Loss of Libido

Loss of libido is a sexual dysfunction relating to loss of sexual desire or sexual drive and is also termed hypoactive sexual desire disorder (DSM-IV). Loss of libido must not be confused with sexual dysfunction although one might lead to the other.

One problem, in terms of assessing the prevalence of loss of libido, is the difficulty in defining what is normal. It is a highly variable parameter and very few who suffer it consult a doctor about the problem although it may be a cause of strife within a relationship.
It is normal for sexual drive to diminish with the passage of years¹ but the degree is highly variable. Some people are shocked to find that even the elderly often enjoy a carnal relationship and sex into later life is not unusual.² Diminished sexual potency and vaginal dryness may contribute to reduced libido. Perhaps the "spark" is ebbing from their relationship and sex has become mundane and unimaginative. Perhaps the expanding waistline makes them less attractive people than once they were, although this is not necessarily an impediment to a voracious sexual appetite. Loss of libido is only a problem if one partner is not willing or able to meet the desires of the other. If their libido is matched, it does not matter if the frequency of sexual intercourse is twice a night or twice a year. For a person who is not in a relationship, loss of libido is not a problem.

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. Hence it may present as a "While I'm here, doctor." It may be the true reason for the consultation but an "opening gambit" is felt necessary. Hope that the patient does not indulge in trivia for a full 10 minutes before the "throw away line" whilst heading for the door.
There are certain facts to be established:

• 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:
  • During the last month, have you often been bothered by feeling down, depressed or hopeless?
  • 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?"

• 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. On the other hand one partner may be eager to be rather more ambitious and imaginative, whether in technique or "swingers' parties" whilst the other party is horrified at the prospect.

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.

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.

• Probably the most frequent co-existent disease to discover is depression.
• Hormone inadequacy, including hypothyroidism is less common.
• Problems with relationships are common.

Management depends upon cause.

• If there are problems with the relationship, then counselling is 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. A financial adviser may be able to help with such matters as credit card debt or mortgage arrears. These are not matters for a doctor but a doctor can indicate where the patient may go for help and advice.
• Depression needs 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 condition that it is treating.
• Antipsychotics such as phenothiazines and haloperidol raise prolactin.
• 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.³
• 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.⁴
• If there seems to be an underlying problem of a psychosexual nature, then Relate may also be useful. Sildenafil or the like 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."⁵

A suggestion that the cause of impaired libido is deficiency of hormones is far too simplistic. It does seem that male hormones are more important than female ones, and this is not a dogmatic reflection of the philosophy that libido is a male affliction and something that ladies have to tolerate to please their husbands. The idea that men have androgens and women have oestrogens is also too simplistic. They are the dominant hormones in each but both hormones are present in both sexes. Lack of androgens and excess of prolactin⁶ both appear to be important.
In women with symptoms of the climacteric, HRT with 17-β-oestradiol was less effective than tibolone is raising libido.⁷ 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.⁸ 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,⁹ indicating a strong psychological component rather than the importance of hormones.
The treatment of sexual offenders is an issue that raises much commotion and very little educated debate. Reduction in androgen levels can be achieved by the use of cyproterone or goserelin and surgical castration is not necessary. 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.¹⁰ However, sexual offenders are a very heterogeneous group and good trials comparing like with like are lacking.¹¹ 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.¹²