Loss of libido

Loss of libido is a common symptom that affects both men and women, though it tends to be more frequently reported by women.
The prevalence increases with age, particularly in postmenopausal women and older men.
Psychological factors such as stress, anxiety, and depression are common contributors across all age groups.
Endocrine disorders, particularly hypogonadism in men and hypothyroidism in both sexes, are significant medical causes.
Certain medications, including antidepressants and antihypertensives, are known to affect libido.
In younger individuals, relationship factors and psychological stressors are more prominent, while in older adults, medical conditions and medications play a larger role.

Psychological Causes

Depression: Often presents with a loss of interest in activities, including sexual activity, along with other depressive symptoms.
Anxiety: Generalized anxiety disorder or performance anxiety can lead to reduced libido.
Stress: Chronic stress from work, financial issues, or relationships can significantly impact sexual desire.
Relationship Issues: Marital or partnership discord, lack of intimacy, or unresolved conflicts can diminish sexual interest.
Sexual Trauma: History of sexual abuse or trauma can lead to a long-term decrease in sexual desire.
Body Image Issues: Negative body image or self-esteem problems may reduce sexual confidence and desire.
Sexual Orientation and Identity Conflicts: Individuals grappling with their sexual orientation or gender identity may experience reduced libido.

Endocrine Causes

Hypogonadism: Low levels of testosterone in men can lead to a decrease in sexual desire and erectile dysfunction.
Hypothyroidism: Can cause fatigue, depression, and reduced libido in both men and women.
Hyperprolactinemia: Elevated prolactin levels can suppress gonadal function, leading to reduced libido.
Diabetes Mellitus: Poorly controlled diabetes can lead to vascular and neurological complications affecting sexual function.
Menopause: Hormonal changes during menopause, including reduced estrogen levels, often lead to decreased libido in women.
Cushing’s Syndrome: Chronic cortisol excess can result in decreased libido.
Androgen Insensitivity Syndrome: Affects sexual development and may present with low libido in affected individuals.
Adrenal Insufficiency: Can lead to a decrease in androgen production, affecting libido.

Medications and Substance Use

Antidepressants: Particularly SSRIs and SNRIs, are commonly associated with sexual side effects including loss of libido.
Antihypertensives: Beta-blockers and some diuretics can cause sexual dysfunction.
Contraceptives: Hormonal contraceptives may reduce libido in some women.
Antipsychotics: Can lead to hyperprolactinemia, contributing to reduced sexual desire.
Recreational Drugs: Alcohol, cannabis, and opioids can impair sexual desire and function.
Substance Abuse: Chronic use of drugs such as cocaine or heroin can lead to long-term sexual dysfunction.
Smoking: Nicotine use is associated with decreased libido due to its vascular effects.
Steroids: Anabolic steroids can disrupt normal hormone production, leading to reduced libido.
Chemotherapy: Often causes a temporary or permanent reduction in sexual desire due to its effects on hormone levels.
Hormone Replacement Therapy: Inconsistent hormone levels during treatment can lead to fluctuations in libido.

Background

Onset and Duration: Determine when the loss of libido began and whether it has been gradual or sudden.
Sexual History: Explore previous sexual function, libido levels, and any changes over time.
Relationship Factors: Assess the quality of the patient’s current relationship, any changes in partner status, and levels of intimacy.
Psychological Symptoms: Inquire about symptoms of depression, anxiety, or stress that might contribute to loss of libido.
Medical History: Consider any history of endocrine disorders, chronic illnesses, or previous surgeries that could affect libido.
Medication Review: Identify any medications that may contribute to the loss of libido, including recent changes in dosage.
Substance Use: Ask about alcohol, tobacco, and recreational drug use, and their possible impact on sexual desire.
Hormonal Symptoms: Explore symptoms suggestive of hormonal imbalances, such as fatigue, weight gain, or changes in body hair.
Social Factors: Consider stressors such as work, financial issues, or family dynamics that could influence libido.
Cultural and Religious Beliefs: Understand any cultural or religious factors that may influence attitudes towards sex and libido.

Clinical Examination

General Physical Examination: Assess overall health, including signs of chronic illness or poor self-care.
Endocrine Examination: Evaluate for signs of hypogonadism, thyroid disease, or adrenal insufficiency, such as testicular atrophy or gynecomastia in men.
Mental State Examination: Consider psychological evaluation for depression, anxiety, or other mental health conditions.
Gynecological Examination: In women, consider a pelvic exam to assess for conditions such as atrophic vaginitis or pelvic organ prolapse that may contribute to discomfort during sex.
Urological Examination: In men, consider a genital examination to assess for Peyronie’s disease, prostatitis, or other conditions affecting sexual function.
Skin Examination: Look for signs of systemic disease such as hyperpigmentation, striae, or hirsutism that may suggest endocrine disorders.
Neurological Examination: Consider if there is any suspicion of neurological causes such as multiple sclerosis or spinal cord injuries.

Laboratory Tests

Serum Testosterone: To assess for hypogonadism in men, particularly in those with erectile dysfunction or other symptoms.
Thyroid Function Tests: To rule out hypo- or hyperthyroidism as a cause of reduced libido.
Prolactin Levels: Elevated levels can suppress sexual desire and are often seen with pituitary tumors or medications.
LH and FSH: To assess pituitary function, particularly in suspected hypogonadism or polycystic ovary syndrome (PCOS).
Blood Glucose and HbA1c: To rule out diabetes mellitus, which can contribute to erectile dysfunction and reduced libido.
Liver Function Tests (LFTs): Consider if there is a suspicion of chronic liver disease, which can affect hormone metabolism.
Lipid Profile: Dyslipidemia can contribute to atherosclerosis, potentially affecting sexual function.
Cortisol Levels: Elevated in cases of Cushing’s syndrome or chronic stress, which can impact libido.
Sex Hormone-Binding Globulin (SHBG): Can help interpret testosterone levels, particularly in women or men with borderline levels.
Vitamin D Levels: Deficiency is associated with fatigue and low mood, which may contribute to reduced libido.
DHEA-S: An adrenal androgen that may be low in cases of adrenal insufficiency.

General practice