What are the management options for low libido?

Management of Low Libido

The management of low libido requires a comprehensive approach addressing underlying biological, psychological, and relationship factors, with treatment options including hormonal therapy, psychological interventions, and lifestyle modifications tailored to the specific cause identified during evaluation.

Initial Evaluation

• Hormonal Assessment:

  • Measure total and free testosterone levels (even when total testosterone is normal, free testosterone may be low due to high sex hormone-binding globulin) 1
  • Check luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin levels 1
  • Evaluate estradiol levels in men with breast symptoms 1

• Medication Review:

  • Identify medications that may cause low libido (antidepressants, antihypertensives, hormonal contraceptives)
  • Consider alternative medications with lower risk of sexual dysfunction:
    • Adrenergic blockers, ACE inhibitors, calcium channel blockers instead of other antihypertensives
    • Loop diuretics instead of thiazides 2

• Psychological Assessment:

  • Evaluate for depression, anxiety, stress, relationship issues
  • Assess for history of sexual trauma or negative sexual experiences

Treatment Algorithm

1. Hormonal Interventions

• For Men with Low Testosterone:

  • Testosterone replacement therapy if levels are below 230 ng/dL 2
  • Consider a 4-6 month trial of testosterone therapy for symptomatic men with levels between 231-346 ng/dL 2
  • Target testosterone levels in the middle range (350-600 ng/dL), especially in men with history of heart failure 2
  • Use easily titratable formulations (gel, spray, patch) in men over 70 or with chronic illness 2

• For Women with Hormonal Issues:

  • Consider discussion of available drugs including androgens and flibanserin for premenopausal women with low desire 2, 3
  • Flibanserin is FDA-approved for premenopausal women with hypoactive sexual desire disorder (HSDD) but has side effects including dizziness, somnolence, and fatigue 3
  • Important safety considerations with flibanserin:
    • Must be taken at bedtime only
    • Avoid alcohol completely until the following day
    • Contraindicated with moderate/strong CYP3A4 inhibitors 3

2. Psychological Interventions

• Psychosexual Therapy:

  • First-line treatment with 50-80% success rate 2, 1
  • Addresses underlying psychological factors affecting desire
  • Can improve couple's communication and address partner's problems 2
  • May be used in conjunction with physical/hormonal therapies

• Cognitive-Behavioral Therapy:

  • Helps identify and modify negative thoughts and behaviors related to sexuality
  • Particularly effective when anxiety or depression contribute to low desire

3. Lifestyle Modifications

• Exercise and Physical Activity:

  • Regular dynamic exercise improves sexual function and cardiovascular health 2, 4
  • Can improve body image and reduce stress

• Stress Management:

  • Mindfulness and yoga can enhance sexual satisfaction 4
  • Stress reduction techniques may improve hormonal balance

• Dietary Changes:

  • Mediterranean diet (emphasizing fruits, vegetables, whole grains, lean proteins) 2
  • Moderate alcohol consumption (if not taking medications that interact with alcohol)

4. Treatment of Coexisting Sexual Dysfunctions

• For Erectile Dysfunction in Men:

  • PDE5 inhibitors (sildenafil, tadalafil, vardenafil) may improve both erectile function and libido 2, 1
  • Consider vacuum erection devices, intracavernosal injections, or intraurethral suppositories as second-line options 2

• For Women with Vaginal Issues:

  • Vaginal moisturizers, lubricants, and topical vitamin D or E for vaginal dryness 2
  • Ospemifene for dyspareunia (not for breast cancer survivors) 2
  • Topical anesthetics for pain during intercourse 2

Special Considerations

• Cancer Survivors:

  • May require specialized approaches due to treatment effects on hormonal function
  • Consider referral to sexual medicine specialist 2

• Partner Involvement:

  • Include partner in treatment discussions when possible 1
  • Address partner's sexual health issues that may impact the relationship

• Monitoring and Follow-up:

  • Regular assessment of symptom improvement
  • Evaluation of relationship functioning and quality of life
  • Adjustment of treatment approach based on response 1

Common Pitfalls to Avoid

1. Focusing solely on hormonal factors while ignoring psychological and relationship issues
2. Overlooking medication side effects as a cause of low libido
3. Failing to address coexisting sexual dysfunctions that may contribute to low desire
4. Not involving the partner in the treatment process when appropriate
5. Neglecting to consider cultural and personal values that influence sexual desire and expression

Remember that low libido is often multifactorial, and successful management typically requires addressing multiple contributing factors simultaneously.