured as modular interventions combining education and at-home exercises grounded in CBT or mindfulness principles. Collectively, these approaches are positioned as foundational components of care, particularly when relational or psychological factors are prominent.

4. What pharmacologic and hormonal therapies have evidence for HSDD, and what safety considerations apply?
The consensus reviews trial data supporting several pharmacologic options, while emphasizing evidence limits and safety caveats. Flibanserin is described as having supportive evidence in premenopausal women, with efficacy data also reported in postmenopausal populations. Bremelanotide is discussed as an as-needed option with evidence in premenopausal women. For postmenopausal women, randomized trials and meta-analyses are cited supporting physiologic-dose transdermal testosterone for HSDD, with efficacy and safety data extending up to 24 months in published analyses. At the same time, the document highlights important constraints: serious adverse-event data for physiologic-dose transdermal testosterone are not available beyond short-term use in some summaries, and caution is advised in women with hormone-sensitive cancers. For many other pharmacologic, hormonal, complementary, or lifestyle interventions, the consensus describes the evidence as limited or mixed, reinforcing the need for individualized, evidence-informed decision-making.