What is the appropriate workup for a woman with low libido?

Workup for Low Libido in Women

Begin with a detailed sexual history using the Brief Sexual Symptom Checklist for Women as your primary screening tool, followed by systematic evaluation of psychological, medication-related, and organic causes. 1

Initial Assessment and History

Document the following specific elements:

• Sexual function history: Current sexual activity, pre-existing sexual function before any changes, and how symptoms impact intimacy and relationships 1
• Relationship factors: Partner's sexual health status (particularly erectile dysfunction in male partners), relationship quality, and communication patterns about sex 2
• Psychological screening: Depression, anxiety, body image concerns, and relationship distress—these are major contributors and nearly double the prevalence of reduced libido 3, 4
• Substance use: Alcohol consumption, recreational drug use, and smoking history 3
• Life stressors and fatigue: Work stress, caregiving responsibilities, and chronic fatigue 2

Medication Review

Identify medications that commonly suppress libido:

• SSRIs (paroxetine, sertraline, citalopram, fluoxetine)—these are among the most common culprits 4
• Hormonal therapies: Particularly aromatase inhibitors and hormonal contraceptives 3
• Antihypertensives: Beta-blockers are strongly associated with sexual dysfunction 4
• Opioids, corticosteroids, and H2-receptor antagonists 4

Consider switching to alternatives with lower sexual side effect profiles when feasible 4.

Physical Examination

Perform a gynecologic examination specifically assessing for:

• Vaginal atrophy: Mucosal thinning, loss of rugae, and tissue friability 1
• Anatomic changes: Scarring, stenosis, or structural changes from prior surgery or radiation 1
• Points of tenderness: Particularly at the introitus and pelvic floor 1
• Signs of menopause: Assess for menopausal symptoms including vaginal dryness and dyspareunia 3

Laboratory Workup

Order the following tests based on clinical suspicion:

• Morning testosterone (free testosterone or androgen index preferred over total testosterone): This prevents unnecessary endocrine investigation in up to 50% of cases 3, 4
• TSH and free T4: If thyroid dysfunction is suspected 3
• Prolactin level: When there is loss of libido with low testosterone 3
• Fasting glucose or HbA1c: Screen for diabetes, which affects sexual function through vascular and neurological mechanisms 3, 4
• Complete metabolic panel: If renal or hepatic impairment is suspected 3

Validated Assessment Tools

For more comprehensive evaluation beyond initial screening:

• Female Sexual Function Index (FSFI): This 19-item instrument has been validated in cancer survivors and assesses desire, arousal, lubrication, orgasm, and satisfaction 1
• Arizona Sexual Experience Scale (ASEX): A 5-item tool covering sexual drive, arousal, lubrication, ability to reach orgasm, and satisfaction 1

Both tools have established reliability and can guide treatment decisions 1.

Assessment of Chronic Medical Conditions

Screen for conditions that impair sexual function:

• Cardiovascular disease and hypertension: These impair sexual function through vascular mechanisms 4
• Diabetes mellitus: Causes dysfunction through both vascular and neurological pathways 4
• Chronic kidney disease, liver failure, and metabolic syndrome (obesity, insulin resistance) 4
• Neurological conditions: Multiple sclerosis, Parkinson's disease 4
• Cancer treatment history: Chemotherapy, radiation, and hormonal cancer treatments commonly suppress libido 4

Referral Indications

Refer to appropriate specialists when:

• Multiple endocrine abnormalities are identified requiring specialized evaluation 3
• Primary reduced libido persists despite addressing obvious contributing factors 4
• Patient desires specialized sexual health counseling but declines discussion at current visit 1
• Complex psychological factors require cognitive behavioral therapy or psychosexual therapy (which shows 50-80% success rates) 3, 4

Common Pitfalls to Avoid

Do not automatically attribute low libido to "normal aging" or menopause alone—many contributing factors are addressable, including vaginal symptoms, partner erectile dysfunction, and medication side effects 2. The NCCN emphasizes that sexual health is often overlooked in survivorship care but should be systematically addressed 3. Additionally, recognize that low libido is relative and depends on the patient's definition, not an absolute standard of sexual frequency 5.