How is decreased libido managed?

Management of Decreased Libido

The management of decreased libido requires a systematic approach beginning with identifying and treating reversible causes—including medication side effects, hormonal deficiencies, and psychological factors—before considering specific pharmacologic interventions. 1, 2

Initial Assessment

Hormonal Evaluation

• Measure morning total testosterone in all patients with decreased libido, as levels <300 ng/dL (or <230 ng/dL in some guidelines) indicate potential testosterone deficiency requiring treatment consideration. 3, 2
• Free testosterone or androgen index is preferred over total testosterone alone, as this prevents unnecessary endocrine workup in up to 50% of patients with borderline low total testosterone. 3, 2
• Measure prolactin if testosterone is low OR if loss of libido is the primary complaint, as elevated prolactin universally causes reduced libido. 3, 2
• If testosterone is low, measure luteinizing hormone (LH) to distinguish primary from secondary hypogonadism. 2
• Check thyroid function (TSH, free T4) if thyroid dysfunction is suspected, as both hyper- and hypothyroidism affect sex hormone binding globulin and indirectly impact libido. 2
• In women, assess for menopausal symptoms including vaginal dryness and dyspareunia that may contribute to decreased desire. 1

Medication Review

Identify and address medication-induced causes as a priority, as this represents a highly reversible contributor to decreased libido:

• SSRIs (paroxetine, sertraline, fluoxetine) commonly cause reduced libido and sexual dysfunction—consider switching to bupropion, which has lower rates of sexual side effects and may even improve libido. 3, 4
• Beta-blockers are strongly associated with sexual dysfunction—consider switching to ACE inhibitors, calcium channel blockers, or loop diuretics (furosemide, bumetanide) which have lower risk. 2
• 5-alpha reductase inhibitors (finasteride, dutasteride) cause decreased libido, ejaculatory dysfunction, and erectile dysfunction as antiandrogenic side effects, particularly in the first year of therapy. 3
• Spironolactone causes decreased libido, impotence, and gynecomastia in men due to its antiandrogenic activity; tamoxifen 20 mg twice daily can manage gynecomastia if spironolactone must be continued. 3
• Antipsychotics, opioids, and H2-receptor antagonists are also associated with reduced libido. 2

Psychological and Relationship Assessment

• Screen for depression and anxiety, as these are major contributors to low libido and treating the underlying psychiatric condition frequently improves sexual function. 2, 5
• Evaluate for relationship conflicts, marital dissatisfaction, and partner-specific problems (including partner's erectile dysfunction), as relationship dissatisfaction is the most common factor in patients with depressed desire. 2, 6
• Assess for major life events, chronic stress, and body image concerns that may contribute. 3

Medical Comorbidities

• Screen for diabetes with fasting glucose or HbA1c, as diabetes is associated with sexual dysfunction through vascular and neurological mechanisms. 3, 2
• Evaluate for cardiovascular disease, chronic kidney disease, liver failure, and metabolic syndrome, all of which reduce libido. 2

Treatment Approach

First-Line Interventions

For Women:

• Vaginal moisturizers, lubricants, and gels are first-choice treatments for vaginal dryness and dyspareunia that contribute to low libido. 1
• Low-dose estrogen vaginal tablets or estradiol vaginal ring may be considered for urogenital atrophy, though results take 6-12 weeks and safety in breast cancer survivors is not established. 3
• DHEA supplementation (10-50 mg daily) can be considered for persistent lack of libido and/or low energy in postmenopausal women. 1
• Flibanserin is FDA-approved for acquired, generalized hypoactive sexual desire disorder in premenopausal women. 1

For Men:

• Testosterone replacement therapy (TRT) is indicated when morning testosterone is <230 ng/dL and the patient is symptomatic with decreased libido or erectile dysfunction. 3
• For testosterone levels 231-346 ng/dL, a 4-6 month trial of TRT may be considered after careful discussion of risks and benefits, continuing only if clinical benefit is demonstrated. 3
• Use easily titratable formulations (gel, spray, or patch) rather than long-acting injectables in patients >70 years or with chronic illness. 3
• Caution in congestive heart failure due to fluid retention risk; target mid-range testosterone levels (350-600 ng/dL) in this population. 3
• Baseline hematocrit and prostate-specific antigen testing with 6-month monitoring are necessary. 3

Psychosexual Therapy

• Psychosexual therapy shows 50-80% success rates and can be used alone or in conjunction with physical therapies. 3, 2
• Therapy addresses anxiety, stress, sexual comfort, mood changes, communication issues, and partner problems. 3
• Refer for brief psychoeducational support, group therapy, sexual counseling, marital counseling, or intensive psychotherapy as appropriate. 3, 1

Medication Adjustments for SSRI-Induced Sexual Dysfunction

When SSRIs are necessary for depression but causing decreased libido:

• Consider switching to bupropion, which has significantly lower rates of decreased libido (2-3%) compared to SSRIs and may improve sexual function. 4
• Alternatively, consider dose reduction if clinically appropriate for the underlying psychiatric condition. 3

Common Pitfalls to Avoid

• Do not prescribe testosterone to men with normal testosterone levels (>350 ng/dL), as this does not usually require substitution. 3
• Do not use hormonal therapies for vaginal dryness in women on aromatase inhibitors, as this is contraindicated. 3
• Do not overlook medication side effects—patients rarely volunteer sexual problems and physicians rarely ask, but addressing medication-induced causes significantly improves treatment compliance. 5
• Do not assume decreased libido is purely psychological without ruling out organic causes including hormonal deficiencies, medication effects, and medical comorbidities. 6
• Do not continue testosterone therapy beyond 6 months without documented clinical benefit. 3