Management of Decreased Sexual Libido

Initial Diagnostic Evaluation

The American College of Physicians does not recommend routine hormonal testing in all men with erectile dysfunction due to insufficient evidence 4
Assess for reversible factors, including medication side effects, hormonal abnormalities, chronic illness effects, and psychosocial factors, then treat vaginal symptoms with non-hormonal lubricants as first-line therapy, followed by psychosexual counseling which achieves success in 50-80% of patients 1
Antidepressants are among the most common culprits for libido impairment, along with spironolactone and beta-blockers 2, 1
Evaluate for vaginal dryness, dyspareunia, hot flashes, and sleep disturbance which directly impact sexual desire 1
Depression, anxiety, chronic stress, body image concerns, and relationship conflicts are major contributors to decreased libido 1
Fatigue and symptoms from conditions like liver disease, diabetes, or cancer significantly reduce libido 2, 3

Non-hormonal water-based lubricants and moisturizers are the primary recommended treatment for women with vaginal dryness or dyspareunia 5, 6, 7, 1
Silicone-based products may last longer than water-based or glycerin-based options 5, 6, 7
Combination therapy may provide additional benefit 5, 6, 7
Atrophic vaginitis affects approximately 50% of postmenopausal women and requires ongoing treatment 1
Trial of PDE-5 inhibitors (sildenafil, vardenafil, tadalafil) is appropriate for men with erectile dysfunction, as erectile function may recover up to 2-4 years after prostate surgery 8
Early penile rehabilitation with PDE-5 inhibitors may preserve smooth muscle and improve outcomes through increased tissue oxygenation 8
Psychoeducational support, group therapy, sexual counseling, or marital counseling achieves successful outcomes in 50-80% of patients 1
Brief psychoeducational interventions addressing anxiety, stress, and mood changes should be offered to all patients with sexual complaints 5, 6, 7

Sexual dysfunction affects at least 50% of cancer survivors and is frequently overlooked, include sexual health assessment in survivorship care plans 1
For breast cancer survivors on aromatase inhibitors, vaginal dryness occurs in 18% (vs. 8% with tamoxifen) and markedly affects quality of life and treatment compliance 1
Young women with bilateral oophorectomy experience severe, long-lasting menopausal symptoms including sexual dysfunction 1
Men with same-sex partners are significantly more bothered by loss of ejaculate and at greater risk of depression 8
In women with advanced liver disease, altered estrogen metabolism and hypothalamic-pituitary axis disruption lead to anovulation and amenorrhea in >25% of patients 2
In men with advanced liver disease, low testosterone from hypogonadotropic hypogonadism plus increased peripheral conversion to estrogen causes erectile dysfunction, oligospermia, and testicular atrophy 2

Do not prescribe hormonal contraception to breast cancer survivors—use alternative non-hormonal methods 1
Do not overlook medication-induced dysfunction, particularly from antidepressants and endocrine therapies which profoundly impact desire and arousal 1
Do not ignore partner factors: Partner sexual dissatisfaction negatively affects erectile function recovery, and many couples require support to recover sexual intimacy 8
Do not assume libido decline is "normal aging": Open, directed inquiry in clinic provides opportunity for patients to disclose dysfunction that they may not volunteer 2, 3