Pharmacologic Treatment for Low Libido in Men
For men with low sexual desire after appropriate evaluation, testosterone replacement is indicated only if total morning testosterone is <300 ng/dL and there are no contraindications; otherwise, no FDA-approved pharmacologic agents exist specifically for increasing libido in men, and treatment should focus on addressing underlying causes such as depression, relationship issues, or medication side effects. 1, 2
Diagnostic Approach
Hormonal Assessment
- Measure total morning testosterone if low libido is present 1, 2
- Check prolactin levels if testosterone is low or clinical suspicion exists, as severe hyperprolactinemia (>700 mU/L) has a stronger association with hypoactive sexual desire (RR=7.5) than hypogonadism (RR=1.5) 3
- Hypogonadism (testosterone <12 nmol/L or <300 ng/dL) occurs in approximately 23% of men with sexual dysfunction 3, 1
Psychosocial Factors to Evaluate
- Depression and anxiety symptoms - strongly associated with low desire 2, 3, 4
- Relationship factors: partner's libido, relationship conflicts, partner diseases, relationship duration 3
- Medication review: antidepressants, antipsychotics, antihypertensives can cause sexual dysfunction 5
- Lifestyle factors: work satisfaction, domestic relationship quality 3
Treatment Algorithm
If Testosterone <300 ng/dL
- Prescribe testosterone replacement therapy if no contraindications exist 1, 6
- This is an off-label use for sexual dysfunction specifically 6
- Do not prescribe testosterone if levels are normal - it provides no benefit 6
If Severe Hyperprolactinemia Present
- Treat the underlying cause (prolactinoma, medications) 2, 3
- This has the strongest hormonal association with low desire 3
If Depression or Anxiety Present
- Treat the underlying mood disorder 2
- Important caveat: SSRIs commonly used for depression frequently cause sexual dysfunction including decreased libido 5
- Consider bupropion as an alternative antidepressant, which has lower rates of sexual side effects 5
If Medication-Induced
- Review all medications for sexual side effects 2, 5
- Options include: dose reduction, switching to alternative agent, or adding adjunctive treatment 5
- Common offenders: SSRIs, antipsychotics, antihypertensives, sedatives 5
If Relationship Issues Identified
- Refer for couples counseling or sex therapy 2, 3
- Partner's sexual function, relationship conflicts, and communication issues significantly impact male desire 3, 4
No FDA-Approved Pharmacologic Options for Primary Low Libido
There are no FDA-approved medications specifically for treating low sexual desire in men when testosterone is normal. 2, 6 Unlike erectile dysfunction where PDE5 inhibitors are highly effective, or premature ejaculation where SSRIs and topical anesthetics work well, isolated low libido without hormonal abnormalities lacks proven pharmacologic treatment 1, 2.
Common Pitfall
Do not confuse erectile dysfunction with low desire - they are distinct conditions requiring different approaches 2, 6. PDE5 inhibitors (sildenafil, tadalafil, vardenafil) treat erectile dysfunction but do not increase sexual desire 1. Men may have normal desire with erectile problems, or conversely, adequate erectile function but no interest in sex 2.
Off-Label Considerations
While some clinicians have tried various agents off-label, no pharmacologic treatments have established efficacy for primary hypoactive sexual desire disorder in men with normal testosterone 2, 6. Treatment must be etiologically oriented - addressing the specific underlying cause rather than attempting to pharmacologically boost desire directly 2.