What makes HSDD different from just "not being in the mood"
Low desire is common. Stress, sleep deprivation, relationship dynamics, certain medications — all of these can temporarily suppress libido, and none of them are HSDD. The defining feature of HSDD is the combination of persistently low or absent sexual desire and personal distress about it. Both have to be present.
That distress criterion matters because it reframes the question. HSDD isn't about meeting some external benchmark of how often women should want sex. It's about whether your desire (or absence of it) is causing you suffering. Many women have lower desire than their partners and feel completely fine about it. That's not HSDD. The women this article is for are the ones who feel the absence and are bothered by it — who miss wanting to want sex, and don't know if there's anything to do about it.
What drives it — and why the brain is usually the starting point
Female sexual desire is primarily driven by the brain's dopamine and serotonin systems, not just hormones. This is why flibanserin — the first FDA-approved HSDD treatment — acts on neurotransmitter pathways, not estrogen or testosterone. It works by increasing dopamine and norepinephrine while reducing serotonin activity in relevant brain regions: essentially adjusting the neurochemical balance between "want" and "braking" systems. Think of it as recalibrating the accelerator-to-brake ratio in the brain's desire circuit.
Hormones play a role too, particularly testosterone. Women produce testosterone (primarily from the adrenal glands and ovaries), and declining testosterone — which happens gradually from the 30s and more sharply around menopause — is associated with reduced desire. This is the basis for off-label testosterone use, which the 2019 international consensus panel found has the strongest overall evidence of any treatment for HSDD in postmenopausal women.
2019 Global Consensus (Journal of Sexual Medicine): An international panel of 48 experts reviewed all available evidence for testosterone therapy in women. Their conclusion: testosterone therapy for HSDD in postmenopausal women has the most robust evidence of any pharmacological option. The testosterone doses used are much lower than in men — roughly one-tenth — and the formulations approved for men are used off-label in women at adjusted doses because no dedicated female formulation is currently FDA-approved in the US.
What the FDA has approved — and what else works
Two drugs are FDA-approved specifically for HSDD. Flibanserin (brand: Addyi) was originally approved for premenopausal women in 2015; in March 2026, the FDA expanded its indication to postmenopausal women under 65. It's taken daily at bedtime, and alcohol is contraindicated due to hypotension risk — a real limitation that affects adherence. Effect sizes in trials are modest, and it takes 4-8 weeks for full effect.
Bremelanotide (brand: Vyleesi) is a self-injectable taken on-demand about 45 minutes before sexual activity, approved for premenopausal women. It works on melanocortin receptors and can cause temporary nausea and flushing — common enough that some women discontinue, but manageable for many. Neither drug is a cure; both work best as one component of a broader approach.
- Name it precisely with your OB-GYN: "I have low sexual desire that's causing me distress" is the language that triggers a proper HSDD workup. Vague language about "feeling off" often doesn't get there. Your doctor should review your medications too — SSRIs, hormonal contraceptives, and antihistamines can all suppress desire.
- Ask about mindfulness-based sex therapy: Dr. Lori Brotto's work at UBC produced some of the strongest evidence in this space. A therapist trained in this approach is different from general couples therapy — the focus is specifically on attention, embodiment, and desire as a learnable skill.
- Ask about testosterone: It's off-label for HSDD in the US but widely used and well-evidenced. A gynecologist familiar with women's sexual health can prescribe it at appropriate doses and monitor blood levels. The doses used are small; masculinizing side effects are rare at therapeutic levels.
- Review your contraception: The combined oral contraceptive pill suppresses free testosterone via sex hormone binding globulin — this is a real and underacknowledged mechanism for low desire in pill users. Some women see significant improvement after switching to a non-hormonal method or progesterone-only option.
HSDD often coexists with other conditions — depression, relationship distress, pelvic pain, or hormonal changes — so a thorough evaluation matters. If your primary care doctor isn't familiar with HSDD treatments, asking for a referral to a gynecologist or sexual health specialist is a reasonable next step. Both flibanserin and bremelanotide require a prescription and medical supervision; testosterone use in women requires monitoring of blood levels to stay within the therapeutic range.
- FDA (March 2026). FDA approves expanded use of flibanserin for hypoactive sexual desire disorder in women. contemporaryobgyn.net
- Brotto L et al. (2022). Mindfulness-based sex therapy for low sexual desire in women: a randomized controlled trial. Journal of Sexual Medicine, 19(1):48-64.
- Davis SR et al. (2019). Global Consensus Position Statement on the Use of Testosterone Therapy for Women. Journal of Sexual Medicine, 16(9):1331-1333. doi:10.1016/j.jsxm.2019.07.012
- American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5). FSIAD / HSDD criteria.
- Simon JA et al. (2019). Efficacy and safety of flibanserin in postmenopausal women with HSDD. Menopause, 26(6):692-699.