From the Guidelines
For low libido associated with low free testosterone, I recommend a comprehensive approach including both lifestyle modifications and potential medical interventions, prioritizing the most recent and highest quality study from 2020 1.
Approach to Managing Decreased Libido and Low Free Testosterone Levels
Start with optimizing sleep (7-8 hours nightly), regular exercise (particularly resistance training 3-4 times weekly), stress reduction techniques, and a balanced diet rich in healthy fats, zinc, and vitamin D. If these measures don't improve symptoms after 2-3 months, consider testosterone replacement therapy (TRT) under medical supervision.
Testosterone Replacement Therapy (TRT)
Common options include testosterone cypionate or enanthate injections (50-100mg weekly or 100-200mg every 2 weeks), daily transdermal gels like AndroGel (50-100mg daily), or testosterone pellets implanted every 3-6 months.
- Before starting TRT, comprehensive blood work should be done, including total and free testosterone, estradiol, prolactin, thyroid function, and PSA (for men over 40) as suggested by recent guidelines 1.
- TRT requires regular monitoring of testosterone levels, hematocrit, liver function, and PSA.
- Some men may benefit from adjunct medications like anastrozole (0.5mg twice weekly) if estrogen levels rise excessively during treatment.
Considerations
TRT works by directly increasing testosterone levels, which can improve libido, energy, mood, and body composition. However, it may affect fertility and is contraindicated in men with prostate cancer, severe sleep apnea, or polycythemia.
- The choice between intramuscular and transdermal formulations should consider costs and patient preferences, with intramuscular formulations being more cost-effective as noted in the American College of Physicians guideline from 2020 1.
- Regular reevaluation of symptoms and potential discontinuation of TRT if no improvement is seen within 12 months is recommended 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Approach to Managing Decreased Libido and Low Free Testosterone Levels
- The approach to managing decreased libido and low free testosterone levels involves a systematic diagnosis of hypogonadism, which includes establishing the presence of symptoms/signs of testosterone deficiency and excluding conditions that transiently suppress testosterone 2.
- Hypogonadism is confirmed by measuring fasting serum total testosterone in the morning on at least 2 separate days, or free testosterone by equilibrium dialysis or calculated free testosterone in men with conditions that alter sex hormone-binding globulin or serum total testosterone near lower limit of normal 2.
- Testosterone replacement therapy (TRT) is recommended for the treatment of most cases of male hypogonadism, and transdermal testosterone gels are commonly used in clinical practice 3.
- Monitoring of TRT with transdermal gels involves assessing serum total testosterone, bioavailable testosterone, and free testosterone levels at peak and minimum levels to provide a finely tailored treatment for hypogonadal men 3.
- The application site of transdermal testosterone gel can affect absorption, with arms/shoulders being the most effective site 4.
- Transdermal testosterone substitution therapy has been shown to be effective in increasing serum testosterone levels in hypogonadal men, with no significant side effects 5.
- In women, decreased libido has been linked to low testosterone levels, and treatment with oral DHEA has been shown to restore sexual desire in some cases 6.
Treatment Options
- Testosterone replacement therapy (TRT) with transdermal gels is a common treatment option for male hypogonadism 3, 4, 5.
- Oral DHEA therapy may be effective in treating decreased libido in women with low testosterone levels 6.
- Monitoring of serum testosterone levels is essential to ensure adequate therapeutic levels and prevent supra-physiological levels 3.