What is the drug of choice (DOC) for low libido in males?

Testosterone Replacement Therapy is the Drug of Choice for Low Libido in Males

Testosterone replacement therapy is the drug of choice for low libido in males with documented low testosterone levels, with intramuscular formulations preferred over transdermal due to lower cost and similar efficacy. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Measure serum total testosterone levels (at least twice, in the morning)
• Consider checking:
  • Free testosterone levels
  • Prolactin levels (if libido issues persist)
  • Luteinizing hormone (if pituitary dysfunction is suspected)

The prevalence of low testosterone in men with sexual dysfunction varies from 12.5% to 35%, making hormonal testing an important diagnostic step 1, 2.

Treatment Algorithm

1. For Men with Low Testosterone (<300 ng/dL) and Low Libido:

• First-line: Testosterone Replacement Therapy
  • Intramuscular formulations are recommended over transdermal due to lower cost with similar efficacy and safety 1
  • Expect improvement in:
    • Libido
    • Sexual activity
    • Overall hypogonadal symptoms 3
  • Note: TRT improves sexual desire but may not significantly improve erectile function 3

2. For Men with Normal Testosterone and Low Libido:

• First-line: Address underlying causes

  • Review and modify medications with sexual side effects
  • Treat underlying conditions (depression, anxiety, etc.)
  • Recommend lifestyle modifications:
    • Adequate sleep (7-8 hours)
    • Regular exercise
    • Weight loss if overweight
    • Reduction in alcohol consumption
    • Smoking cessation 2

• Second-line: Consider PDE-5 inhibitors

  • May improve sexual function even in men with normal testosterone
  • Success rates of 69-88% compared to 26-35% with placebo 1
  • Choice between sildenafil, vardenafil, or tadalafil should be based on:
    • Patient preference
    • Cost considerations
    • Side effect profile 1

Monitoring and Follow-up

• Reevaluate symptoms within 12 months of initiating testosterone treatment
• Discontinue treatment if no improvement in sexual function is observed 1
• Monitor for potential adverse effects:
  • Polycythemia
  • Cardiovascular events
  • Prostate-related issues 1

Important Caveats and Pitfalls

1. Avoid testosterone in men with:

   • Desire to preserve fertility (consider gonadotropins instead) 4
   • High risk of prostate cancer
   • Polycythemia
   • Thrombophilia
   • Severe cardiovascular disease 4

2. Do not prescribe testosterone for:

   • Men with normal testosterone levels seeking to improve energy, vitality, physical function, or cognition 1
   • Men with age-related low testosterone without sexual dysfunction 1

3. Alternative treatments:

   • For men wishing to preserve fertility: gonadotropin therapy 4
   • For functional central hypogonadism: clomiphene citrate or tamoxifen (off-label) 4
   • For psychological causes: psychosexual therapy or cognitive behavioral therapy 2

4. Partner involvement:

   • Address partner's concerns and expectations
   • Evaluate relationship dynamics that may contribute to sexual dysfunction 2

The evidence strongly supports testosterone replacement therapy as the drug of choice for men with low libido and documented low testosterone levels, with intramuscular formulations preferred due to cost considerations 1, 5, 3. For men with normal testosterone levels, addressing underlying causes and considering PDE-5 inhibitors are appropriate approaches 1, 2.