Evidence‑Based Work‑Up for Decreased Libido

History Taking

A systematic assessment of whether libido loss is generalized versus situational helps differentiate psychogenic from organic etiologies in adult patients. 1
A comprehensive medication review—including antidepressants (SSRIs, tricyclics), antihypertensives (beta‑blockers, thiazides), antipsychotics, anti‑androgens, and recreational substances—is essential because these agents are frequent iatrogenic contributors to reduced sexual desire. 1
Chronic medical conditions such as diabetes mellitus, hypertension, cardiovascular disease, chronic kidney disease, liver disease, obstructive sleep apnea, inflammatory bowel disease, chronic fatigue syndrome, and prior cancer therapy are associated with decreased libido and should be actively screened for. [1][2]3

A focused physical exam that evaluates body habitus, body‑mass index, signs of hypogonadism (e.g., reduced body hair, gynecomastia, small testes), cardiovascular risk (blood pressure, peripheral pulses), and genital abnormalities is recommended for all patients presenting with libido concerns. 4
Examination of the genitalia for penile deformities (e.g., Peyronie’s disease), testicular atrophy, and prostate abnormalities provides important clues to organic causes of sexual dysfunction. [1][4]
Documentation of BMI is important because obesity both lowers testosterone levels and independently contributes to sexual dysfunction. [2][3]

Morning total testosterone measured between 8 am and 10 am should be obtained in every adult with decreased libido; abnormal results warrant repeat testing to confirm hypogonadism. [2][3]
When low testosterone is confirmed, measurement of luteinizing hormone, follicle‑stimulating hormone, and prolactin is advised to distinguish primary from secondary hypogonadism. [2][3]
Fasting glucose or HbA1c screening is recommended because diabetes mellitus is strongly linked to reduced libido and erectile dysfunction. 1

The International Index of Erectile Function (IIEF) or the Sexual Health Inventory for Men (SHIM) should be used to quantify erectile function alongside libido in male patients. 1
For female patients, validated tools such as the Female Sexual Function Index (FSFI), the Brief Sexual Symptom Checklist for Women, or the Arizona Sexual Experiences Scale (ASEX) are appropriate for assessing sexual function. 5

The American College of Cardiology/American Heart Association (ACC/AHA) atherosclerotic cardiovascular disease (ASCVD) risk calculator, based on pooled‑cohort equations, should be applied to categorize patients as low (<5 %), borderline (5–7.5 %), intermediate (7.5–20 %), or high (>20 %) risk. 1
In patients aged 40–60 years with borderline or intermediate ASCVD risk, coronary artery calcium scoring may be considered to refine risk stratification. 1

Medication‑induced libido loss is common; clinicians must review and, when possible, adjust antidepressants, antihypertensives, antipsychotics, and other implicated drugs. 1
Involving the patient’s sexual partner in the assessment and treatment plan improves adherence and clinical outcomes. 4

A detailed history is the cornerstone of evaluation and should systematically explore multiple domains, including sexual history, medical history, and psychosocial assessment, as recommended by the National Comprehensive Cancer Network 6, 7
The American College of Physicians suggests that the duration and onset of decreased libido, as well as the severity of the problem, should be assessed using validated instruments like the Sexual Desire Inventory-2, with a focus on distinguishing psychogenic from organic causes 7
The European Association of Urology recommends exploring partner-related factors, such as vaginal dryness in female partners, partner's erectile dysfunction, and relationship satisfaction, which can contribute to decreased libido 8, 6
A thorough medical history should include chronic conditions like diabetes, hypertension, cardiovascular disease, depression, and anxiety, as well as endocrine disorders, cancer treatment history, and other conditions that may impact libido, as suggested by the Endocrine Society 8, 6, 7
The American Psychiatric Association recommends assessing psychiatric conditions, such as generalized anxiety, depressive illness, and psychosis, which can contribute to decreased libido 7, 9

A targeted physical examination should focus on signs of hypogonadism and cardiovascular risk, including body habitus, body mass index, virilization status, breast examination, genital examination, and prostate examination, as recommended by the American Urological Association 10, 7
The European Society of Cardiology suggests that cardiovascular assessment, including blood pressure, fundal arterial changes, cardiac auscultation, carotid bruits, and femoral and pedal pulses, is essential in evaluating decreased libido 11, 7

The Endocrine Society recommends measuring total testosterone in all men with decreased libido, with morning measurement preferred, and repeat testing if abnormal 12, 10
The American College of Physicians suggests that free testosterone or androgen index is preferred over total testosterone alone and can prevent unnecessary endocrine investigation in up to 50% of men with low total testosterone 12
Additional hormonal studies, including luteinizing hormone and prolactin, should be performed if testosterone is low, as recommended by the National Institute of Diabetes and Digestive and Kidney Diseases 12, 10
Baseline metabolic testing, including fasting glucose or HbA1c, lipid profile, and complete blood count, should be performed to screen for diabetes and assess cardiovascular risk, as suggested by the American Diabetes Association 8, 12, 10

The International Society for the Study of Women's Sexual Health recommends using structured instruments, such as the Sexual Desire Inventory-2, Brief Sexual Symptom Checklist for Women, International Index of Erectile Function, and Sexual Health Inventory for Men, to quantify severity and facilitate discussion 6
The American Urological Association suggests that these questionnaires should not replace full patient evaluation and laboratory testing, as they have variable specificity and sensitivity 10