What is the workup for a woman with increased libido?

Workup for Increased Libido in Women

The workup for a woman with increased libido should begin with a comprehensive assessment for underlying medical, psychological, and medication-related causes, followed by appropriate laboratory testing and referrals based on the suspected etiology.

Initial Assessment

Medical History

• Evaluate for new medications that may cause hypersexuality
• Screen for neurological conditions (e.g., dementia, brain injury)
• Assess for hormonal changes or disorders
• Review psychiatric history, particularly for bipolar disorder or mania
• Evaluate for substance use/abuse

Medication Review

• Focus on medications known to affect sexual function:
  • Dopaminergic agents
  • Stimulants
  • Hormonal therapies
  • Recent medication changes

Psychosocial Assessment

• Relationship status and satisfaction
• Recent life stressors or changes
• History of sexual trauma
• Assessment for anxiety, depression, or other mood disorders 1
• Drug or alcohol use patterns 1

Physical Examination

• Complete physical examination with focus on:
  • Neurological assessment
  • Endocrine evaluation
  • Gynecological examination to rule out physical causes 1

Laboratory Testing

• Hormone panel:
  • Testosterone levels (total and free)
  • Estrogen levels
  • Thyroid function tests
  • Prolactin levels 2
• Consider additional testing based on clinical suspicion:
  • Complete blood count
  • Comprehensive metabolic panel
  • Drug screening if substance use suspected

Validated Assessment Tools

Several validated instruments can be used to objectively assess sexual function:

• Female Sexual Function Index (FSFI) - validated in patients with cancer and cancer survivors 1
• Brief Index of Sexual Functioning for Women (BISF-W) 1
• Changes in Sexual Functioning Questionnaire (CSFQ) 1
• Brief Sexual Symptom Checklist for Women 1

Differential Diagnosis

Medical Causes

• Hormonal imbalances (particularly elevated testosterone)
• Hyperthyroidism
• Medication side effects
• Neurological disorders (temporal lobe epilepsy, dementia)
• Early stages of certain neurodegenerative diseases

Psychiatric Causes

• Bipolar disorder (manic phase)
• Borderline personality disorder
• Obsessive-compulsive disorder with sexual focus
• Substance use disorders

Psychological Factors

• Relationship issues
• Psychological trauma response
• Anxiety or compulsive behaviors

Management Approach

If hypersexuality is causing distress or impairment:

1. Treat underlying medical conditions first
2. For primary hypersexuality:
   • First-line: SSRIs (sertraline, paroxetine, fluoxetine, or citalopram) 3
   • Psychological interventions including psychosexual therapy and cognitive-behavioral therapy 3
   • Consider mood stabilizers if related to bipolar disorder 3

Referrals

• Endocrinologist for hormonal abnormalities
• Psychiatrist for underlying psychiatric conditions
• Sex therapist or psychologist for psychological factors
• Couples counseling if relationship factors are contributing

Common Pitfalls to Avoid

• Failing to distinguish between healthy increased libido and pathological hypersexuality
• Not addressing the patient's concerns with sensitivity and respect
• Missing underlying psychiatric conditions that may present with hypersexuality
• Overlooking medication side effects as potential causes
• Neglecting to assess relationship factors that may contribute to changes in sexual desire

Remember that increased libido itself is not necessarily pathological unless it causes distress or dysfunction. The goal of evaluation is to identify any underlying medical or psychological conditions that require treatment while respecting the patient's sexual autonomy.