Does PCOS Cause Increased Libido?
No, PCOS does not cause increased libido—in fact, women with PCOS experience significantly higher rates of sexual dysfunction, particularly affecting sexual desire, arousal, and orgasm, with 28-41% meeting criteria for sexual dysfunction compared to 12-24% of controls. 1, 2, 3
Sexual Dysfunction is Common in PCOS
Women with PCOS report significantly lower sexual function scores compared to women without PCOS, with sexual dysfunction present in 27-41% of PCOS patients versus 12-24% of controls. 1, 2, 3
The most commonly affected domains are desire and arousal, with 99.2% of PCOS patients showing impaired desire and 98.5% showing impaired arousal in one study. 1
Sexual distress is markedly elevated in PCOS, with 51.5% of women with PCOS experiencing clinical sexual distress compared to only 19.4% of controls. 3
Orgasm/completion is significantly impaired in women with PCOS compared to controls, representing a consistent finding across multiple studies. 2, 3
The Androgen Paradox: Higher Testosterone Does Not Mean Higher Libido
Contrary to what might be expected, elevated androgens in PCOS do not improve sexual function—in fact, regression analyses show only few and weak associations between androgen levels and sexual function, with models explaining a maximum of only 15% of sexual function variance. 3
Interestingly, women with PCOS whose testosterone levels are in the normal range (not elevated) actually have worse sexual function than those with testosterone levels >1 standard deviation above the mean, suggesting a U-shaped relationship where both deficiency and excess impair function. 2, 4
The pathophysiology of PCOS involves hyperandrogenism through accelerated GnRH pulsatility, elevated LH, and ovarian theca cell hyperactivity, but this hormonal milieu does not translate to enhanced libido. 5, 6
Contributing Factors Beyond Hormones
Body mass index has a significant negative effect on sexual desire and arousal (p=0.02), with increasing BMI associated with significant reduction in orgasm/completion. 1, 2
Hirsutism significantly affects all sexual function domains (p<0.001 for total FSFI score) except dyspareunia, likely through body image disturbance. 1
Body image anxiety and exposure concerns during sexual activities are powerful predictors, with elevated BESAQ (Body Exposure during Sexual Activities Questionnaire) scores increasing the risk of sexual dysfunction by 4.24 times. 4
Weight, body image, and anxiety related to sexual activities appear to be more significant components in the development of sexual dysfunction in PCOS patients than the direct effect of hyperandrogenism. 4
Treatment Can Improve Sexual Function
Intensive lifestyle modification alone or combined with oral contraceptive pills improves sexual desire in women with PCOS, with significant increases in the FSFI desire domain subscore after 16 weeks. 7
Among women with baseline sexual dysfunction (FSFI ≤26.55), lifestyle modification and combined treatment significantly improved overall FSFI scores, suggesting that common PCOS treatments can address sexual dysfunction through multifactorial mechanisms. 7
Oral contraceptive pills alone did not alter FSFI scores, indicating that hormonal suppression of androgens is insufficient without addressing metabolic and psychological factors. 7
Clinical Implications
Screen all PCOS patients for sexual dysfunction using a validated questionnaire such as the FSFI, as this is a highly prevalent comorbidity affecting quality of life. 1
Address sexuality and offer psychosexual counseling as an important component of clinical care for women with PCOS, since endocrine perturbations have minimal direct impact on sexual function. 3
Target weight loss and body image concerns as primary interventions, as these factors appear more influential than androgen levels in determining sexual function outcomes. 7, 4
The BESAQ cutoff point of 1.97 can be used to detect sexual dysfunction in PCOS patients, along with assessment of free testosterone, LH/FSH ratio, and BMI as independent predictors. 4