ICD-11HA00	HYPOACTIVE SEXUAL DESIRE DYSFUNCTION (HSDD) Hypoactive sexual desire dysfunction
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 Disorder (HSDD; ICD-11: HA00 Hypoactive sexual desire dysfunction; 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

• Kaplan H.S. (1977) — inclusion of the desire phase in the sexual response model.
• Basson R. (2000) — circular desire-arousal model in women.
• 2015 — flibanserin FDA approval; 2019 — bremelanotide FDA approval.
• 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. Aetiology 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 Source-specific clarifications

• 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

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

6.4 Differential diagnosis

7. Examination and assessment

• DSDS, FSFI, IIEF.
• Hormonal panel.
• Depression/anxiety scales.

8. Treatment

8.1 General principles (ISSWSH 2018)

1. Biological-psychological-social approach — multimodal according to etiology.
2. Psychotherapy and couple therapy — CBT, mindfulness, sensate focus (Masters & Johnson).
3. Medication change — In SSRI-induced cases, bupropion, mirtazapine, vortioxetine alternatives.
4. Pharmacotherapy in Women (Premenopausal Hypoactive Sexual Desire Disorder):
   • Flibanserin (100 mg at night) — FDA 2015 approval; with alcohol, 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);
   • Bremelanotide (1.75 mg s/c as needed) — FDA 2019 approval; melanocortin agonist.
5. In postmenopausal women: Transdermal testosterone in low doses (off-label, international consensus Davis S.R. 2019) – careful monitoring.
6. In males: hypogonadism confirmed → TRT (≥2 low morning measurements + symptoms).
7. Relationship and communication work is critical.

8.2 Source-specific clarifications

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

Treatment methods

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

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: SSRI, OC, 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

1. WHO. ICD-11. HA00 Hypoactive sexual desire dysfunction. 2024.
2. APA. DSM-5-TR. 2022.
3. 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.
4. 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.
5. Basson R. The female sexual response: a different model. J Sex Marital Ther 2000;26(1):51–65.
6. Brotto L.A. Better Sex Through Mindfulness: How Women Can Cultivate Desire. Vancouver: Greystone Books, 2018.