Loss of Libido
Libido is conscious or unconscious sexual desire. Loss of libido is a sexual dysfunction relating to loss of sexual desire or sexual drive and is also termed hypo active sexual desire disorder (DSM-IV). Loss of libido must not be confused with other sexual dysfunctions as these can impair libido. Epidemiology
It is a common problem but it is difficult to quantify because:
» Definitions may vary. » There is a wide ‘normal’ range.
» Few sufferers consult a doctor even when it may be the cause of relationship difficulties.
» Few sufferers consult a doctor even when it may be the cause of relationship difficulties.
A review of articles revealed some interesting points:
» In Hong Kong a telephone survey showed a high prevalence of sexual problems generally and in women a 25% prevalence of loss of interest in sex. Sex-related knowledge, perceived importance of sex, perceived physical health status and sexual satisfaction were predictors of sexual problems.1
» Gender differences and strong cultural influences were apparent. Moreover, sexual problems and sexual satisfaction were associated with mental health, quality of life indicators and overall life satisfaction.1,2
» It is normal for sexual drive to diminish with the passage of years3 but the degree is highly variable. Elderly people often enjoy sex into later life, often beyond the expectations of others.4 Diminished sexual potency and vaginal dryness may contribute to reduced libido.
» It also seems that qualitative aspects of sexual activity may change and improve with age.5 It would be a mistake to link libido with either ‘performance’ or sexual satisfaction.
PRESENTATION
It is fairly uncommon for a patient to present directly with a complaint of loss of libido. It is more likely to be a component of other complaints. Many people are still reluctant to discuss such matters and feel embarrassed. It is often introduced into the consultation by patients as an apparent after thought. The following are likely to need consideration:
It is fairly uncommon for a patient to present directly with a complaint of loss of libido. It is more likely to be a component of other complaints. Many people are still reluctant to discuss such matters and feel embarrassed. It is often introduced into the consultation by patients as an apparent after thought. The following are likely to need consideration:
* What does the patient mean by loss of sexual drive? Is it loss of the will or loss of the way?
* Is there a problem with performance? If so, which came first?
* How long ago did it start? Was it gradual or sudden? Has it been progressive?
* How is the relationship? If it is problematical, which came first?
* Has there been criticism from the partner or even a sympathetic discussion?
* How does the patient feel about the loss of libido? Perhaps the patient feels that it is not really a problem, except for the demands of the partner.
* Ask about sexual difficulties including erectile dysfunction or dyspareunia.
* Whose idea was the consultation? Is the patient here willingly or under duress?
* Are there any other problems of health? Are there any chronic diseases? What medication is taken? Has there been any recent change?
* Ask about alcohol intake.
* If a woman of appropriate age, ask about symptoms of the climacteric.
* If appropriate, ask about contraception. There may be fear of pregnancy.
* Ask about mental health too. Screening for depression in general practice can be performed with just 2 questions:
o During the last month, have you often been bothered by feeling down, depressed or hopeless?
o During the last month, have you often been bothered by having little interest or pleasure in doing things?
* Ask about work. Are there pressures there? Are there financial problems or family difficulties?
* Ask what may be the most revealing question of them all. “What do you think is the reason for your loss of sexual drive?”
* Difficulties with sexuality may lead to problems with libido.
* Is there a problem with performance? If so, which came first?
* How long ago did it start? Was it gradual or sudden? Has it been progressive?
* How is the relationship? If it is problematical, which came first?
* Has there been criticism from the partner or even a sympathetic discussion?
* How does the patient feel about the loss of libido? Perhaps the patient feels that it is not really a problem, except for the demands of the partner.
* Ask about sexual difficulties including erectile dysfunction or dyspareunia.
* Whose idea was the consultation? Is the patient here willingly or under duress?
* Are there any other problems of health? Are there any chronic diseases? What medication is taken? Has there been any recent change?
* Ask about alcohol intake.
* If a woman of appropriate age, ask about symptoms of the climacteric.
* If appropriate, ask about contraception. There may be fear of pregnancy.
* Ask about mental health too. Screening for depression in general practice can be performed with just 2 questions:
o During the last month, have you often been bothered by feeling down, depressed or hopeless?
o During the last month, have you often been bothered by having little interest or pleasure in doing things?
* Ask about work. Are there pressures there? Are there financial problems or family difficulties?
* Ask what may be the most revealing question of them all. “What do you think is the reason for your loss of sexual drive?”
* Difficulties with sexuality may lead to problems with libido.
DIFFERENTIAL DIAGNOSIS
* Any form of mental illness is likely to be associated with loss of libido. The commonest of these is depression. Other features of depression may be clear or a tool such as the Hospital Anxiety and Depression Scale may be needed to test the diagnosis or to convince the patient.
* Libido is associated with wellbeing. Hence illness will depress libido. Loss of libido is very common during cancer treatment.
* Overwork, chronic tiredness and anxiety can all depress libido.
* Falling levels of hormones may impair libido. This can occur in the climacteric or with the treatment of carcinoma of prostate.
* Some drugs may induce loss of libido, perhaps through an element of depression. Antihypertensives are the most notorious.
* Loss of libido after having a baby is not uncommon. Hormonal fluctuation can be a problem. There may have been vaginal trauma and there may still be some tenderness. There may have been a change in self image. Mothers with small babies are often very tired and may be frequently disturbed at night.
* Chronic high intake of alcohol depresses sexual desire and cirrhosis can depress androgen levels.
* If sex is not fulfilling, then interest will wane. There may be erectile dysfunction, premature ejaculation, failure of ejaculation or performance anxiety due to criticism. Dyspareunia, often due to vaginal dryness or even susceptibility to recurrent cystitis, may take the pleasure from sex and hence the drive.
* Libido will suffer if there are problems within a relationship. Sex may be less attractive to one who thinks that the partner is having an affair.
* Sex may have become ritualistic and mundane. There may be differences in ambition and imagination between partners when considering how to enliven their sex life.
* Any form of mental illness is likely to be associated with loss of libido. The commonest of these is depression. Other features of depression may be clear or a tool such as the Hospital Anxiety and Depression Scale may be needed to test the diagnosis or to convince the patient.
* Libido is associated with wellbeing. Hence illness will depress libido. Loss of libido is very common during cancer treatment.
* Overwork, chronic tiredness and anxiety can all depress libido.
* Falling levels of hormones may impair libido. This can occur in the climacteric or with the treatment of carcinoma of prostate.
* Some drugs may induce loss of libido, perhaps through an element of depression. Antihypertensives are the most notorious.
* Loss of libido after having a baby is not uncommon. Hormonal fluctuation can be a problem. There may have been vaginal trauma and there may still be some tenderness. There may have been a change in self image. Mothers with small babies are often very tired and may be frequently disturbed at night.
* Chronic high intake of alcohol depresses sexual desire and cirrhosis can depress androgen levels.
* If sex is not fulfilling, then interest will wane. There may be erectile dysfunction, premature ejaculation, failure of ejaculation or performance anxiety due to criticism. Dyspareunia, often due to vaginal dryness or even susceptibility to recurrent cystitis, may take the pleasure from sex and hence the drive.
* Libido will suffer if there are problems within a relationship. Sex may be less attractive to one who thinks that the partner is having an affair.
* Sex may have become ritualistic and mundane. There may be differences in ambition and imagination between partners when considering how to enliven their sex life.
EXAMINATION
Examination is likely to be unrewarding unless there are specific indicators from the history. However, it may be reassuring to the patient to show that the doctor is taking the issue seriously and there is no physical abnormality. Investigations If the diagnosis is already clear, then further investigations are not required.
* A tool such as the Hospital Anxiety and Depression Scale may be useful.
* FBC is a good, general screening test. A raised MCV may point to excessive alcohol consumption.
* U&E will check for renal disease and Na and K may be deranged in adrenal disease.
* LFTs may also suggest excessive intake of alcohol, especially if gamma GT is raised.
* TFTs may demonstrate hypothyroidism.
* FSH, LH, prolactin and either oestradiol or testosterone may indicate hormonal inadequacy. This may be due to drugs or alcohol.
* If erectile dysfunction appears to be a problem, and poor performance may have led to loss of interest, then fasting glucose and cholesterol are in order as there is a strong link between erectile dysfunction and coronary heart disease.
Examination is likely to be unrewarding unless there are specific indicators from the history. However, it may be reassuring to the patient to show that the doctor is taking the issue seriously and there is no physical abnormality. Investigations If the diagnosis is already clear, then further investigations are not required.
* A tool such as the Hospital Anxiety and Depression Scale may be useful.
* FBC is a good, general screening test. A raised MCV may point to excessive alcohol consumption.
* U&E will check for renal disease and Na and K may be deranged in adrenal disease.
* LFTs may also suggest excessive intake of alcohol, especially if gamma GT is raised.
* TFTs may demonstrate hypothyroidism.
* FSH, LH, prolactin and either oestradiol or testosterone may indicate hormonal inadequacy. This may be due to drugs or alcohol.
* If erectile dysfunction appears to be a problem, and poor performance may have led to loss of interest, then fasting glucose and cholesterol are in order as there is a strong link between erectile dysfunction and coronary heart disease.
ASSOCIATED DISEASES
* Probably the most frequent co-existent disease to discover is depression.
* Hormone inadequacy, including hypothyroidism is less common.
* Problems with relationships are common.
* Probably the most frequent co-existent disease to discover is depression.
* Hormone inadequacy, including hypothyroidism is less common.
* Problems with relationships are common.
MANAGEMENT
Management depends upon cause.
Management depends upon cause.
* If there are problems with the relationship, then counselling may be required. An agency such as Relate, may be very valuable.
* If the problem is over-work, financial worries and associated anxiety, lifestyle needs to be considered. The relationship between work and the rest of life needs to be examined by the patient and spouse. If there is worry over financial matters these may need appropriate professional help and advice.
* Depression may need treatment. Some of the antidepressants have been associated with loss of libido but it may be difficult to know if the cause is the drug or the underlying depression.
* Antipsychotics such as phenothiazines and haloperidol raise prolactin. Raised prolactin is associated with dampened sexual arousal.
* Counselling may be required with regard to alcohol use.
* If hypotensive treatment is thought to be a problem, a change in the type of medication may be tried.
* If hypothyroidism has been diagnosed, then thyroxine is started to suppress the level of TSH.
* If a woman’s hormones are thought to be inadequate and this is the problem, then HRT can be used but with the same caveats and precautions as at any other time. However, a recent American consensus panel felt that use of HRT to promote libido was not appropriate on the balance of efficacy and risks.6
* The value of androgen patches for treating hormone deficient men is somewhat dubious. The effects of the hormone on liver and cholesterol may be adverse and an opinion from secondary care would probably be wise. The use of testosterone in men is controversial and in women even more so.7
* If there seems to be an underlying problem of a psychosexual nature, then an appropriate referral may be offered. Relate may be a useful source of help. Medication (such as Sildenafil) may be valuable if there is erectile dysfunction.
A review in the Journal of Sexual Medicine concerning female hypoactive sexual desire concluded, “There is a rapidly expanding knowledge base concerning the diagnosis and treatment of HSDD. However, the contemporary clinician is faced with the absence of an approved treatment for this disorder and the lack of clear guidelines concerning the indications and safety of the use of non-approved agents”.8 A multidisciplinary approach to treatment has been recommended by others which reflects the diverse factors in causation.9
HORMONES OF LOBIDO
* If the problem is over-work, financial worries and associated anxiety, lifestyle needs to be considered. The relationship between work and the rest of life needs to be examined by the patient and spouse. If there is worry over financial matters these may need appropriate professional help and advice.
* Depression may need treatment. Some of the antidepressants have been associated with loss of libido but it may be difficult to know if the cause is the drug or the underlying depression.
* Antipsychotics such as phenothiazines and haloperidol raise prolactin. Raised prolactin is associated with dampened sexual arousal.
* Counselling may be required with regard to alcohol use.
* If hypotensive treatment is thought to be a problem, a change in the type of medication may be tried.
* If hypothyroidism has been diagnosed, then thyroxine is started to suppress the level of TSH.
* If a woman’s hormones are thought to be inadequate and this is the problem, then HRT can be used but with the same caveats and precautions as at any other time. However, a recent American consensus panel felt that use of HRT to promote libido was not appropriate on the balance of efficacy and risks.6
* The value of androgen patches for treating hormone deficient men is somewhat dubious. The effects of the hormone on liver and cholesterol may be adverse and an opinion from secondary care would probably be wise. The use of testosterone in men is controversial and in women even more so.7
* If there seems to be an underlying problem of a psychosexual nature, then an appropriate referral may be offered. Relate may be a useful source of help. Medication (such as Sildenafil) may be valuable if there is erectile dysfunction.
A review in the Journal of Sexual Medicine concerning female hypoactive sexual desire concluded, “There is a rapidly expanding knowledge base concerning the diagnosis and treatment of HSDD. However, the contemporary clinician is faced with the absence of an approved treatment for this disorder and the lack of clear guidelines concerning the indications and safety of the use of non-approved agents”.8 A multidisciplinary approach to treatment has been recommended by others which reflects the diverse factors in causation.9
HORMONES OF LOBIDO
The suggestion that the cause of impaired libido is a deficiency of hormones is usually over simplistic. It does seem that male hormones have an important role in libido for men and women. Lack of androgen and excess of prolactin10 both appear to be important.
The changes in reproductive capacity and their relationship with reproductive behaviour are complex.11,12
In women with symptoms of the climacteric, HRT with 17-ß-oestradiol was less effective than tibolone in raising libido.13 Tibolone has androgenic properties. In both males and females with growth hormone deficiency, adding dihydroepiandrosterone (DHEA) to growth hormone improved wellbeing and libido and more in women than in men.14 A trial of testosterone replacement in depressed men did show improvement in libido and sexual performance but this was no more so than with the placebo.15
In women with symptoms of the climacteric, HRT with 17-ß-oestradiol was less effective than tibolone in raising libido.13 Tibolone has androgenic properties. In both males and females with growth hormone deficiency, adding dihydroepiandrosterone (DHEA) to growth hormone improved wellbeing and libido and more in women than in men.14 A trial of testosterone replacement in depressed men did show improvement in libido and sexual performance but this was no more so than with the placebo.15
The treatment of sexual offenders is an issue that raises concern. Reduction in androgen levels can be achieved by the use of cyproterone or goserelin (rather than by surgical castration). There is some evidence that hormone suppression may reduce the rate of re-offending and that this result may be comparable with that obtained by cognitive and behavioural therapy.16 However, sexual offenders are a very heterogeneous group and good trials comparing like with like are lacking.17 Numbers tend to be small and controls are poor. Libido may not be the underlying problem. Rape is about abuse of power rather than sexual gratification. In both rapists and paedophiles, negative affect is a crucial component in the chain that leads to deviant sexual behaviours.18
DOCUMENT REFERENCES
1. Lau JT, Kim JH, Tsui HY; Prevalence of male and female sexual problems, perceptions related to sex and association with quality of life in a Chinese population: a population-based study. Int J Impot Res. 2005 Nov-Dec;17(6):494-505. [abstract]
2. Lau JT, Kim JH, Tsui HY; Prevalence and factors of sexual problems in Chinese males and females having sex with the same-sex partner in Hong Kong: a population-based study. Int J Impot Res. 2006 Mar-Apr;18(2):130-40. [abstract]
3. Araujo AB, Mohr BA, McKinlay JB; Changes in sexual function in middle-aged and older men: longitudinal data from the Massachusetts Male Aging Study.; J Am Geriatr Soc. 2004 Sep;52(9):1502-9. [abstract]
4. Helgason AR, Adolfsson J, Dickman P, et al; Sexual desire, erection, orgasm and ejaculatory functions and their importance to elderly Swedish men: a population-based study.; Age Ageing. 1996 Jul;25(4):285-91. [abstract]
5. Hurd Clarke L; Older women and sexuality: experiences in marital relationships across the life course. Can J Aging. 2006 Summer;25(2):129-40. [abstract]
6. Ettinger B, Barrett-Connor E, Hoq LA, et al; When is it appropriate to prescribe postmenopausal hormone therapy?; Menopause. 2006 May-Jun;13(3):404-10. [abstract]
7. Margo K, Winn R; Testosterone treatments: why, when, and how?; Am Fam Physician. 2006 May 1;73(9):1591-8. [abstract]
8. Segraves R, Woodard T; Female hypoactive sexual desire disorder: History and current status.; J Sex Med. 2006 May;3(3):408-18. [abstract]
9. Wylie K, Daines B, Jannini EA, et al; Loss of sexual desire in the postmenopausal woman. J Sex Med. 2007 Mar;4(2):395-405. [abstract]
10. Corona G, Petrone L, Mannucci E, et al; The impotent couple: low desire.; Int J Androl. 2005 Dec;28 Suppl 2:46-52. [abstract]
11. Randolph Jr JF; The Endocrinology of the Reproductive Years. J Sex Med. 2008 Jul 1. [abstract]
12. Wylie KR; Sexuality and the menopause. J Br Menopause Soc. 2006 Dec;12(4):149-52. [abstract] 13. Somunkiran A, Erel CT, Demirci F, et al; The effect of tibolone versus 17beta-estradiol on climacteric symptoms in women with surgical menopause: A randomized, cross-over study.; Maturitas. 2006 Jul 8;. [abstract]
14. Brooke AM, Kalingag LA, Miraki-Moud F, et al; Dehydroepiandrosterone (DHEA) improves psychological well-being in male and female hypopituitary patients on maintenance growth hormone replacement.; J Clin Endocrinol Metab. 2006 Jul 18;. [abstract]
15. Seidman SN, Roose SP; The sexual effects of testosterone replacement in depressed men: randomized, placebo-controlled clinical trial.; J Sex Marital Ther. 2006 May-Jun;32(3):267-73. [abstract]
16. Hall GC; Sexual offender recidivism revisited: a meta-analysis of recent treatment studies.; J Consult Clin Psychol. 1995 Oct;63(5):802-9. [abstract]
17. Grossman LS, Martis B, Fichtner CG; Are sex offenders treatable? A research overview.; Psychiatr Serv. 1999 Mar;50(3):349-61. [abstract]
18. McKibben A, Proulx J, Lusignan R; Relationships between conflict, affect and deviant sexual behaviors in rapists and pedophiles.; Behav Res Ther. 1994 Jun;32(5):571-5. [abstract]
