Is low libido normal in women with polycystic ovary syndrome?

Low Libido in Women with PCOS

Low libido is common in women with PCOS, affecting approximately 28-58% of patients, and should be considered a recognized comorbidity rather than dismissed as "normal." 1, 2, 3

Prevalence and Clinical Significance

Sexual dysfunction, including reduced libido, occurs at significantly higher rates in PCOS compared to the general population:

• Sexual dysfunction affects 27-58% of women with PCOS, with desire and arousal being the most commonly affected domains (impacting up to 99% of those with dysfunction). 1, 2, 3
• The desire domain specifically shows impairment in the vast majority of affected women, making low libido one of the most prevalent sexual complaints. 3
• Marital sexual dysfunction is diagnosed in 28.6% of women with PCOS versus only 10.5% of healthy controls, representing a nearly three-fold increase. 2

Key Contributing Factors

Hormonal Mechanisms

The relationship between androgens and libido in PCOS is paradoxical and counterintuitive:

• Women with PCOS whose testosterone levels are in the normal range (not elevated) are at increased risk for sexual dysfunction. 4
• Conversely, women with testosterone levels >1 standard deviation above the mean have significantly better sexual functioning compared to those with normal or low-normal levels. 4
• This suggests that the hyperandrogenism characteristic of PCOS (present in 75% of cases) may not directly cause low libido, and other mechanisms predominate. 5, 4

Physical and Metabolic Factors

Body composition and metabolic health significantly impact sexual function:

• Increasing BMI is associated with significant reduction in sexual desire and arousal, independent of other PCOS features. 4, 3
• Central obesity exacerbates metabolic, reproductive, and psychological features of PCOS, all of which can indirectly affect libido. 6, 7
• Weight gain is a major trigger for PCOS symptom worsening in genetically susceptible women. 5, 7

Psychological and Appearance-Related Factors

The visible manifestations of PCOS create substantial psychological burden:

• Hirsutism severity has a significant negative effect on sexual function across all domains (p<0.001 for total sexual function scores). 3
• Quality of life parameters are significantly lower in PCOS women, particularly in emotional wellbeing, energy/fatigue, and social functioning—all of which correlate with sexual desire. 2
• Anxiety, depression, and eating disorders are prevalent in PCOS and significantly impact quality of life and sexual function. 7

Treatment Approaches That Improve Libido

Lifestyle Modification (First-Line)

Intensive lifestyle modification alone or combined with hormonal contraceptives improves sexual desire in women with PCOS. 1

• After 16 weeks of intensive lifestyle intervention, the desire domain subscore significantly improved. 1
• Among women meeting criteria for sexual dysfunction at baseline (FSFI score ≤26.55), lifestyle modification produced measurable improvement in overall sexual function scores. 1
• The mechanism is likely multifactorial, involving weight loss, improved metabolic parameters, enhanced body image, and reduced psychological distress. 1

Combined Approach

• The combination of intensive lifestyle modification plus oral contraceptive pills produces the greatest improvement in sexual desire, though OCPs alone do not alter sexual function scores. 1
• This suggests that addressing the metabolic and psychological components is more critical than hormonal manipulation alone. 1

Critical Clinical Pitfalls

Diagnostic Confusion with FHA-PCOM

Be aware that functional hypothalamic amenorrhea with polycystic ovarian morphology (FHA-PCOM) can mimic PCOS:

• 41.9-46.7% of women with FHA have polycystic ovarian morphology on ultrasound, which can lead to misdiagnosis as PCOS. 6
• FHA-PCOM patients have signs of estrogen deficiency, low or normal BMI, and history of low energy availability or stress—features distinct from typical PCOS. 6
• Estrogen deficiency in FHA would be expected to cause low libido through different mechanisms than PCOS. 6

Partner Discordance

• The discrepancy in arousal between women with PCOS and their male partners is substantial (mean difference -2.32, Cohen's d = -1.26), indicating that "normal" sexual function scores in PCOS women may not reflect adequate sexual functioning within the relationship context. 8

Screening Recommendation

All women with PCOS should be screened for sexual dysfunction using a validated questionnaire such as the Female Sexual Function Index (FSFI) or Changes in Sexual Functioning Questionnaire (CSFQ-14). 3

• This screening should occur at initial diagnosis and periodically during follow-up, as sexual dysfunction represents a significant quality of life issue that warrants targeted intervention. 3
• The importance and level of sexual satisfaction correlate with almost all domains of sexual function, making these simple questions valuable screening tools. 8