Treatment Options for Low Libido in Men
For men with low libido, measure morning testosterone levels and initiate testosterone replacement therapy if total testosterone is <300 ng/dL, while simultaneously addressing psychological factors, lifestyle modifications, and considering PDE5 inhibitors if erectile dysfunction coexists. 1
Initial Diagnostic Approach
Measure morning serum testosterone levels in all men presenting with low libido, as this is the cornerstone of evaluation. 1 Treatment should be considered when total testosterone falls below 300 ng/dL. 2, 1
If total testosterone levels are borderline, check sex hormone-binding globulin to clarify the diagnosis, particularly in men with diabetes or metabolic conditions. 1 Further hormonal testing including luteinizing hormone and follicle-stimulating hormone may be needed to distinguish primary from secondary hypogonadism. 1
Screen for underlying contributors including depression, anxiety, relationship conflicts, and medication side effects (particularly antidepressants and antihypertensives). 2, 3, 4 Depression disproportionately affects libido, and treating depression frequently improves sexual desire. 4
First-Line Treatment: Testosterone Replacement Therapy
Testosterone replacement therapy is the first-line treatment for men with documented low testosterone (<300 ng/dL) and low libido, with demonstrated benefits in improving sexual function and desire. 1 Available formulations include oral, intramuscular, gel, cream, or patch preparations. 2
Critical contraindication: Testosterone therapy is NOT indicated for men with normal serum testosterone levels, as it provides no benefit and carries unnecessary risks. 5
Cardiovascular risk assessment is mandatory before initiating testosterone therapy, as erectile dysfunction and low libido may signal underlying cardiovascular disease. 1 Testosterone replacement in older hypogonadal men has been associated with increased coronary artery plaque volume and potential cardiovascular events. 1
Addressing Erectile Dysfunction Component
Many men with low libido have coexisting erectile dysfunction, which can secondarily diminish sexual desire. 2, 3
PDE5 inhibitors (sildenafil, vardenafil, tadalafil) should be prescribed for men with both low libido and erectile dysfunction, as improving erectile function often restores sexual confidence and desire. 5, 1 These medications have 69% success rates compared to 35% with placebo. 5
Start with conservative dosing and titrate to maximum dose if needed, with at least 5 separate attempts at maximum dose before declaring treatment failure. 5 The choice between specific PDE5 inhibitors should be based on patient preference, ease of use, and cost. 5
Absolute contraindication: PDE5 inhibitors are contraindicated in patients taking nitrates due to dangerous hypotension risk. 5, 6 At least 48 hours must elapse after the last tadalafil dose before nitrate administration. 6
Combination Therapy for Hypogonadal Men
For hypogonadal men with persistent erectile dysfunction despite testosterone replacement, adding a PDE5 inhibitor may improve outcomes, though evidence quality is limited. 5 Testosterone supplementation combined with PDE5 inhibitors shows promise in this specific population. 5
Psychological and Behavioral Interventions
Psychosexual therapy and counseling achieve successful outcomes in 50-80% of patients by improving communication about sexual concerns, reducing anxiety, and integrating treatments into sexual relationships. 1 This is particularly important for men with primary reduced libido (not associated with hypogonadism or psychopathology), who often have disturbances in domestic and dyadic relationships. 3
For men with anxiety or depression contributing to low libido, psychotropic medications may be appropriate, but exercise caution as many antidepressants (particularly SSRIs) can worsen sexual dysfunction. 2, 4 Bupropion is often preferred as it has minimal sexual side effects.
Lifestyle Modifications
All men with low libido should implement risk factor modifications including smoking cessation, weight loss, increased physical activity, and avoiding excess alcohol consumption. 5, 1 These interventions improve vascular function and overall sexual health.
Men with primary reduced libido tend to have healthier metabolic profiles (lower glycemia and triglyceride levels) and lower cardiovascular risk compared to those with secondary causes. 3
Referral Indications
Refer to a sexual health specialist when:
- Multiple issues are identified contributing to low libido 2
- Complex cases involving cancer survivorship 1
- Failure of first-line treatments 2
- Need for second-line erectile dysfunction therapies (vacuum devices, intracavernosal injections, intraurethral suppositories) 2, 5
Common Pitfalls to Avoid
Do not prescribe testosterone without documenting low testosterone levels, as supplementation provides no benefit in eugonadal men and carries cardiovascular risks. 5, 1
Do not overlook relationship factors and psychological contributors, as these are frequently the primary drivers in men with normal testosterone levels. 3
Do not assume all low libido is testosterone-related—primary reduced libido (without hypogonadism) is characterized by relationship disturbances and requires different management than secondary causes. 3
Ensure cardiovascular safety before prescribing PDE5 inhibitors—patients unable to walk 1 mile in 20 minutes or climb 2 flights of stairs in 20 seconds without symptoms require cardiology referral first. 5