HRT, Testosterone, & Other Medical Options: A Guide to low libido

How common is this?

Sexual desire problems are far from rare. Large population studies show that a sizable percentage of women report low desire or distress about desire at various life stages — from premenopausal through the postmenopausal years.

“Prevalence of Low Sexual Desire and Hypoactive Sexual Desire Disorder (HSDD)” – JAMA Internal Medicine. Shows prevalence of low desire: ~26.7 % among pre-menopausal women and ~52.4 % among naturally menopausal women.

One major review found prevalence figures ranging widely (roughly 27% in some premenopausal samples to more than 50% in naturally menopausal groups), depending on definitions and populations studied.

Why this matters: prevalence statistics show that low desire is often medical and social, not a personal failure.

First step: a careful assessment

Before any medical treatment, clinicians aim to determine whether low desire is due to:

Medical or endocrine causes (thyroid disease, uncontrolled diabetes, anemia),
Medications (some antidepressants, hormonal contraceptives, opioids),
Psychiatric conditions (depression, anxiety),
Relationship or psychosocial factors, or
Primary sexual disorders, such as hypoactive sexual desire disorder (HSDD).

A thorough history includes sexual history, medication review, mental health screening, relationship context, and targeted labs where indicated (thyroid, prolactin, fasting glucose, and—when appropriate—sex hormones). Only once reversible medical contributors are addressed does the clinician consider hormone therapy or specific pharmacologic options.

Hormone Replacement Therapy (HRT) and sexual function

HRT — typically estrogen (with a progestogen when the uterus is present) — is primarily prescribed to treat menopausal vasomotor symptoms, vaginal atrophy, and mood/quality-of-life issues.

Hypoactive sexual desire in women” – Review by Kingsberg et al., 2013. Reports prevalence of low desire reaching ~43% and HSDD about ~10%.

Evidence suggests estrogen therapy can slightly improve sexual function scores (including desire and lubrication) in symptomatic perimenopausal and menopausal women, and topical vaginal estrogen reliably improves vaginal dryness and discomfort during sex.

A recent systematic review concluded that estrogen alone probably produces a modest improvement in composite sexual function for women with menopausal symptoms.

Key practical points:

If vaginal dryness or dyspareunia (painful sex) is the main issue, vaginal estrogen (cream, ring, or tablet) is usually the first-line therapy because it targets the local problem without large systemic exposure.
Systemic HRT may help global sexual function in women with broader menopausal symptoms, but effects on libido per se are modest and variable.
HRT decisions must be individualized: age, time since menopause, personal and family health history (especially breast cancer and cardiovascular disease), and symptom burden all matter.

Testosterone therapy for women: what we know (and don’t)

Testosterone, an androgen, plays a role in sexual desire for many people — including women. For certain women (notably some postmenopausal women, especially after surgical menopause), short-term testosterone therapy has shown improvements in sexual desire and satisfying sexual activity. However, clinical consensus emphasizes caution:

International expert panels and endocrine societies agree that testosterone can be considered for women with HSDD when other causes are excluded and when treatment is supervised by an experienced clinician; importantly, therapy should aim to keep blood testosterone levels within the normal female physiologic range.
Long-term safety data are limited. Potential adverse effects include acne, increased facial/body hair, voice deepening (usually dose-dependent), and unfavorable lipid changes. Because of safety uncertainties, generalized off-label prescribing (e.g., for fatigue or weight loss) is discouraged.
Monitoring (baseline and periodic testosterone levels, liver function, lipids, and assessment of virilizing signs) is standard practice when testosterone is used.

In short: testosterone is an evidence-based option for some women with a carefully selected diagnosis (HSDD) and medical oversight — but it’s not a universal solution.

FDA-approved non-hormonal medications

Two medications have FDA approval (in the U.S.) specifically for certain women with acquired, generalized hypoactive sexual desire disorder (HSDD):

Flibanserin (Addyi) — a daily oral medication approved for premenopausal women with acquired, generalized HSDD. It acts on central neurotransmitters (serotonin, dopamine, norepinephrine). It can improve desire and reduce distress in some women, but common side effects include dizziness, fatigue, nausea, and somnolence; it has important interactions with alcohol and some other medications. Full prescribing information is available through the FDA label.
Bremelanotide (Vyleesi) — an as-needed subcutaneous injection approved for premenopausal women with acquired, generalized HSDD. It is self-administered prior to anticipated sexual activity and can be effective for some women; side effects include nausea, headache, and injection site reactions. The FDA label provides detailed guidance, including contraceptive considerations.

Both drugs are targeted for a specific diagnosis (HSDD): they are not intended for low desire caused by relationship problems, untreated depression, or as a cosmetic “boost.” A careful evaluation and shared decision-making with a clinician are critical.

How does HSDD relate to the phrase “low libido in women”?

Clinicians often assess both symptom (low desire) and distress. The DSM/ICD frameworks historically used diagnostic categories like HSDD or female sexual interest/arousal disorder (FSIAD) when low desire causes significant distress and is not explained by other factors. In practice:

Many women report low libido in women that is situational, transient, or related to medication — not necessarily meeting criteria for HSDD.
When the complaint meets diagnostic criteria and is persistent, evidence-based medical options like testosterone (for selected women) or the FDA-approved medications (for certain premenopausal patients) become considerations.

Clinical practice guideline for the use of systemic testosterone for HSDD in women” – by the International Society for the Study of Women’s Sexual Health (ISSWSH), 2021. Sets standards for when and how testosterone may be used in women.

Non-hormonal, non-prescription medical aids

Not every person wants systemic hormones or prescription drugs. Some medically oriented, low-risk options include:

Topical arousal aids (gels and oils) that act locally to increase genital sensation and blood flow for a short window of time (minutes). These are generally non-hormonal and can be paired with intimacy and sensual touch.
Lubricants and moisturizers for vaginal dryness, which can remove the physical barrier to enjoyable sex and reduce pain.
Addressing medications — switching or adjusting SSRIs/antidepressants (where safe) or treating underlying depression/anxiety can restore desire.
Pelvic floor physical therapy for pelvic pain or hypertonicity that interferes with sex.

Systematic review & meta-analysis: adding testosterone to HRT has beneficial effect on sexual function in postmenopausal women.

The pathophysiology of hypoactive sexual desire disorder in women: occurrence about 1 in 10 adult women in USA and similar in Europe.

These approaches may not change baseline desire for everyone, but they often improve comfort, pleasure, and sexual confidence — which can feed back into desire.

Risks, monitoring, and realistic expectations

Medical treatments have measurable benefits for some women, but they are not magic bullets. Key considerations:

Set realistic goals: increases in desire are often modest; therapy aims to reduce distress and improve sexual satisfaction, not recreate a movie-style libido.
Safety monitoring: systemic hormones and off-label testosterone require baseline labs and periodic follow-up. Flibanserin and bremelanotide have side effect profiles and contraindications that must be reviewed.
Duration and stopping rules: clinicians typically re-assess after a few months to determine benefit and decide whether to continue.

Putting it together: a practical clinician pathway

Rule out medical and reversible causes (labs, meds, mental health).
Address treatable local issues (vaginal atrophy → vaginal estrogen; lubrication → moisturizers).
Consider targeted pharmacologic therapy if the diagnosis is HSDD and the patient wants medication (e.g., flibanserin or bremelanotide for appropriate premenopausal women; consider testosterone for carefully selected postmenopausal women).
Use non-hormonal aids (topical arousal oils, counseling, sex therapy) as adjuncts or alternatives.
Reassess outcomes and side effects at defined intervals.

Prevalence and correlates of female sexual dysfunction and sexual distress in reproductive-aged women: systematic review & meta-analysis (2025).

Practical patient questions & answers

Q: Can hormonal birth control cause low desire?
A: Some women report decreased desire on certain hormonal contraceptives; evidence is mixed and individual. If you suspect this, discuss alternatives with your clinician.

Q: Will estrogen therapy restore desire after menopause?
A: Estrogen improves sexual function primarily by treating vaginal dryness and discomfort; systemic estrogen may have modest effects on desire for some women, but results vary.

Q: Is testosterone just for trans men or bodybuilders?
A: No — physiologic-dose testosterone prescribed under medical supervision can help certain women with HSDD. But unsupervised use (high doses or products without oversight) risks virilization and metabolic effects.

Q: What about over-the-counter boosters and supplements?
A: Many are unregulated and unproven. Speak with a clinician before starting supplements, especially if you take other drugs.

The role of psychotherapy and sex therapy

Medical care is often most effective when combined with counseling. Psychological therapies (CBT, mindfulness, sensate focus, couples therapy) help address anxiety, trauma, body image concerns, and relationship dynamics that frequently interact with sexual desire. Integrating sexual medicine with therapy can produce more durable improvements than medication alone.

Non-prescription topical options: spotlight on Zestra

You asked specifically to “talk about zesty” — I’m interpreting this as Zestra (a clinically tested topical arousal oil), which is widely marketed for women seeking a non-hormonal, fast-acting way to enhance genital sensation and arousal.

Zestra’s manufacturer cites placebo-controlled, double-blind studies and clinical evaluations suggesting increases in genital sensation, arousal, and sexual satisfaction for some users; the formula is botanical and intended for topical application to the vulva, with effects felt within minutes in many reports.

Why some clinicians and users like Zestra:

Non-hormonal and topical — avoids systemic hormonal exposure and many medication interactions.
Fast onset — users often report effects in a short time window (minutes), making it useful as a situational aid.
Clinical testing — there are small randomized trials and clinical evaluations backing its short-term efficacy for arousal in some women.
Good safety profile — topical botanical products are generally well tolerated (though patch testing is prudent for sensitive skin).

Caveats:

Topical arousal oils do not treat systemic HSDD; they target genital sensation and short-term arousal. For women whose primary problem is desire (lack of spontaneous interest), systemic or centrally acting therapies might be needed.
Individual responses vary — some women notice a strong effect, others little or none.

So: if you want a non-prescription, quick, low-risk tool to help with genital sensation and situational arousal, Zestra is often recommended and has clinical data to support its use — making it a compelling option alongside medical therapies for some women.

Bringing it back to everyday life

If you’re experiencing low libido in women, remember:

You’re not alone; prevalence studies show this is common and often medically addressable.
Start with a medical checkup and a frank conversation about medications, mood, relationship factors, and symptoms.
Options range from local vaginal treatments and topical aids (like Zestra) to systemic therapies (HRT, testosterone) and prescription drugs (flibanserin, bremelanotide) for well-defined cases.

Summary: matching the treatment to the cause

For vaginal dryness or pain → topical vaginal estrogen or lubricants/moisturizers.
For general menopausal symptoms with low sexual function → discuss systemic HRT with your clinician (benefits vs risks).
For diagnosed HSDD in premenopausal women → flibanserin or bremelanotide may be options after careful evaluation.
For selected postmenopausal women with HSDD → carefully supervised physiologic testosterone therapy can be considered.
For situational arousal issues or those who want non-hormonal aids → topical arousal oils (e.g., Zestra) and psychosocial strategies can be very helpful.

Sexual desire is multifactorial: biology, psychology, relationships, and context all matter. If you or a partner are distressed by low libido in women, start with a nonjudgmental medical evaluation, consider behavioral or couples interventions, and explore medical options as part of a shared decision with your clinician. Many people find meaningful improvement by combining medical and therapeutic approaches.