Bradley C. Gill, MD, MS
Sandip P. Vasavada, MD, FACS
BASICS
DESCRIPTION
• Diminished libido, low sexual drive, or hyposexuality are defined by a lack of desire for sexual activity.
• Hypoactive sexual desire disorder or subjective sexual arousal disorder may be implicated.
EPIDEMIOLOGY
Incidence
• More common with advancing age and especially following menopause
• A congenital syndrome may be causative at a young age.
Prevalence
Estimated prevalence of 25–75% of women varies by study sample and assessment
RISK FACTORS (1)
• Low testosterone (physiologic or iatrogenic)
• Advanced age
• Menopause (physiologic or iatrogenic)
• Pelvic floor disorder (incontinence or prolapse)
• Physical or psychological trauma (sexual assault, physical abuse, or verbal abuse)
• Pregnancy (multifactorial per hormonal, emotional, and physical changes)
Genetics
Early onset menopause may be implicated
PATHOPHYSIOLOGY (2,3)
• Testosterone drops 50% from age 30 to 60 years and is linked to low libido as are other androgens.
• Estrogen can increase sex hormone–binding globulin concentrations and lower free testosterone.
• Progesterone may lower mood and decrease sex drive as seen with some contraceptives.
• Follicle-stimulating and luteinizing hormone reduction by contraceptives lowers androgen creation.
• Serotonin level alterations from certain antidepressants can decrease sex drive.
ASSOCIATED CONDITIONS
• Vaginal atrophy
• Congenital syndromes
• Posttraumatic stress disorder (prior physical or psychological trauma)
GENERAL PREVENTION
Exercise, balanced diet, healthy lifestyle
DIAGNOSIS
HISTORY
• Details of low libido
– Acquired or lifelong problem
– Always or intermittently present
– With only specific sexual partners
– After a new diagnosis or procedure
– Following use of a new medication
– Association with life events
• Reproductive information
– Age of menarche or onset of menses
– Pregnancies and deliveries
– Contraception use and type
– Infertility and treatment
• Other sexual information
– Sexually transmitted infection
– Pain or discomfort with sexual activity
– Problems with sexual function of the partner
• Current or prior abuse
– Sexual
– Verbal or physical
• Symptoms of androgen insufficiency
– Dysphoria, fatigue, low sense of well-being
– Reduced sexual receptivity and pleasure
– Decreased vaginal lubrication despite estrogen treatment
• Signs of androgen insufficiency
– Bone loss, decreased muscle mass, less strength
– Memory changes and altered cognitive function
• Other endocrine disorders
– Hypothyroidism
– Cushing syndrome
– Diabetes
• Urogenital conditions
– Urinary incontinence or fecal incontinence
– Pelvic organ prolapse
• Medications
– Oral contraceptives, estrogens, progestins, gonadotropin-releasing hormone agonists
– Antidepressants, amphetamines, anticonvulsants, antiepileptics, psychotropics
– Antihypertensives, antilipidemics, antiarrhythmics
– Steroids, narcotics
• Chronic medical conditions
– Psychiatric conditions
– Substance abuse
PHYSICAL EXAM
• Assessment of nongenital sexual characteristics
– Breast development
– Axillary hair
• Signs of endocrinologic disorder
– Cushingoid appearance
– Hypothyroid skin and hair changes
– Diabetic neuropathy
• Visual inspection of the external genitalia
– Distribution of pubic hair
– Ulcerations, pustules, discharge, or bleeding
– Prolapsed urethra, vagina, or cervix
• Speculum exam
– Mucosal rugae, moisture, thinning, or excoriation
– Ulcerations, pustules, discharge, or bleeding
– Cystocele, rectocele, or enterocele
– Vaginal wall masses
• Palpation of the external genitalia, vaginal sidewalls, pelvic floor muscles, cervix, and ovaries
– Urethral or vaginal sidewall masses
– Surgically placed foreign bodies
– Pelvic floor muscle tension, spasm, or tenderness
– Cervical motion, ovarian, or adnexal tenderness
– Vaginal cul-de-sac mass or tenderness
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Estrogens: Estradiol and estrone
• Androgens: Dehydroepiandrosterone, androstenedione, testosterone, and dihydrotestosterone
• Proteins: Sex hormone–binding globulin (SHBG) with free testosterone and total testosterone
• Adjunctive: Thyroid-stimulating hormone, glycosylated hemoglobin
Imaging
Brain magnetic resonance imaging to assess the hypothalamus and pituitary gland
DIFFERENTIAL DIAGNOSIS
• Hormonal
– Decreased free testosterone or increased sex hormone–binding globulin
– Decreased androgen
– Hypogonadotropic hypogonadism
– Adrenal insufficiency or adrenal suppression
– Adrenal suppression or glucocorticoid excess
– Hypothyroidism or hyperthyroidism
• Psychological
– Hypoactive sexual desire disorder, subjective sexual arousal disorder, sexual aversion disorder
– Sexual dysfunction in a partner
• Iatrogenic
– Medication side effect
• Gynecologic
– Dyspareunia, pelvic organ prolapse, sexually transmitted infection
• Urologic
– Urinary incontinence
• Colorectal
– Fecal incontinence
• Congenital syndrome
TREATMENT
GENERAL MEASURES (1)
• Behavioral
– Identify and eliminate any libido-reducing behaviors, habits, or addictions
– Psychological counseling, couples therapy, or sex therapy as indicated
– Encourage a healthy lifestyle with balanced diet, exercise, work, and sleep
MEDICATION
First Line
• Testosterone alone or in combination has been used off-label to increase drive
– Postmenopausal women with decreased libido who are not receiving estrogen therapy have modest success using an experimental testosterone patch delivering 300 μg/d testosterone
• If possible elimination or replacement of medications that may reduce libido
• Adjunctive treatment of vaginal atrophy with topical estrogen can be helpful
• Also consider appropriate goal-directed treatment of other medical conditions
Second Line
N/A
SURGERY/OTHER PROCEDURES
Appropriate treatment of possibly causative medical (ie, endocrine tumor) conditions
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Results vary with etiology and treatment for many is long-term
• Multimodal approach to any etiology should be most beneficial
COMPLICATIONS
Loss of libido can result in depression, infertility
FOLLOW-UP
Patient Monitoring
• Frequent follow-up with initiation of new therapy is best with regular lab work if hormones are used.
• If using testosterone, monitor for signs of testosterone excess (acne, hirsutism, male pattern baldness, hyperlipidemia)
Patient Resources
N/A
REFERENCES
1. Maclaran K, Panay N. Managing low sexual desire in women.Womens Health. 2011;7(5):571–581.
2. Brotto LA, Petkau AJ, Labrie F, et al. Predictors of sexual desire disorders in women. J Sex Med. 2011;8(3):742–753.
3. Clayton AH. The pathophysiology of hypoactive sexual desire disorder in women. Int J Gynaecol Obstet. 2010;110(1): 7–11.
ADDITIONAL READING
McDougal WS, Wein AJ, Kavoussi LR, et al. Female Sexual Function and Dysfunction. In: Moore CK, ed. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Elsevier; 2012:823–833.
See Also (Topic, Algorithm, Media)
• Dyspareunia
• Female Hypoactive Sexual Desire Disorder
• Urinary Incontinence
• Vaginal Atrophy
CODES
ICD9
• 799.81 Decreased libido
• 627.2 Symptomatic menopausal or female climacteric states
• 302.71 Hypoactive sexual desire disorder
ICD10
• F52.0 Hypoactive sexual desire disorder
• N95.1 Menopausal and female climacteric states
• R68.82 Decreased libido
CLINICAL/SURGICAL PEARLS
• A good social history is essential.
• Sexual dysfunction in partners can cause this.
• Overall physical health helps maintain libido.