Daniel Box, MD
Anish K. Shah, MD
BASICS
DESCRIPTION
• Diminished libido (hyposexuality) is the lack of desire to engage in sexual experience.
• Hypoactive sexual desire disorder is characterized by reduced libido and interest in sexual activity causing distress in women.
• This section primarily focuses on decreased libido in men.
EPIDEMIOLOGY
Incidence
• 10–15% of men
• 20–25% of women
Prevalence
N/A
RISK FACTORS
• Therapy for prostate cancer
• Congenital absence of the testicles
• Inflammatory insults to the testicles
• Surgical injury or removal of the testicles
• Metabolic syndrome
Genetics
• Loss of libido may be associated with some of the genetic disorders/syndromes, listed below:
– 17α-Hydroxylase deficiency
– Autoimmune polyendocrine syndrome
– Klinefelter syndrome
– Inactivation of the luteinizing hormone (LH)-receptor gene
– Mutations of steroid 5α-reductase gene
PATHOPHYSIOLOGY
• Psychological causes of diminished libido
– Libido (sexual drive) is mediated by the cerebral cortex.
– Psychological disturbances of all degrees, from anxiety to major psychiatric disorders
– May be secondary to medical conditions (ie, congenital anomaly, disfiguring injury, etc.)
– Erectile dysfunction may cause loss of libido
• Hormonal causes of diminished libido
– Hypogonadism: Androgen deficiency, particularly testosterone, whether primary (testicular defect) or secondary to hypothalamic–pituitary dysfunction, Cushings syndrome
– Hyperprolactinemia with or without pituitary lesion (1)[B]
– Thyroid: Both hyper- and hypothyroidism can lead to diminished sexual desire
• Drugs: β-blockers, clonidine, diuretics, lithium, major tranquilizers, methyldopa, sedatives, ketoconazole, α-blockers, dihydrotestosterone inhibitors, cimetidine, antiandrogens, androgen analogs, selective serotonin reuptake inhibitors
• Temporal lobe epilepsy
• Prostatitis
• Chronic and serious diseases can lead to loss of libido through psychological or physiologic effects
ASSOCIATED CONDITIONS
• Erectile dysfunction (ED) and infertility may be associated with loss of libido and vice versa (2)[B].
• Hypothyroidism
• Alcoholism
• Syndromes, listed above in the Genetics section
GENERAL PREVENTION
N/A
DIAGNOSIS
HISTORY
• Sexual history:
– Frequency and level of sexual desire
– Difficulty in achieving or maintaining an erection
– Evidence of ejaculation disorder, overall satisfaction with sexual life
– If semen volume is normal, it is unlikely that endocrine factors are responsible for loss of libido
– Sexual Health Inventory of Men (SHIM) score
• History of psychiatric illness
• Symptoms to suggest decreased testosterone: ED, increased irritability or depression, fatigue, reduced muscle mass and strength, inability to concentrate, decreased bone density/osteoporosis
• Previous/current medication
• History of endocrine disorder
• Therapy for prostate cancer
• Chronic alcoholism may result in decreased serum testosterone, testicular atrophy, and decreased libido.
PHYSICAL EXAM
• Assessment of secondary sexual characteristics.
– Absence of secondary sexual characteristics suggests hormonal etiology.
• Detailed exam of external genitalia for abnormalities
• Assessment of testicular volume and atrophy
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Serum testosterone
• Serum prolactin
• If any disturbances of the above, then serum follicle-stimulating hormone and LH
• Serum-free T4 and TSH
• Serum GH and IGF-1 (primarily in children)
• Evlauation for increased cortisol if Cushing’s is suspected
Imaging
MRI of the brain if prolactin is elevated
DIFFERENTIAL DIAGNOSIS
• Psychiatric disturbances
• Hormonal disturbances
• Drug induced
• Chronic and serious diseases
TREATMENT
GENERAL MEASURES
• Determine the cause and correct, if possible.
• Identify potential medications causing libido issues.
• Psychiatric consultation/sexual function therapist
• Endocrinology consultation
MEDICATION
First Line
• Decreased testosterone (3)[B]
– Hormonal supplementation. For replacement dosing, see chapter on “Testosterone, decreased (hypogonadism).”
• Patients interested in sustaining fertility: Avoid exogenous testosterone; stimulate with human chorionic gonadotropin.
• If sexual dysfunction is identified as the cause: Phosphodiesterase inhibitors (sildenafil, tadalafil, etc.) are potentially useful 1st-line therapies
• Bromocriptine for prolactin-secreting tumors
Second Line
N/A
SURGERY/OTHER PROCEDURES
Only useful for pituitary adenomas causing hyperprolactinemia or in cases of Cushing’s disease
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
L-arginine and yohimbine are touted but not proven
ONGOING CARE
PROGNOSIS
The prognosis is good when there is a treatable underlying cause for loss of libido. Otherwise it can be permanent.
COMPLICATIONS
Loss of libido can result in depression, infertility, and erectile dysfunction.
FOLLOW-UP
Patient Monitoring
Men treated with androgens should be followed closely with digital rectal exam and prostate-specific antigen every 6 mo
Patient Resources
• http://www.merckmanuals.com/home/mens_health_issues/sexual_dysfunction_in_men/decreased_libido_in_men
• http://men.webmd.com/mens-libido-directory
REFERENCES
1. Shimon I, Benbassat C. Male prolactinomas presenting with normal testosterone levels. Pituitary. 2014;17(3):246–250.
2. Malavige LS, Jayaratne SD, Kathriarachchi ST, et al. Erectile Dysfunction among men with diabetes is strongly associated with premature ejaculation and reduced libido. J Sex Med. 2008;5(9):2125–2134.
3. Aydogan U, Aydogdu A, Akbulut H, et al. Increased frequency of anxiety, depression, quality of life and sexual life in young hypogonadotropic hypogonadal males and impacts of testosterone replacement therapy. Endocr J. 2012;59(12):1099–1105.
ADDITIONAL READING
• Carey JC. Pharmacological effects of sexual function. Obstet Gynecol Clin North Am. 2006;33(4):599–620.
• Swerdloff R, Wang C, Goldman. Cecil Medicine. 23rd ed. Philadelphia, PA: WB Saunders; 2007.
• Wilson B. The effect of drugs on male sexual function and fertility. Nurse Pract. 1991;16(9):12–17, 21–24.
See Also (Topic, Algorithm, Media)
• Andropause (Late Onset Male Hypogonadism)
• Erectile Dysfunction
• Female Hypoactive Sexual Desire Disorder
• Testosterone, Decreased (Hypogonadism)
CODES
ICD9
• 302.71 Hypoactive sexual desire disorder
• 752.89 Other specified anomalies of genital organs
• 799.81 Decreased libido
ICD10
• F52.0 Hypoactive sexual desire disorder
• Q55.0 Absence and aplasia of testis
• R68.82 Decreased libido
CLINICAL/SURGICAL PEARLS
• Decreased libido can be from a number of causes (medications, hormonal or psychiatric disorders, etc.).
• A thorough history (including sexual history and SHIM score) and physical exam (assessment of secondary sex characteristics and testicular volume) are critical and can often point to a diagnosis.
• It is very important to distinguish decreased libido from other disorders of sexual function (arousal, erectile dysfunction, premature ejaculation, orgasm, and sexual pain disorders) but patients can often have multiple issues simultaneously.
• Surgery is usually designated for pituitary adenomas (ie, prolactinomas), which can be found on brain MRI.