What are the treatment options for male low libido?

Treatment Options for Male Low Libido

Testosterone replacement therapy (TRT) is the first-line treatment for male low libido when associated with hypogonadism, showing significant improvements in sexual desire and activity. 1

Diagnostic Approach

Before initiating treatment, determine if low libido is associated with:

• Hypogonadism (testosterone <300 ng/dL)
• Erectile dysfunction
• Psychological factors
• Medication side effects
• Chronic illness

Treatment Algorithm

1. For Low Libido with Hypogonadism

First-line: Testosterone Replacement Therapy

• Forms available:

  • Transdermal (gels): Most convenient, easy to use 2
  • Intramuscular injections: More cost-effective ($156.24 vs $2135.32 annually for transdermal) 2
  • Oral testosterone: Emerging option with comparable efficacy 3
  • Buccal and nasal formulations 4

• Dosing:

  • Intramuscular: 100-200 mg every 2 weeks or 50 mg weekly 5
  • Target testosterone levels: 450-600 ng/dL (mid-normal range) 5

• Monitoring:

  • Check testosterone levels 2-3 months after initiation
  • Monitor hemoglobin and hematocrit for polycythemia
  • Assess cardiovascular status regularly 5

• Contraindications:

  • Desire for fertility (TRT suppresses spermatogenesis) 5
  • Prostate cancer, breast cancer
  • Severe sleep apnea
  • Uncontrolled heart failure
  • Recent cardiovascular events 5, 6

Alternative for Men Desiring Fertility

• Human chorionic gonadotropin (hCG): 500-2500 IU, 2-3 times weekly 5

  • Stimulates endogenous testosterone without suppressing spermatogenesis
  • Consider adding FSH injections if needed after testosterone normalizes

• Enclomiphene citrate:

  • Blocks estrogen receptors at hypothalamic level
  • Increases endogenous testosterone while preserving fertility 5
  • Not recommended for men with estrogen receptor-positive malignancies

2. For Low Libido with Normal Testosterone

Psychological Interventions

• Sexual skills training
• Cognitive behavioral therapy (individual or online) 2

Address Underlying Causes

• Review and modify medications that may affect libido
• Treat depression if present
• Manage chronic conditions

3. For Low Libido with Erectile Dysfunction

• PDE5 inhibitors: First-line for erectile dysfunction
• Combination therapy: TRT plus PDE5 inhibitors for men with hypogonadism and erectile dysfunction 7
• Other options for refractory cases:
  • Intracavernous injections 2
  • Vacuum erection devices (90% initial efficacy) 2
  • Low-intensity shock wave therapy (LI-SWT) for mild vasculogenic ED 2

Efficacy of TRT for Low Libido

Recent high-quality evidence from the TRAVERSE study (2024) showed that TRT in hypogonadal men with low libido:

• Significantly improved sexual activity compared to placebo
• Enhanced sexual desire
• Improved hypogonadal symptoms
• Effects were maintained for at least 24 months
• Did not significantly improve erectile function 1

Potential Side Effects of TRT

• Erythrocytosis (2.8-17.9%, dose-dependent)
• Suppression of spermatogenesis
• Peripheral edema
• Emotional lability
• Potential cardiovascular effects (long-term safety uncertain) 5, 6
• Gynecomastia
• Sleep apnea (especially in obese patients or those with lung disease)
• Changes in lipid profile 6

Important Considerations

• Discontinuation rates for TRT range from 30% to 62% 2
• Lifestyle modifications (weight loss, physical activity) can improve testosterone levels in obese men 5
• Regular monitoring is essential to assess efficacy and detect adverse effects
• Evidence on long-term benefits or harms of testosterone treatment beyond 24 months is limited 2