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
Orgasm/completion is significantly impaired in women with PCOS compared to controls, representing a consistent finding across multiple studies. 2, 3
Sexual distress is markedly elevated, with 51.5% of PCOS women meeting criteria for clinical sexual distress compared to only 19.4% of controls. 3
The Androgen Paradox: Higher Testosterone Does Not Mean Higher Libido
Contrary to what might be expected, elevated androgens in PCOS do not increase libido—in fact, the relationship is complex and often inverse. 2, 3, 4
Women with PCOS whose testosterone levels are in the normal range paradoxically have better sexual function than those with elevated levels, suggesting that hyperandrogenism itself may contribute to sexual dysfunction rather than enhance it. 2
Only weak and inconsistent associations exist between androgen levels and sexual function in PCOS patients, with regression models explaining a maximum of only 15% of sexual function variance. 3
Free testosterone has a U-shaped effect on sexual function—both deficiency and excess impair sexual function, meaning the hyperandrogenism of PCOS is detrimental rather than beneficial. 4
Contributing Factors Beyond Hormones
Body mass index has a significant negative effect on sexual desire, arousal, and orgasm, with overweight PCOS women showing significantly worse sexual function than normal-weight PCOS women. 1, 4
Hirsutism significantly affects all domains of sexual function except dyspareunia, likely through psychological mechanisms affecting body image and self-esteem. 1
Body image anxiety and exposure concerns during sexual activities are powerful predictors, with elevated Body Exposure during Sexual Activities Questionnaire (BESAQ) scores increasing the risk of sexual dysfunction by 4.24 times. 4
The BESAQ score cutoff of 1.97 strongly predicts sexual dysfunction in PCOS patients, making it a useful clinical screening tool alongside free testosterone, LH/FSH ratio, and BMI. 4
Treatment Can Improve Sexual Function
Intensive lifestyle modification alone or combined with oral contraceptive pills improves sexual desire in women with PCOS over 16 weeks, particularly in those who already have sexual dysfunction at baseline. 5
Weight loss and lifestyle interventions improve sexual function through multifactorial mechanisms, likely including improved body image, reduced insulin resistance, and psychological benefits beyond direct hormonal effects. 5
Oral contraceptive pills alone do not alter sexual function scores, suggesting that metabolic and psychological interventions are more important than hormonal suppression for sexual health. 5
Clinical Implications
Screen all PCOS patients for sexual dysfunction using validated questionnaires such as the Female Sexual Function Index (FSFI), as this comorbidity is highly prevalent but often unaddressed. 1, 3
Address sexuality and offer psychosexual counseling as part of routine clinical care for women with PCOS, since endocrine perturbations have minimal direct impact and psychological factors predominate. 3
Target weight management and body image concerns as primary interventions for sexual dysfunction in PCOS, as these factors are more modifiable and impactful than hormonal manipulation alone. 5, 4