Treatment for Low Libido
Initial Assessment: Identify the Underlying Cause
The treatment of low libido depends entirely on whether you are treating a male or female patient, and whether the cause is primary (no identifiable medical cause) or secondary (due to medications, hormones, or medical conditions). Start by measuring morning testosterone levels in all patients, as levels <300 ng/dL indicate potential testosterone deficiency requiring treatment 1, 2.
Critical Laboratory Workup
- Measure total morning testosterone in all patients with low libido, as this is the single most important initial test 1, 2
- If testosterone is low, measure LH to distinguish primary (testicular) from secondary (pituitary/hypothalamic) hypogonadism 2
- Measure prolactin if testosterone is low OR if loss of libido is the primary complaint, as elevated prolactin universally causes reduced libido 2
- Consider free testosterone or androgen index rather than total testosterone alone, as this prevents unnecessary investigation in up to 50% of men with low total testosterone 2
- Check fasting glucose or HbA1c to exclude diabetes, and TSH/free T4 if thyroid dysfunction is suspected 2
Medication Review: Common Culprits
- SSRIs (paroxetine, sertraline, citalopram, fluoxetine) commonly cause reduced libido and should be identified and potentially switched 1, 2
- Beta-blockers are strongly associated with sexual dysfunction; consider switching to ACE inhibitors, calcium channel blockers, or loop diuretics 2
- Opioids, corticosteroids, antipsychotics (via prolactin elevation), and 5-alpha reductase inhibitors (finasteride, dutasteride) all reduce libido 2
- In women, hormonal therapies and spironolactone can impair libido 3
Treatment for Males with Low Libido
When Testosterone is <300 ng/dL
Testosterone replacement therapy is indicated when morning testosterone is <300 ng/dL and there are no contraindications 1, 2. This is the cornerstone of treatment for hypogonadism-related low libido.
- Testosterone therapy can be administered as gel, injections, or patches 4
- Monitor for serious adverse effects including cardiovascular events (myocardial infarction, stroke), polycythemia (hematocrit >58%), and hepatic dysfunction 4
- Avoid testosterone in men with prostate cancer, severe heart failure, or untreated sleep apnea 4
- Monitor hematocrit, hemoglobin, lipid profile, and liver function periodically after starting therapy 4
For Erectile Dysfunction Contributing to Low Libido
- PDE5 inhibitors (sildenafil, tadalafil) are first-line for erectile dysfunction that may be contributing to reduced desire 1, 5, 6
- These should not be used in men taking nitrates (contraindicated for at least 48 hours after tadalafil) or with recent cardiovascular events 5, 6
- PDE5 inhibitors can also help with orgasmic problems 1
For Primary Reduced Libido (Normal Testosterone)
- Refer to a sexual health specialist when multiple issues are identified or when libido remains low despite normal testosterone 1, 2
- Psychosexual therapy shows 50-80% success rates and should be considered, especially for relationship-based causes 2
- Address underlying depression and anxiety with appropriate psychiatric treatment, as psychopathology nearly doubles the prevalence of reduced libido 2, 7
Treatment for Females with Low Libido
FDA-Approved Pharmacologic Options for Premenopausal Women
For premenopausal women with hypoactive sexual desire disorder (HSDD), flibanserin (100 mg once daily at bedtime) is the primary FDA-approved medication, resulting in approximately one additional satisfying sexual event every two months 3, 8.
- Bremelanotide is an alternative FDA-approved option, administered as a subcutaneous injection as needed before anticipated sexual activity 3, 8
- Both medications have demonstrated statistically significant increases in sexual desire and reductions in distress 8
Off-Label Options
- Bupropion may be considered as a second-line off-label treatment for HSDD, with small studies suggesting improvement in sexual function, particularly in breast cancer survivors 3, 8
- Buspirone may also be considered as a second-line option, though data are limited 3, 8
For Postmenopausal Women
- Testosterone therapy has demonstrated efficacy in postmenopausal women with low desire, though it is not FDA-approved for this indication and may not be effective without adequate circulating estrogen 8
- Vaginal DHEA (prasterone) has shown significant improvements in sexual desire, arousal, pain, and overall sexual function in survivors of breast or gynecologic cancer 3, 8
Addressing Concurrent Vaginal Symptoms
Vaginal dryness and dyspareunia are critical contributors to sexual avoidance and must be treated concurrently:
- Vaginal estrogen (pills, rings, or creams) is the most effective treatment for vaginal dryness leading to sexual dysfunction in postmenopausal women 3, 8
- Water-, oil-, or silicone-based lubricants and vaginal moisturizers are first-choice treatments, with silicone-based products lasting longer 3, 8
- Pelvic floor physical therapy can improve sexual pain, arousal, lubrication, orgasm, and satisfaction 3, 8
Non-Pharmacologic First-Line Approaches
- Cognitive behavioral therapy (CBT) has demonstrated effectiveness for improving sexual functioning in women with low libido 3, 8
- Psychosexual therapy, sexual counseling, and couples therapy can address relationship issues and psychological factors 3
Critical Contraindications and Special Populations
Cancer Survivors
- Exercise extreme caution with hormonal therapies in cancer survivors, particularly those with estrogen-sensitive cancers, where hormonal treatments are contraindicated 3
- Vaginal DHEA is a preferred hormonal option for breast or gynecologic cancer survivors 3
- Ospemifene may be considered for dyspareunia in survivors of cancers that are not hormonally sensitive 3
What NOT to Use
- PDE5 inhibitors (sildenafil, tadalafil) are NOT recommended for female sexual dysfunction due to lack of effectiveness data in women 3
- Vaginal laser therapy is not currently recommended due to limited safety and effectiveness data 3
Common Pitfalls to Avoid
- Failing to screen for reversible contributing factors (medications, psychological issues, relationship distress, vaginal symptoms) can hinder effective treatment 3, 8
- Not measuring testosterone in all patients with low libido misses a treatable cause 2
- Prescribing hormonal therapies without considering cancer history, especially estrogen-sensitive cancers, is dangerous 3
- Ignoring concurrent depression, anxiety, or relationship issues will limit treatment success, as these factors are major contributors to low libido 2, 7