Loss of sexual desire

Specialty: Nephrology and urology.

• decreased libido
• hypoactive sexual desire
• sexual apathy

Why it occurs

• Androgenic deficiency / Hypogonadism (low total and free testosterone, which decreases the stimulation of the cerebral medial preoptic centers responsible for libido)
• Major depression or generalized anxiety disorders (alteration of pelvic and central serotonergic and dopaminergic neurotransmitters that nullify sexual drive)
• Hyperprolactinemia (excess prolactin due to pituitary prolactinomas directly suppresses the pituitary gonadotropic axis and testosterone secretion)
• Decompensated chronic systemic diseases (end-stage chronic renal failure, decompensated chronic liver disease or advanced cancer)
• Adverse effect of systemic medications (SSRI antidepressants, non-selective beta blockers, aldosterone receptor antagonists, antiandrogens for prostate cancer)
• Serious interpersonal conflicts or chronic fatigue/work burnout

Initial workup

Determination of fasting serum levels of total and free testosterone (preferably extracted first thing in the morning between 8:00 and 10:00 h given its circadian rhythm); serum prolactin, thyroid-stimulating hormone (TSH), luteinizing hormone (LH), and follicle-stimulating hormone (FSH); basic biochemical profile with estimation of glomerular filtration rate and liver function tests; brain magnetic resonance imaging (MRI) focused on the sella turcica if significant hyperprolactinemia or clinical suspicion of a pituitary tumor is observed.

Standard management

• Testosterone gel 1% or testosterone undecanoate — daily transdermal application gel or quarterly depot injections; indicated only if clinical hypogonadism and hypoandrogenemia are documented in the blood and there is no suspicion or diagnosis of active prostate or breast cancer, or hematocrit >50%
• Cabergoline — 0.25-0.5 mg twice a week orally, dopamine D2 receptor agonist indicated if loss of libido is due to hyperprolactinemia due to prolactinoma
• Bupropion (150 mg daily orally, antidepressant with dopaminergic and noradrenergic action that can be used as an alternative to treat depression without inducing sexual dysfunction or to reverse sexual dysfunction induced by other antidepressants).