The International Society for the Study of Women's Sexual Health Process of Care for Management of Hypoactive Sexual Desire Disorder in Women
Clayton AH, Goldstein I, Kim NN, Althof SE, Faubion SS, Faught BM, Parish SJ, Simon JA, +9 more
Mayo Clinic Proceedings (2018)
The ISSWSH consensus algorithm for HSDD diagnosis and treatment — biopsychosocial assessment first, modifiable-factor management second, then central-acting pharmacotherapy with menopausal-status-stratified selection — produced via modified Delphi across 17 international panelists.
This is the International Society for the Study of Women's Sexual Health (ISSWSH) consensus Process of Care for the clinical management of hypoactive sexual desire disorder (HSDD) in women — the first formal consensus algorithm offering structured diagnostic and treatment guidance for HSDD developed by a multidisciplinary expert panel using modified-Delphi methodology. Seventeen international panelists representing gynecology, endocrinology, psychiatry, primary care, sexual medicine, and behavioral psychology converged on a structured workflow operationalizing the diagnosis-to-treatment pathway for women presenting with HSDD across reproductive-status strata.
The recommended algorithm proceeds in defined stages. Diagnostic assessment begins with explicit clinical screening for sexual concerns (the "ask the question" recommendation), differentiates HSDD from other sexual dysfunctions through a structured biopsychosocial interview, distinguishes generalized acquired HSDD (the FDA-approved indication for flibanserin and bremelanotide) from situational, lifelong, and secondary forms, and addresses comorbidity with depression, relationship dysfunction, medication-induced sexual dysfunction, and menopausal physiology. Treatment proceeds through a graduated framework: (1) patient education and management of modifiable factors (sleep, fatigue, relationship dynamics, medication review with prescriber to address SSRI- and oral-contraceptive-mediated sexual side effects), (2) structured behavioral interventions (sex therapy, CBT-SC, mindfulness-based therapy, sensate focus), (3) central-nervous-system pharmacotherapy with menopausal-status-stratified agent selection, and (4) hormonal therapy where appropriate (transdermal testosterone for postmenopausal HSDD per the parallel Davis et al. 2019 global consensus, vaginal estrogen for GSM-related complaints).
For pharmacotherapy specifically, the consensus identified flibanserin as the only FDA-approved CNS agent for HSDD in premenopausal women at the time of writing (with bremelanotide approval following in June 2019 after the consensus paper went to press but reflected in the framework). Off-label transdermal testosterone for postmenopausal HSDD is recommended at female-physiologic dosing under specialist supervision with explicit advice against compounded testosterone products. The consensus document is the operational backbone of contemporary HSDD clinical practice and the framework that the FDA-approved PT-141 / bremelanotide RECONNECT trials and the Simon 2019 long-term safety extension deploy into clinic.
This is an expert consensus document developed through modified-Delphi methodology, not a randomized trial or systematic review. The evidence basis for individual recommendations varies — some elements (vaginal estrogen for GSM-related dyspareunia, mindfulness-based therapy for FSIAD) are supported by high-quality RCT data, while others reflect expert consensus in the absence of trial-grade evidence. The consensus authorship includes industry-supported clinicians and academic-society leaders; the relevant disclosures appear in the paper. The framework is HSDD-specific and operates within the legacy ISSWSH four-domain framework (desire, arousal, orgasm, pain) rather than the DSM-5 FSIAD combined-diagnosis framework — the two diagnostic systems are partially overlapping and the algorithmic differences matter for practitioner-side interpretation, with the McCabe et al. 2016 ICSM definitions consensus walking the broader diagnostic landscape. The recommendations are calibrated to U.S. regulatory and prescribing landscape; international applicability varies. The bremelanotide-specific evidence post-dates the publication; the consensus framework has been operationalized into the FDA-labeled prescribing pattern for PT-141 under the female sexual dysfunction beyond Vyleesi dossier. The companion ISSWSH paper (Parish et al., Climacteric 2021, 24:533–550) extends the consensus into systemic testosterone for HSDD specifically. The framework is the load-bearing reference for the contemporary FSD-care landscape and has been incorporated by reference into AUA/ACOG guidance and into the major sexual-medicine fellowship curricula.
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