From the Guidelines
The best approach to evaluate and manage decreased libido in a 67-year-old man involves a comprehensive assessment followed by targeted interventions, starting with a thorough medical history and laboratory testing, including morning total testosterone levels, as recommended by the American College of Physicians 1.
Evaluation and Management
Begin with a thorough medical history to identify potential contributing factors such as medications (particularly antidepressants, antihypertensives, and opioids), chronic illnesses, psychological issues, relationship problems, or lifestyle factors.
- Laboratory testing should include morning total testosterone levels, with values below 300 ng/dL suggesting testosterone deficiency, as supported by the standards of medical care in diabetes-2023 1.
- Additional tests may include luteinizing hormone, prolactin, thyroid function, and comprehensive metabolic panel.
Testosterone Replacement Therapy
For testosterone deficiency, testosterone replacement therapy can be considered, typically starting with testosterone gel (50-100 mg daily) or injections (testosterone cypionate 100-200 mg every 1-2 weeks), with a preference for intramuscular formulations due to lower costs and similar clinical effectiveness and harms 1.
- Before initiating therapy, screen for prostate cancer with PSA testing and evaluate for sleep apnea.
Alternative Interventions
For men with normal testosterone, consider addressing modifiable factors like:
- Improving sleep
- Reducing alcohol consumption
- Increasing physical activity
- Managing stress Psychological interventions may include cognitive behavioral therapy or couples therapy.
- Phosphodiesterase-5 inhibitors like sildenafil (25-100 mg) or tadalafil (5-20 mg) may help if erectile dysfunction coexists.
Follow-up
Regular follow-up is essential to monitor treatment efficacy and potential side effects, with testosterone levels checked at 3-6 months after initiating replacement therapy, and reevaluation of symptoms within 12 months and periodically thereafter, as suggested by the American College of Physicians 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Evaluation Approach
To evaluate decreased libido in a 67-year-old man, the following steps can be taken:
- A thorough medical history, including a review of medical risk factors such as hypertension, diabetes, cardiovascular disease, renal failure, and medications, as well as lifestyle risk factors such as obesity and tobacco, alcohol, and illicit drug use 2
- A detailed sexual history, including assessment of duration of decreased libido, loss of libido, and overall sexual satisfaction 2
- A physical examination 2
- A psychosocial assessment, with particular attention to depressive symptoms 2
- Appropriate laboratory tests, including measurement of morning testosterone levels on two different occasions 3
Diagnosis of Male Hypogonadism
Male hypogonadism can be diagnosed based on clinical signs and symptoms, plus laboratory confirmation via the measurement of low morning testosterone levels on two different occasions 3
- Serum luteinizing hormone and follicle-stimulating hormone levels can distinguish between primary (hypergonadotropic) and secondary (hypogonadotropic) hypogonadism 3
- Hypogonadism associated with aging (andropause) may present a mixed picture, with low testosterone levels and low to low-normal gonadotropin levels 3
Treatment Options
Treatment options for decreased libido in a 67-year-old man may include:
- Testosterone replacement therapy, which can improve sexual function, enhance sense of well-being, increase lean body mass, decrease body fat, and increase bone density 3, 4, 5
- Medical management of underlying medical conditions, such as hypertension, diabetes, and cardiovascular disease 2
- Oral therapy, intracavernosal injection, vacuum erection devices, and penile prostheses may also be considered 2
- Weekly-to-biweekly injections of testosterone cypionate or testosterone enanthate, or once-daily transdermal therapies, such as patch or gel systems, can be used for testosterone replacement therapy 3, 4
Monitoring and Follow-up
Monitoring and follow-up are essential to confirm an adequate replacement dosage and to detect potential risks, such as:
- Measurement of serum testosterone levels 3, 4
- Assessment of clinical responses, such as improvement in sexual function and overall sense of well-being 3, 5
- Measurement of hematocrit for detection of polycythemia and digital rectal examination with serum prostate-specific antigen level measurement for prostate cancer screening 3