What are the causes and treatments for a decline in sexual libido?

Management of Decreased Sexual Libido

Begin with a comprehensive assessment for reversible causes—including medication side effects (especially antidepressants, spironolactone, beta-blockers), hormonal abnormalities, chronic illness effects, and psychosocial factors—then treat vaginal symptoms with non-hormonal lubricants as first-line therapy, followed by psychosexual counseling which achieves success in 50-80% of patients. 1

Initial Diagnostic Evaluation

Key History Elements to Obtain

Assess for these specific reversible factors:

• Medication review: Antidepressants are among the most common culprits for libido impairment, along with spironolactone and beta-blockers 2, 1
• Menopausal symptoms: Evaluate for vaginal dryness, dyspareunia, hot flashes, and sleep disturbance which directly impact sexual desire 1
• Psychological screening: Depression, anxiety, chronic stress, body image concerns, and relationship conflicts are major contributors 1, 3
• Chronic illness context: Fatigue and symptoms from conditions like liver disease, diabetes, or cancer significantly reduce libido 2
• Menstrual patterns: In premenopausal women, assess for hormonal irregularities 2

Laboratory Workup

For men with erectile dysfunction and low libido:

• Consider sex hormone levels (testosterone, SHBG) and thyroid function, though refer to specialists for definitive management 2
• The American College of Physicians does not recommend routine hormonal testing in all men with erectile dysfunction due to insufficient evidence 2

For women:

• Do not obtain testosterone levels in non-research settings—this is not recommended 1
• Thyroid function testing may be appropriate based on clinical suspicion 2

Treatment Algorithm

Step 1: Address Physical/Vaginal Symptoms (First-Line)

For women with vaginal dryness or dyspareunia:

• Non-hormonal water-based lubricants and moisturizers are the primary recommended treatment 2, 1
• Silicone-based products may last longer than water-based or glycerin-based options 2
• Combination therapy may provide additional benefit 2
• Atrophic vaginitis affects approximately 50% of postmenopausal women and requires ongoing treatment 1

For men with erectile dysfunction:

• Trial of PDE-5 inhibitors (sildenafil, vardenafil, tadalafil) is appropriate, as erectile function may recover up to 2-4 years after prostate surgery 2
• Early penile rehabilitation with PDE-5 inhibitors may preserve smooth muscle and improve outcomes through increased tissue oxygenation 2

Step 2: Psychosexual Therapy (Second-Line)

Refer for psychoeducational support, group therapy, sexual counseling, or marital counseling:

• This achieves successful outcomes in 50-80% of patients 1
• Particularly valuable when sexual dysfunction is multifactorial, involving body image changes, relationship factors, and psychosocial trauma 1
• Brief psychoeducational interventions addressing anxiety, stress, and mood changes should be offered to all patients with sexual complaints 2

Step 3: Pharmacologic Options

For premenopausal women:

• Flibanserin (ADDYI) is FDA-approved for acquired, generalized hypoactive sexual desire disorder 1
• This is specifically indicated when distress accompanies low desire 1

For postmenopausal women:

• DHEA supplementation (10-50 mg daily) can be considered for persistent lack of libido and/or low energy 1
• Low-dose vaginal estrogen (tablets or ring) may be recommended for urogenital atrophy, though results take 6-12 weeks 2
• Caution: The safety of vaginal estrogen in breast cancer survivors is not well established, and use is not recommended in women on aromatase inhibitors 2

For men:

• If PDE-5 inhibitors fail or are contraindicated, refer to urology for intraurethral prostaglandin pellets, intracavernosal injections, vacuum erection devices, or penile prosthesis 2
• Combination therapy (e.g., sildenafil plus vacuum constriction) may improve outcomes but requires specialist management 2

Special Population Considerations

Cancer Survivors

Sexual dysfunction affects at least 50% of cancer survivors and is frequently overlooked:

• Include sexual health assessment in survivorship care plans 1
• For breast cancer survivors on aromatase inhibitors, vaginal dryness occurs in 18% (vs. 8% with tamoxifen) and markedly affects quality of life and treatment compliance 1
• Young women with bilateral oophorectomy experience severe, long-lasting menopausal symptoms including sexual dysfunction 1
• Men with same-sex partners are significantly more bothered by loss of ejaculate and at greater risk of depression 2

Chronic Liver Disease

In women with advanced liver disease:

• Altered estrogen metabolism and hypothalamic-pituitary axis disruption lead to anovulation and amenorrhea in >25% of patients 2
• Pregnancies can still occur even in decompensated disease, necessitating contraception counseling 2

In men with advanced liver disease:

• Low testosterone from hypogonadotropic hypogonadism plus increased peripheral conversion to estrogen causes erectile dysfunction, oligospermia, and testicular atrophy 2
• Differential diagnosis includes medication effects (spironolactone, beta-blockers), hemochromatosis, and diabetic autonomic dysfunction 2

Critical Pitfalls to Avoid

• Do not prescribe hormonal contraception to breast cancer survivors—use alternative non-hormonal methods 1
• Do not overlook medication-induced dysfunction, particularly from antidepressants and endocrine therapies which profoundly impact desire and arousal 1
• Do not ignore partner factors: Partner sexual dissatisfaction negatively affects erectile function recovery, and many couples require support to recover sexual intimacy 2
• Do not assume libido decline is "normal aging": Open, directed inquiry in clinic provides opportunity for patients to disclose dysfunction that they may not volunteer 2

When to Refer to Specialists

• Refractory symptoms despite initial management 1
• Complex hormonal issues requiring specialist menopause services 1
• Men with persistent erectile dysfunction after PDE-5 inhibitor trial 2
• Fertility concerns in women with chemotherapy-related amenorrhea (refer within 6 months of difficulty conceiving) 2