Workup for Long-Standing Low Libido in a 37-Year-Old Female
Begin with a structured assessment that includes screening for psychological distress, relationship issues, medication effects, and hormonal abnormalities, followed by targeted laboratory testing when clinically indicated. 1
Initial Clinical Assessment
History Taking
The evaluation should systematically address multiple domains:
Psychological factors: Screen for depression, anxiety, body image concerns, and general distress related to the low libido 1. Depression disproportionately affects libido, and the relationship between these conditions is bidirectional 2.
Relationship dynamics: Assess relationship satisfaction and communication patterns, as relationship dissatisfaction is the most common factor in patients with decreased desire 3.
Medication review: Identify all prescription and over-the-counter medications, particularly antidepressants (especially SSRIs), antihypertensives, and hormonal contraceptives, which commonly impair libido 1, 4.
Menopausal symptoms: Evaluate for vaginal dryness, dyspareunia, and other symptoms that may contribute to decreased sexual desire 1.
Substance use: Document alcohol consumption, recreational drug use, and smoking history 5.
Medical history: Review for chronic illnesses including diabetes, cardiovascular disease, thyroid disorders, and liver disease that can affect sexual function 5.
Physical Examination
Perform a focused examination including:
- Blood pressure measurement 5
- Gynecologic examination to assess for vaginal atrophy, anatomic changes, and points of tenderness 5
Laboratory Workup
Morning testosterone testing is recommended when there is clinical suspicion of hypogonadism or to reassure the patient; free testosterone or androgen index is preferred over total testosterone. 5
Additional laboratory tests should be obtained based on clinical findings:
- Thyroid function tests (TSH, free T4) if thyroid dysfunction is suspected 5
- Prolactin level if there is loss of libido with low testosterone 5
- Fasting glucose or HbA1c to screen for diabetes 5
- Complete metabolic panel if renal or hepatic impairment is suspected 5
Important caveat: Testosterone measurement is not mandatory in all cases but should be considered when hypogonadism is clinically suspected or when patients request reassurance 5. Morning measurements are preferred to identify occult hypogonadism 5.
Validated Assessment Tools
Consider using standardized instruments to quantify the problem:
- Brief Sexual Symptom Checklist for Women as a primary screening tool 5
- Female Sexual Function Index (FSFI) for more comprehensive evaluation, which has been validated in various populations 5, 4
- Female Sexual Distress Scale-Revised (FSDS-R) to assess distress related to sexual dysfunction 4
Diagnostic Considerations
The diagnosis requires that low sexual desire is:
- Persistent and troubling to the patient 4
- Not better explained by medical conditions, mental health disorders, relationship problems, or substance use 4
- Present regardless of the type of sexual activity, situation, or partner (generalized) 4
Referral Indications
Refer to appropriate specialists when:
- Multiple endocrine abnormalities are identified 5
- Significant psychological or psychiatric conditions are present 1
- Relationship counseling is needed 1
- Initial screening reveals important abnormalities requiring specialized evaluation 5
Common Pitfalls to Avoid
- Failing to ask: Patients rarely volunteer sexual concerns, so direct inquiry is essential 2, 3.
- Assuming age-related normalcy: At 37 years, this patient is premenopausal and long-standing low libido warrants thorough evaluation 1.
- Over-testing: Not all patients require extensive hormonal workup; tailor investigations to clinical findings 5.
- Ignoring medication effects: Always review the medication list, as many commonly prescribed drugs affect libido 1, 4.
- Overlooking relationship factors: Even when organic causes exist, relationship dynamics often play a significant role 3.