What are the treatment options for low libido in patients with testicular cancer?

Treatment Options for Low Libido in Testicular Cancer Patients

Testosterone replacement therapy is the primary treatment for low libido in testicular cancer patients with documented hypogonadism, which affects 12-16% of survivors.

Understanding Low Libido in Testicular Cancer Survivors

Testicular cancer survivors frequently experience sexual dysfunction, with low libido being a common complaint. This occurs due to several mechanisms:

• Hypogonadism: 12-16% of long-term testicular cancer survivors develop hypogonadism by laboratory standards 1
• Psychological factors: Fear, anxiety, and changes in body image following diagnosis and treatment
• Treatment effects: Surgery, radiation, and chemotherapy can all impact sexual function

Diagnostic Approach

1. Hormone Assessment

• Measure serum testosterone levels (morning sample preferred)
• Check luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels
• Consider inhibin B measurement to assess Sertoli cell function 2

2. Determine Type of Hypogonadism

• Primary hypogonadism: Low testosterone with elevated LH/FSH (testicular failure)
• Secondary hypogonadism: Low testosterone with normal/low LH/FSH (pituitary/hypothalamic issue)
• Adult-onset hypogonadism: Low testosterone with normal/low gonadotropins 1

3. Rule Out Other Causes

• Depression and anxiety screening
• Medication review (many medications can cause low libido)
• Assessment for relationship issues

Treatment Algorithm

For Hypogonadal Patients (Low Testosterone)

1. Testosterone Replacement Therapy

   • Primary treatment for documented hypogonadism
   • Testosterone enanthate injection is FDA-approved for hypogonadism due to testicular failure or orchidectomy 3
   • Dosing: Typically 200-250 mg IM every 2-3 weeks

2. Monitoring During Treatment

   • Follow testosterone levels to maintain in mid-normal range
   • Monitor hematocrit (risk of polycythemia)
   • Prostate screening as appropriate for age
   • Bone density assessment if long-term hypogonadism

For Patients with Normal Testosterone

1. Psychological Interventions

   • Sexual counseling and therapy
   • Cognitive behavioral therapy for anxiety/depression
   • Relationship counseling when appropriate

2. Lifestyle Modifications

   • Regular physical activity
   • Stress reduction techniques
   • Limiting alcohol consumption
   • Smoking cessation

Special Considerations

Impact of Treatment Modality

Different treatments have varying impacts on sexual function:

• Surgery: Retroperitoneal lymph node dissection (RPLND) is significantly associated with loss of ejaculation but has less impact on libido 4
• Radiation: Associated with delayed recovery of normal erectile function (median 60 months) 5
• Chemotherapy: Can cause temporary hypogonadism, but most patients recover normal sexual function over time 5

Long-term Follow-up

• Sexual function assessment should be part of routine survivorship care
• Regular hormone level monitoring is recommended, especially in high-risk patients
• Lifelong follow-up is recommended for all testicular cancer survivors 1

Pitfalls and Caveats

1. Don't assume all sexual dysfunction is due to testosterone deficiency

   • Psychological factors play a major role in many cases
   • Multiple studies show sexual dysfunction can occur even with normal hormone levels 6

2. Don't overlook rare causes

   • Leydig cell tumors can present with isolated loss of libido 7
   • Consider this possibility in patients with persistent symptoms despite normal testosterone

3. Don't neglect fertility concerns

   • Testosterone replacement will further suppress spermatogenesis
   • Consider sperm banking before initiating treatment if fertility is desired

4. Don't miss secondary hypogonadism

   • Some patients may have pituitary/hypothalamic dysfunction rather than primary testicular failure
   • Treatment approach differs for secondary hypogonadism

In conclusion, low libido in testicular cancer survivors requires a systematic approach to diagnosis and treatment, with testosterone replacement therapy being the cornerstone of treatment for those with documented hypogonadism. However, psychological support and lifestyle modifications are equally important components of comprehensive care.