Hypoactive sexual desire dysfunction (HSDD)

ICD-10F52.0	Lack or loss of sexual desire
DSM-5-TRF52.0 / F52.22	Male Hypoactive Sexual Desire Disorder / Female Sexual Interest/Arousal Disorder

1. Definition and nosology

Hypoactive sexual desire dysfunction (HSDD; ICD-11: HA00; DSM-5-TR in females Female Sexual Interest/Arousal Disorder F52.22, in males Male Hypoactive Sexual Desire Disorder F52.0) — persistent decrease or absence of sexual fantasies and desire for sexual activity; with distress.

Duration ≥ 6 months; situational or generalized; lifelong or acquired.

2. History

1. Kaplan H.S. (1977) — inclusion of the desire phase in the sexual response model.
2. Basson R. (2000) — circular desire-arousal model in women.
3. 2015 — flibanserin FDA approval; 2019 — bremelanotide FDA approval.
4. ISSWSH (International Society for the Study of Women’s Sexual Health) Process of Care 2018 (Clayton A.H.).

3. Epidemiology

• Women: 8–10% distress (HSDD); men: 14–17%.
• Age-related increase; perimenopause is a risk period.
• Comorbidity: depression, antidepressant use (SSRIs), relationship problems.

4. Etiology and pathogenesis

• Biological — hormonal (testosterone, estrogen), medication-related (SSRIs, OCs, antihypertensives), chronic diseases.
• Psychological — depression, anxiety, body image, trauma history.
• Relationship — conflict, partner sexual dysfunction.
• Social-cultural — taboo, lack of knowledge.

5. Clinical features

• Reduction or absence of spontaneous sexual fantasy and thought.
• Not initiating and not responding to partner’s initiative.
• Distress (critical criterion — mere low desire is insufficient).

6. Diagnosis

6.1 Unified diagnostic criteria (DSM-5-TR · ISSWSH)

A. Persistent reduction or absence of sexual fantasies and desire.

B. Duration ≥ 6 months.

C. Clinically significant distress.

D. Not better explained by another mental disorder, medication, or medical condition.

6.2 Differences between sources

• ISSWSH Process of Care (Clayton A.H. et al. Mayo Clin Proc 2018).
• DSM-5-TR — desire and arousal combined in women (FSIAD).

6.3 Diagnostic algorithm

• Clinical interview (sexual and relationship history).
• DSDS (Decreased Sexual Desire Screener) — 5-item in women.
• Hormonal assessment (morning testosterone in men; when indicated in women).
• Medication and comorbidity analysis.
• Depression, anxiety screening.

6.4 Differential diagnosis

7. Examination and assessment

1. DSDS, FSFI, IIEF.
2. Hormonal panel.
3. Depression/anxiety scales.

8. Treatment

8.1 General principles (ISSWSH 2018)

• Biological-psychological-social approach — multimodal according to etiology.
• Psychotherapy and couple therapy — CBT, mindfulness, sensate focus (Masters & Johnson).
• Medication change — In SSRI-induced cases, bupropion, mirtazapine, vortioxetine alternatives.
• Pharmacotherapy in Women (Premenopausal Hypoactive Sexual Desire Disorder):
  1. Flibanserin (100 mg at night) — FDA 2015 approval; with alcohol there is a risk of severe hypotension and syncope (the FDA relaxed the boxed warning in 2019: wait at least 2 hours after 1–2 standard drinks, skip that evening’s dose after 3 or more);
  2. Bremelanotide (1.75 mg s/c as needed) — FDA 2019 approval; melanocortin agonist.
• In postmenopausal women: Transdermal testosterone in low doses (off-label, international consensus Davis S.R. 2019) — careful monitoring.
• In males: hypogonadism confirmed → TRT (≥2 low morning measurements + symptoms).
• Relationship and communication work is critical.

8.2 Treatment methods

• Flibanserin — Serotonin 1A agonist / 2A antagonist; nightly dose; in premenopausal women.
• Bremelanotide — Melanocortin agonist; s/c as needed.
• Testosterone in women (off-label) — Postmenopausal; low dose; monitoring.
• CBT and Mindfulness — Brotto L.A. studies — effective in female sexual dysfunction.
• Sensate Focus — Couple therapy technique.

8.3 Differences between sources

1. Clayton A.H. et al. ISSWSH Process of Care. Mayo Clin Proc 2018.
2. Davis S.R. et al. Global Consensus Position Statement on Testosterone Therapy for Women. J Clin Endocrinol Metab 2019.

9. Prognosis

With multimodal approach, most patients improve; chronic form requires ongoing strategy.

10. Myths and misconceptions

Myth 1: “Low desire is always a disorder”

Evidence: distress critical criterion; low desire without distress normal variation — not pathological.

Myth 2: “Testosterone is a libido enhancer for all women”

Evidence: Davis 2019 consensus — low-dose off-label only for postmenopausal HSDD; general timing of administration is not an official recommendation.

Myth 3: “Flibanserin is ‘female Viagra’”

Evidence: The mechanisms are entirely different (serotonergic, central nervous system); daily use; the effect is modest (comparison with sildenafil is incorrect).

Myth 4: “Desire dysfunction is only due to psychological causes”

Evidence: SSRIs, oral contraceptives (OCs), antihypertensives, and hormonal changes have a strong effect; biological research is important.

Myth 5: “Over-the-counter ‘aphrodisiacs’ are effective”

Evidence: Cochrane and systematic reviews — small or no effect; FDA warnings about hidden components.

11. Sources

• WHO. ICD-11. HA00 Hypoactive sexual desire dysfunction. 2024.
• APA. DSM-5-TR. 2022.
• Clayton A.H. et al. The International Society for the Study of Women’s Sexual Health Process of Care for Management of HSDD in Women. Mayo Clin Proc 2018;93(4):467–487.
• Davis S.R. et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab 2019;104(10):4660–4666.
• Basson R. The female sexual response: a different model. J Sex Marital Ther 2000;26(1):51–65.
• Brotto L.A. Better Sex Through Mindfulness: How Women Can Cultivate Desire. Vancouver: Greystone Books, 2018.