What are the treatment options for low libido in men?

Treatment Options for Low Libido in Men

Testosterone replacement therapy should be considered as first-line treatment for men with low libido who have documented low testosterone levels (total morning testosterone <300 ng/dL). 1

Diagnostic Evaluation

• Assess for symptoms of hypogonadism including decreased sexual desire (libido), decreased sexual activity, and erectile dysfunction 1
• Measure morning serum testosterone levels; consider treatment if total testosterone <300 ng/dL 1
• If total testosterone levels are close to the lower limit, check sex hormone-binding globulin, as it is often low in certain conditions (e.g., diabetes) and associated with lower testosterone levels 1
• Further testing (luteinizing hormone and follicle-stimulating hormone levels) may be needed to determine if the patient has primary or secondary hypogonadism 1

Treatment Options

Hormonal Treatments

• Testosterone replacement therapy (TRT) for men with documented low testosterone levels:

  • FDA-approved for replacement therapy in males with conditions associated with deficiency or absence of endogenous testosterone 2
  • Available in various formulations: intramuscular injections, transdermal patches, gels, and pellets 2
  • Benefits include improved sexual function, sexual desire, and overall sexual activity 3, 4
  • Recent evidence shows TRT improves sexual activity, hypogonadal symptoms, and sexual desire for up to 24 months in men with hypogonadism and low libido 3

• Selective Estrogen Receptor Modulators (SERMs) such as clomiphene or tamoxifen:

  • May be used off-label to increase endogenous testosterone production 1
  • Can be considered in men with low or low-normal testosterone who wish to preserve fertility 1

Non-hormonal Pharmacological Options

• Phosphodiesterase type 5 inhibitors (PDE5i) such as sildenafil, tadalafil, vardenafil, and avanafil:

  • Primary indication is for erectile dysfunction, but may help with libido issues secondary to erectile concerns 1
  • Instructions should be provided to maximize efficacy 1
  • Dose should be titrated for optimal effect 1
  • Common side effects include dyspepsia, headache, flushing, back pain, nasal congestion, myalgia, visual disturbance, and dizziness 1

• Psychotropic medications for underlying psychological issues:

  • Anxiolytics or antidepressants may be appropriate if anxiety or depression is contributing to low libido 1
  • Caution: Some antidepressants (particularly SSRIs) can worsen sexual dysfunction 1

Psychological and Behavioral Approaches

• Psychosexual therapy and counseling:

  • Successful outcomes reported in 50-80% of patients 1
  • Can be used in conjunction with physical/pharmacological therapies 1
  • Helps improve communication about sexual concerns, reduce anxiety, and integrate treatments into sexual relationships 1
  • Particularly beneficial when relationship issues, stress, or psychological factors contribute to low libido 1, 5

• Lifestyle modifications:

  • Smoking cessation, weight loss, increased physical activity, and avoiding excess alcohol consumption 1
  • Several trials have shown these modifications can improve sexual function in men 1

Special Considerations

• Cardiovascular risk assessment:

  • Erectile dysfunction and low libido may be markers for underlying cardiovascular disease 1, 5
  • Testosterone replacement in older men with hypogonadism has been associated with increased coronary artery plaque volume and potential cardiovascular events in some studies 1
  • Cardiovascular risk should be evaluated before initiating testosterone therapy 1

• Cancer survivors:

  • For cancer survivors with low libido, testosterone therapy may be indicated if morning testosterone levels are <300 ng/dL and there are no contraindications 1
  • Referral to a sexual health specialist is recommended for complex cases 1

• Integrative approaches:

  • Yoga, meditation, and other integrative therapies may help with global symptoms of distress that affect libido 1
  • Evidence for supplements and vitamins is limited; they are likely not harmful but of questionable value 1

Treatment Algorithm

1. Measure morning total testosterone level

   • If <300 ng/dL, consider testosterone replacement therapy 1
   • If normal, evaluate for other causes of low libido 1, 5

2. Assess for psychological and relationship factors

   • If present, consider psychosexual therapy/counseling 1

3. Evaluate for comorbid sexual dysfunction (e.g., erectile dysfunction)

   • If present, consider PDE5 inhibitors if not contraindicated 1

4. Address lifestyle factors

   • Encourage smoking cessation, weight loss, physical activity, and limiting alcohol 1

5. For complex or refractory cases

   • Consider referral to a sexual health specialist 1