What are the treatment options for low libido in men?

Treatment Options for Low Libido in Men

Testosterone replacement therapy is the first-line treatment for men with low libido who have documented low testosterone levels (below 300 ng/dL), while PDE5 inhibitors, psychosexual therapy, and lifestyle modifications are appropriate for men with normal testosterone levels. 1

Diagnosis and Evaluation

When evaluating men with low libido, the following assessments are crucial:

• Morning serum testosterone level (low is defined as <300 ng/dL) 2
• Evaluation of psychological factors (depression, anxiety, relationship issues) 1
• Review of medications that may cause sexual dysfunction (antidepressants, antihypertensives, antipsychotics) 1
• Assessment of comorbid conditions (diabetes, cardiovascular disease) 1

Treatment Algorithm Based on Testosterone Status

For Men with Low Testosterone (<300 ng/dL):

1. Testosterone Replacement Therapy (TRT) 2, 1

   • Intramuscular formulations are preferred over transdermal due to lower cost with similar efficacy 1
   • TRT significantly improves sexual desire and activity but may not significantly improve erectile function 3
   • Recent evidence from the TRAVERSE study confirms that TRT improves sexual activity, hypogonadal symptoms, and sexual desire over a 2-year period 3

2. Monitoring and Follow-up

   • Reevaluate symptoms within 12 months of starting treatment 1
   • Discontinue if no improvement in sexual function is observed 1
   • Monitor for adverse effects including polycythemia and cardiovascular events 1

For Men with Normal Testosterone:

1. PDE5 Inhibitors 2, 4

   • May improve sexual function even in men with normal testosterone levels 1
   • Success rates of 69-88% compared to 26-35% with placebo 1
   • Options include sildenafil, vardenafil, or tadalafil based on patient preference and side effect profile 4
   • Tadalafil has shown efficacy for up to 36 hours after dosing 4

2. Psychosexual Therapy 1

   • Addresses relationship issues, performance anxiety, and psychological barriers
   • Success rates of 50-80% in patients with psychogenic sexual dysfunction 1

3. Lifestyle Modifications 1

   • Adequate sleep (7-8 hours)
   • Regular exercise
   • Weight loss if overweight/obese
   • Reduction in alcohol consumption
   • Smoking cessation

Special Considerations

• Cancer Survivors: Consider testosterone therapy if levels are low, but also evaluate for other contributing factors 2
• Diabetes: Men with diabetes have higher rates of sexual dysfunction and may benefit from both testosterone (if levels are low) and PDE5 inhibitors 2, 4
• Cardiovascular Risk: ED and low libido may be markers for cardiovascular disease; appropriate referrals should be made 2

Common Pitfalls to Avoid

1. Treating without confirming low testosterone: Testosterone therapy is not recommended for men with normal testosterone levels seeking to improve energy, vitality, or cognition 2, 1

2. Ignoring psychological factors: Low libido often has psychological components that need addressing alongside medical treatment 1, 5

3. Failing to review medications: Many common medications can contribute to low libido and should be evaluated for possible alternatives 1

4. Not distinguishing between primary and secondary reduced libido: Primary reduced libido (not associated with medical conditions) and secondary reduced libido (associated with conditions like hypogonadism) have different characteristics and treatment approaches 5

5. Overlooking partner involvement: Partner's concerns and relationship dynamics often play a significant role in sexual dysfunction 1

By following this evidence-based approach, clinicians can effectively address low libido in men, improving quality of life and potentially identifying underlying health concerns that require attention.