What are the treatment options for low libido, including medications like testosterone replacement therapy and sildenafil (Viagra)?

Treatment of Low Libido

For low libido specifically, refer to a sexual health specialist for comprehensive evaluation and management, as this represents a complex multidimensional problem requiring specialized assessment. 1

Initial Assessment and Diagnostic Approach

Before initiating any treatment, determine the underlying cause by evaluating:

• Check morning total testosterone levels - if <300 ng/dL, testosterone replacement therapy may be indicated 1
• Screen for psychological factors including depression, anxiety, chronic stress, and relationship conflicts 1
• Review all medications that may suppress libido (SSRIs, antipsychotics, opioids) 1
• Assess for concurrent erectile dysfunction - if present, this requires different treatment algorithms 1

Testosterone Replacement Therapy for Low Libido

Testosterone replacement therapy should be considered for men with low libido AND documented testosterone deficiency (<300 ng/dL). 1, 2

Evidence for Testosterone in Low Libido:

• A 2024 randomized trial in 1161 hypogonadal men with low libido demonstrated that testosterone therapy significantly improved sexual activity and sexual desire over 24 months compared to placebo 3
• Critical limitation: Testosterone therapy improved libido and sexual activity but did NOT improve erectile function 3
• Testosterone can be administered as intramuscular injections (250 mg testosterone cypionate every 4 weeks) 4, 5

Contraindications to Testosterone:

• Prostate cancer on active surveillance or androgen deprivation therapy 1
• Men actively trying to conceive - exogenous testosterone suppresses sperm production 1
• Any primary oncologic diagnosis where androgens are contraindicated 1

Role of PDE5 Inhibitors (Sildenafil, Tadalafil) in Low Libido

PDE5 inhibitors like sildenafil and tadalafil are NOT primary treatments for low libido alone - they treat erectile dysfunction, not desire. 1

When PDE5 Inhibitors May Help:

• If low libido coexists with erectile dysfunction, PDE5 inhibitors can improve erectile function but will not directly increase desire 1
• For orgasmic problems (less intensity, difficulty achieving), PDE5 inhibitors may be beneficial if not contraindicated 1
• Sildenafil 50-100 mg or tadalafil 10-20 mg taken as needed before sexual activity 6

Critical Safety Screening:

• Absolute contraindication: Never prescribe PDE5 inhibitors to patients taking nitrates (oral, sublingual, patches, or "poppers") due to risk of fatal hypotension 1, 6, 7
• Verify cardiovascular fitness - patients should be able to perform moderate physical activity 6
• Wait 24 hours after sildenafil or 48 hours after tadalafil before administering emergency nitrates 6

Combination Therapy: Testosterone Plus PDE5 Inhibitors

For men with BOTH low testosterone (<300 ng/dL) AND erectile dysfunction, combining testosterone with PDE5 inhibitors is more effective than either alone. 1, 6

• Small studies in bone marrow transplant recipients and dialysis patients showed favorable responses to combined testosterone cypionate 250 mg monthly plus sildenafil 50-100 mg as needed 4, 5
• This combination addresses both the hormonal component (libido) and vascular component (erectile function) 4, 5
• However, testosterone alone does NOT effectively treat erectile dysfunction - it primarily improves desire 1, 3

Psychological and Behavioral Interventions

Referral to sexual health specialists, sex therapy, or couples counseling is recommended for low libido, particularly when psychological factors are identified. 1

• Address anxiety, depression, relationship conflicts, and partner-specific issues 1
• Consider anxiolytics or antidepressants if global distress, anxiety, or depression are present 1
• Integrative therapies including yoga and meditation may help 1

Lifestyle Modifications

Risk factor modification should be implemented regardless of other treatments:

• Smoking cessation 1
• Weight loss if overweight 1
• Increased physical activity 1
• Avoid excess alcohol consumption 1

Common Pitfalls to Avoid

• Do not prescribe PDE5 inhibitors expecting improvement in libido alone - they treat erectile dysfunction, not desire 1
• Do not start testosterone without checking levels - testosterone therapy is only indicated when levels are <300 ng/dL 1
• Do not use testosterone in men actively trying to conceive - it suppresses spermatogenesis 1
• Always ask about nitrate use (including recreational "poppers") before prescribing PDE5 inhibitors 1, 6, 7
• Recognize that low libido is multifactorial - biological, psychological, and relational factors all contribute and may require specialist evaluation 1, 8

Medications NOT Recommended for Low Libido

• Flibanserin - FDA-approved for premenopausal women with hypoactive sexual desire disorder, but has substantial side effects (dizziness, somnolence, nausea, fatigue) and controversial efficacy 1
• Unapproved therapies including stem cell therapy, low-intensity shock wave therapy, and platelet-rich plasma have no clinical data supporting their use 1