What are the treatment options for low libido in males with normal testosterone levels?

Treatment of Low Libido in Males with Normal Testosterone

For men with low libido and normal testosterone levels, address underlying psychological, relational, and lifestyle factors first, as testosterone therapy is not indicated and provides minimal benefit in eugonadal men. 1

Critical Diagnostic Confirmation

Before considering any treatment, confirm the patient truly has normal testosterone:

• Measure morning total testosterone (8-10 AM) on at least two separate occasions, as single measurements are insufficient due to assay variability and diurnal fluctuation 1
• Obtain free testosterone by equilibrium dialysis in addition to total testosterone, particularly when total testosterone is borderline 1
• Measure sex hormone-binding globulin (SHBG) to distinguish true eugonadism from low SHBG-related decreases in total testosterone 1
• Normal testosterone is defined as ≥300 ng/dL (some guidelines use 275-350 ng/dL threshold) 1

Treatment Algorithm for Eugonadal Men with Low Libido

Step 1: Rule Out and Address Reversible Causes

Testosterone therapy is explicitly contraindicated in eugonadal men, even if symptomatic, and should not be used for libido enhancement in men with normal testosterone levels. 1

Evaluate and address the following factors that commonly cause low libido independent of testosterone status:

• Relationship and psychosocial factors: Disturbances in domestic and dyadic relationships are strongly associated with primary reduced libido 2
• Mental health conditions: Depression, anxiety, and other psychopathology almost double the prevalence of reduced libido 2
• Medications: Review for psychoactive medications, statins, opioids, dopamine antagonists, 5-alpha reductase inhibitors, and steroids 3
• Substance use: Assess alcohol consumption, marijuana, and anabolic steroid use 3
• Sleep disorders and thyroid dysfunction: Screen for obstructive sleep apnea and thyroid abnormalities 1
• Metabolic factors: Evaluate for obesity, diabetes, and metabolic syndrome 4, 3

Step 2: Non-Pharmacologic Interventions

Lifestyle modifications should be the foundation of treatment:

• Weight loss through low-calorie diets if obesity is present, as this can improve sexual function 1, 4
• Regular physical activity and exercise 1
• Smoking cessation 1
• Avoiding excess alcohol consumption 1

Step 3: Psychosexual Therapy

Psychosexual therapy is the primary evidence-based treatment for low libido in eugonadal men:

• Success rates range from 50-80% in published outcome studies 5
• Therapy addresses psychological factors preventing normal sexual arousal 5
• Can be used in conjunction with treatment of erectile dysfunction if present 5
• Requires patient motivation and commitment to work with a therapist 5

Step 4: Address Comorbid Erectile Dysfunction

If erectile dysfunction coexists with low libido in a eugonadal man:

• PDE5 inhibitors (sildenafil, tadalafil) are first-line treatment for erectile dysfunction 1
• Treating erectile dysfunction may secondarily improve libido 1
• Pelvic floor muscle training may provide additional benefit in some populations 1

What NOT to Do: Critical Pitfalls

Never prescribe testosterone therapy to eugonadal men for low libido. The evidence is unequivocal:

• Testosterone therapy in eugonadal men provides minimal to no benefit for libido, energy, vitality, physical function, or cognition 5, 1
• The European Association of Urology explicitly recommends against testosterone therapy in eugonadal men, even for weight loss, cardiometabolic improvement, or vitality 1, 4
• Approximately 20-30% of men receiving testosterone in the United States do not have documented low testosterone levels before treatment initiation—this violates evidence-based guidelines 1
• Testosterone therapy can compromise fertility by suppressing the hypothalamic-pituitary-gonadal axis 5, 1

Never diagnose hypogonadism based on symptoms alone without confirmed biochemical testing, as symptoms lack specificity 1

Never use screening questionnaires alone to justify testosterone therapy, as they have poor specificity for hypogonadism 1

Special Considerations

If Testosterone is Low-Normal (300-350 ng/dL Range)

This scenario requires careful evaluation:

• Obesity-associated secondary hypogonadism may be present due to increased aromatization of testosterone to estradiol in adipose tissue, causing estradiol-mediated negative feedback 1
• First-line intervention is weight loss, not testosterone therapy 1, 4
• Repeat testosterone measurements with free testosterone and SHBG to confirm true hypogonadism 1

If Patient Has Comorbid Conditions

• Men with diabetes: Optimize diabetes management with intensification of therapy (GLP-1 receptor agonists or SGLT2 inhibitors provide cardiovascular benefits) rather than initiating testosterone 1
• Men with obesity: Weight loss programs and exercise are first-line interventions 1, 4

Expected Outcomes with Appropriate Treatment

When underlying causes are addressed:

• Psychosexual therapy achieves successful outcomes in 50-80% of motivated patients 5
• Lifestyle modifications improve sexual function independent of testosterone levels 1
• Treatment of comorbid erectile dysfunction with PDE5 inhibitors can secondarily improve libido 1

Monitoring and Follow-Up

• Reassess symptoms at 3-6 months after initiating non-pharmacologic interventions 1
• Consider referral to mental health specialist if psychosocial factors predominate 2
• Recheck testosterone levels if clinical suspicion for hypogonadism persists despite normal initial values 1