What are the treatment options for decreased libido in a cancer patient?

Treatment of Decreased Libido in Cancer Patients

Psychosocial counseling should be offered as first-line therapy for decreased libido in cancer patients, with consideration of testosterone therapy in men if levels are low (<300 ng/dL) and not contraindicated, while women with non-hormone-sensitive cancers may consider hormone therapy or alternative pharmacologic options. 1

Initial Assessment and Approach

For Male Patients

Check testosterone levels even in cancers not typically associated with hormonal changes. 1 This is critical because:

• If total morning testosterone is <300 ng/dL, testosterone replacement therapy may be indicated unless contraindicated by the cancer type 2
• Options should be discussed even when testosterone levels are within normal range if the clinician feels supplementation can provide clinical benefit and is not contraindicated 1

Offer psychosocial counseling to men with cancer and their partners to improve sexual functioning and satisfaction. 1 The ASCO guidelines emphasize that:

• Counseling should be directed at the couple when the patient is partnered 1
• Psychosocial counseling can help couples integrate interventions into their usual sexual activities 1
• Body image issues including weight changes, disfigurement, scarring, and hair loss should be discussed and normalized 1

For Female Patients

Psychosocial counseling directed at the individual or couple should be offered as first-line therapy. 1 Key considerations include:

• Couples-based interventions are effective when compared with usual care if the woman is partnered 1
• Partner involvement should be the patient's choice 1
• Licensed counselors available at the medical center can provide benefit even if specialized sex therapists are not available 1

For women with non-hormone-sensitive cancers experiencing decreased libido, hormone therapy should be counseled until approximately age 51 years. 1 Important caveats:

• Hormone-sensitive breast cancer is a contraindication to systemic hormone therapy 1
• Beyond age 51, hormone therapy should be individually evaluated with intermittent reassessment for long-term use 1
• Risks typically cited for hormone therapy are derived from studies of postmenopausal women 1

Pharmacologic Options

For Women

Flibanserin may be discussed as an option for hypoactive sexual desire disorder in premenopausal women. 2 Critical warnings:

• FDA-approved in 2015 but not contraindicated in breast cancer patients, though no clear data exist for this population 2
• Requires daily dosing with substantial side effects including dizziness, somnolence, nausea, and fatigue 2
• Remains controversial and requires future confirmatory studies 2

Androgens may be discussed as an alternative option. 2

For Men

Testosterone therapy is recommended when total morning testosterone is <300 ng/dL and there is no contraindication. 2 This applies to:

• Ejaculation or orgasm disorders 2
• Overall decreased libido 2
• Men on androgen-deprivation therapy who develop hypogonadism 3, 4

Adjunctive Therapies

Regular sexual stimulation, including masturbation, is likely beneficial for improving sexual response regardless of the type of stimulation used. 1

Integrative therapies such as yoga and meditation may help with global symptoms of distress, anxiety, or depression contributing to decreased libido. 2

Cognitive behavioral therapy may provide benefit and should be offered. 1

Referral Considerations

Refer to a sexual health specialist when: 2

• Symptoms of low or lack of desire, libido, or intimacy persist despite initial interventions 2
• Multiple issues are identified requiring specialized expertise 2
• Patients continue to have relationship issues and/or distress after initial counseling 1

Common Pitfalls to Avoid

Do not assume decreased libido is solely psychological. 1 Always check testosterone levels in men, even with cancers not typically associated with hormonal changes, as hypogonadism from chemotherapy, radiation, or androgen-deprivation therapy is common 3, 4, 5.

Do not overlook the partner. 1 The opportunity for partners to be involved should be offered, and couples-based interventions are more effective than individual therapy when applicable 1.

Do not prescribe testosterone without considering cancer type. 1, 2 Ensure there are no contraindications based on the specific malignancy before initiating testosterone replacement 2.