Sexual desire and arousal problems are strongly influenced by the relational context. It is therefore imperative to have a diagnostic interview with the couple together and with both members of the dyad separately.

Typical for hormonal causes of desire problems is that the desire for sex is initially unaffected, but that there is a marked decrease in arousability: responsivity to stimuli that were effective in the past has disappeared. Often this is described as “It feels as though the motor does not start.” Physical causes for sexual desire and arousal problems often lead to a discrepancy between central arousal (feelings of desire and arousal) and genital swelling and lubrication, where the former may still be present, and the latter is absent.

In all situations, the way the woman has been coping with differences in desire between partners is crucial with regard to the severity of the problem; if she has accepted sexual activity and penetration without arousal and desire—often leading to pain—on a regular basis, the lack of desire and arousal during sexual activity may gradually turn into aversion.

As discussed, most complaints about low sexual desire occur as a result of differences between partners in wishes and expectations. This is illustrated by some quotes of women with experienced low sexual desire as they can be often heard in the consultation room:

Whenever he even starts to touch me I now have the feeling ‘Oh no not again’ because it always is the same…he wants sex and is so pushy about it. Even a hug has a sexual meaning. He does not seem to understand that to get in the mood I need to feel connected. Desire never came out of the blue and now I lost it altogether.

We quarrel a lot about all those crazy daily hassles like who is responsible for what. It all has to do with my feeling that we do not have enough quality time together. After an argument he always wants to make love…I don’t.

In addition to the most important diagnostic tool, the individual and couple histories, the use of validated questionnaires is recommended when there is a need to quantify the arousal/desire problems or to assess the severity of the problem. There are a number of validated questionnaires for the assessment of “female sexual dysfunction” (FSD) [58]. Only those questionnaires that include assessment of the level of distress are suitable as a diagnostic tool.

To diagnose low sexual desire and arousal problems, standard physical examination and/or laboratory tests are generally not indicated, and in the case of a situational problem, such tests are even contraindicated, so as to avoid somatization. However, if there are comorbid complaints of sexual pain or other gynecological symptoms, a pelvic examination is needed to exclude somatic pathology. When history reveals a generalized decreased sexual arousability, relevant hormones may be measured, such as bioavailable and/or free testosterone, prolactin, and TSH. Decreased genital arousal might be the result of underlying cardiovascular disease. If other risk factors are present, it is recommended to measure blood glucose levels and to determine the cholesterol/HDL ratio.

In analogy to the multifactorial pathogenesis of sexual desire problems, the diagnostic and therapeutic approach is usually multidimensional taking into account all possible predisposing, precipitating, maintaining, and contextual factors. Therapy might include psychoeducation, basic counseling, individual and couple psychosexual behavioral therapy, and hormonal and psychopharmacological treatment. Although literature on the effectiveness of sex therapy and of cognitive behavioral therapy in FSD is scarce [59], there is an emerging literature that demonstrates a synergistic benefit from the use of multifaceted treatment approaches [57]. Effective treatments also seem to have a broader approach, in which the couple is treated instead of the woman alone and techniques are applied that not only focus on sexual desire but also on improving arousal, orgasm, and sexual satisfaction [7].

In sexology, often a stepped-care approach according to the PLISSIT model is applied [60]. This stepped care begins with the reassurance that low sexual desire and arousal can be normal reactions to changed circumstances (P = permission—to have the problem and to talk about it), followed by psychoeducation (LI = limited information) that calls upon the couple’s own problem-solving ability. If this has insufficient results, more intensive help can be provided in the next steps: specific suggestions (SS) and intensive therapy (IT).

In the vast majority of cases, complaints of a lack of sexual desire and arousal are secondary and situational. In the absence of physical, hormonal, or iatrogenic contributing factors, these problems are generally the result of an inability to cope with differences in wishes and expectations that develop throughout the relationship, such that over time, a sexual script has emerged that no longer meets the prerequisites for arousal and desire of one of the partners or both. The majority of these couples describe the early stages of their sexual relationship as good and satisfying. In these cases, sexual desire and arousal problems are mainly associated with inadequate erotic stimulation and/or contextual obstacles that have led to disturbances in sexual response. This implies that treatment should mainly be aimed at helping the couple to rediscover those stimuli and contextual factors that were effective in the past and to add (new) stimuli and circumstances to their sexual repertoire. Only the experience of new satisfying sexual events, which result from their investment in restoring the sexual relationship, will lead to renewed sexual arousal and desire.

The therapeutic process starts with an extensive discussion with the couple about all possible contributing, predisposing, precipitating, maintaining, and contextual factors followed by comprehensive psychoeducation on psychological, physical, and relational aspects of sexual desire and arousal. As a next step, specific suggestions may be given to apply new stimuli and circumstances known to be able to elicit desire and arousal, and to focus on one’s feelings of pleasure, without aiming at penetration as the ultimate goal of sexual interactions.

In the more intensive sensate focus home assignments [61] or individualized modifications thereof, a step-by-step strategy is installed aimed at discovering pleasant physical sensations and, later, effective erotic stimulation. Part of the strategy is that intercourse is prohibited for a longer period, so as to prevent goal-oriented behavior. Another central element is that spectatoring—often an important maintaining factor—is diminished by focusing on one’s feelings. In the words of Masters and Johnson, the motto of the exercises is to “self-assert, self-protect, and communicate,” meaning that wishes and boundaries must be explicitly expressed and respected by encouraging both partners to communicate effectively. Nowadays, elements of cognitive behavioral therapy are often incorporated in these sensate focus exercises, in order to restructure dysfunctional cognitions that inhibit pleasure, arousal, and desire. Also, partner-relationship therapeutic interventions and more general communication exercises can be incorporated in the therapy.

In COC users presenting with decreased arousability and other symptoms of testosterone insufficiency, especially when they experience improvements in the pill-free interval, switching to a less antiandrogenic formulation or to another contraceptive method may be helpful [62, 63].

Additional pharmacotherapy might be useful when hormonal deficiencies are identified. Although in postmenopausal women there is no relationship between a loss of sexual desire, dyspareunia, coital vaginal dryness, and estrogen deficiency [39], local estrogens or systemic estrogen/progestagen formulations may be prescribed. These medications are effective in treating climacterial complaints and help to restore urogenital atrophy, but do not by themselves have a positive effect on arousal and sexual lubrication. On the contrary, systematic estrogens may lead to testosterone deficiency because of their effects on sex hormone-binding globulin (SHBG) levels [64]. Moreover, it has been demonstrated repeatedly that although in postmenopausal women without significant comorbidity, vaginal vasocongestion is indeed lower than in premenopausal women in the unaroused state, they respond with similar levels of vaginal vasocongestion and lubrication to sexual stimuli as premenopausal women [4, 39]. Women on HRT experiencing a decrease in sexual arousability might therefore benefit from adding testosterone or from switching to tibolone, a preparation with combined estrogenic and androgenic effects [65, 66]. PDE5 inhibitors such as sildenafil, vardenafil, and tadalafil are only useful as add-back therapy in SSRI-induced sexual dysfunction [67] and in situations where genital arousal is compromised by cardiovascular and neurological conditions or by nerve damage [68, 69]. No therapeutic effect of sildenafil was found in a randomized controlled trial (RCT) in medically healthy women with FSAD, diagnosed using DSM-IV criteria [70].In August of 2015, after intense lobbying by several special interest groups, the FDA approved flibanserin, a 5-HT1A agonist, a 5-HT2A antagonist and a weak partial agonist on dopamine D4 receptors, as a medical treatment for HSDD in premenopausal women. A meta-analysis that included published as well as unpublished studies found the clinical benefits of flibanserin to be marginal, with statistically and clinically significant adverse effects [71. In the first year after approval, prescription of the drug has been slow.Recently, two studies were published in which two different drug combinations (testosterone/sildenafil and testosterone/buspirone) were studied in women with hypoactive sexual desire disorder [72, 73]. Although the authors claim positive effects, others have expressed serious doubts based on identified sources of bias and confounding, questioning the clinical relevance of the findings [74].

Probably, more pharmacological treatments for FSD will be introduced in the future. It is important to keep in mind, however, that drugs are only able to enhance responsivity to sexual stimuli and are therefore unlikely to be beneficial without simultaneous therapeutical focus on psychological, relational, and other contextual factors.