Loss of libido (↓ sexual desire) is a common but often hidden concern in primary care. It refers to a persistent or recurrent reduction in sexual interest that causes personal distress or relationship difficulties.

Although medically defined within DSM-5 as:

• Hypoactive Sexual Desire Disorder (HSDD) – in men

• Female Sexual Interest/Arousal Disorder (FSIAD) – in women

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...GPs typically use the broader, patient-friendly term “low libido.”

Why it Matters in UK General Practice

• Common: ~15% of men, 34% of women (16–74 yrs) report ↓ interest in sex (Natsal-3, 2013) [1].

• Under-discussed: Many affected patients never raise it—GPs must be ready to ask sensitively.

• Multifactorial Causes:

  • Biological: Endocrine disorders, chronic illness, medications

  • Psychological: Depression, anxiety, past trauma

  • Social: Relationship issues, cultural beliefs

Key Causes of Loss of Libido

Category	Males	Females
Biological	↓ Testosterone (e.g. hypogonadism) Chronic illness (DM, CVD) Medication (SSRIs, β-blockers) Obesity Thyroid dysfunction	Hormonal changes (↓ estrogen, menopause, postpartum) Chronic illness (DM, CVD) Medication (SSRIs, OCPs) Thyroid dysfunction Pregnancy, breastfeeding
Psychological	Stress, anxiety Depression Low self-esteem, poor body image Relationship issues Performance anxiety	Stress, anxiety Depression Low self-esteem, poor body image Relationship issues Trauma or abuse history
Social/Cultural	Masculinity pressures Work-life imbalance Cultural/religious beliefs Aging concerns	Body image pressures Work-life imbalance Cultural/religious beliefs Life transitions (motherhood, menopause)

Causes often overlap, but sex-specific hormonal & life-stage factors are distinct. Holistic assessment is key to identifying contributing factors.

Key Points for History Taking in Loss of Libido 

1. Clarify the Symptom

   • Ask what the patient means by "loss of libido" (e.g., reduced desire, arousal issues, or performance difficulties).

   • Differentiate between loss of desire (will) and sexual dysfunction (e.g., erectile dysfunction, dyspareunia).

   • Ask: “Is this issue present in all situations (e.g., with a partner or alone) or specific contexts?”

   • Explore terminology used by the patient, considering cultural or personal language preferences.

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2. Onset and Duration

   • Ask: “When did you first notice a change in your sexual desire? Was it sudden or gradual?”

   • Determine if symptoms are progressive, intermittent, or related to specific times (e.g., worse at night).

   • Explore potential triggers: “Did anything specific happen around the time this started, like a life event or new medication?”

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3. Relationship Context

   • Assess relationship quality: “How would you describe your relationship with your partner(s)?”

   • Ask: “Did relationship issues or loss of libido come first?”

   • Explore partner dynamics: “Have you discussed this with your partner? What is their perspective?”

   • For single patients: “Has this affected your interest in pursuing sexual activity?”

   • Include: “What is your sexual orientation or relationship structure (e.g., monogamous, non-monogamous)?”

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4. Patient’s Perception and Concerns

   • Ask: “How does this change in libido affect you? Is it distressing, or is it more about meeting partner expectations?”

   • Determine who initiated the consultation: “Did you or your partner feel this needed to be addressed?”

   • Explore cultural expectations: “Do you feel pressure to maintain a certain level of sexual activity?”

   • Assess impact: “Does this affect your self-esteem or sense of identity?”

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5. Health and Medications

   • Review general health: chronic illnesses (e.g., diabetes, thyroid disease, cancer), recent acute illnesses, or surgeries (e.g., pelvic surgery, chemotherapy).

   • Document medications, including SSRIs, beta-blockers, hormonal contraceptives, anti-androgens, and over-the-counter supplements.

   • Ask: “Have you started or stopped any medications or supplements recently?”

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6. Psychological Factors

   • Screen for depression/anxiety using PHQ-2: “Over the past two weeks, have you felt down, depressed, or hopeless? Have you had little interest in doing things?”

   • Explore trauma sensitively: “Have you experienced events that make sexual activity difficult?”

   • Assess body image: “Do you feel confident in your body, or has this changed recently?”

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7. Lifestyle Factors

   • Quantify alcohol (units/week), smoking, and recreational drug use.

   • Ask about stress: “Are you experiencing pressures from work, finances, or family?”

   • Explore sleep and fatigue: “Do you feel well-rested, or are you often tired?”

   • Assess exercise: “How active are you, and has this changed recently?”

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8. Reproductive History

   • For women: Ask about menopause, menstrual cycle changes, contraception, pregnancy, childbirth, or breastfeeding.

   • For men: Explore hypogonadism symptoms (e.g., “Have you noticed changes in energy, muscle mass, or body hair?”).

   • Ask both: “Are you concerned about fertility or undergoing fertility treatments?”

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9. Sexual History Specifics

   • Ask: “How often do you engage in sexual activity, and has this changed?”

   • Explore satisfaction: “Are you satisfied with your sexual experiences?”

   • Assess solo activity: “Has your interest in masturbation or solo sexual activity changed?”

   • Inquire about safe sex, STI history, or pornography use if relevant.

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10. Patient’s Insight

    • Ask: “What do you think is the reason for your loss of sexual drive?”

    • Explore barriers: “Are there challenges, like embarrassment or lack of information, that make addressing this difficult?”

    • Consider cultural/religious beliefs: “Do any personal or cultural values affect how you view this issue?”

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11. Safeguarding

    • Screen sensitively: “Do you feel safe and comfortable in your sexual relationships?”

    • Be alert for signs of intimate partner violence or coercion.

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This structured, holistic approach ensures a comprehensive assessment of loss of libido, addressing biological, psychological, and social factors as per RCGP curriculum guidance. It supports culturally sensitive, patient-centered care and facilitates tailored management.

First-Line Tests for Loss of Libido in Primary Care

When a patient presents with loss of libido (LOL), primary care clinicians should adopt a targeted, stepwise approach to investigations, guided by clinical history, examination, and risk factors.

Practical Notes for Primary Care:

• Prioritization: Start with FBC, TFTs, HbA1c, lipids to identify common reversible causes.

• Timing: For testosterone in men, sample in the morning before 11 AM (avoids diurnal variation).

• Cost-Effectiveness: Avoid routine prolactin unless symptoms suggest pituitary dysfunction.

• Referral Threshold: Refer to endocrinology, sexual health clinics, or psychosexual counselling if initial workup is normal or complex issues arise.

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• Patient Communication: Explain the rationale to reduce stigma and support follow-up, aligned with RCGP patient-centered care principles.

This structured approach ensures cost-effective, evidence-based assessment in line with UK guidelines and the RCGP curriculum.

Test	Purpose	When to Order	Gender
Full Blood Count (FBC)	Detect anaemia, chronic illness	Fatigue, pallor, systemic illness	Both
Thyroid Function Tests (TFTs)	Assess hypo ↑ / hyper ↓ thyroidism	Lethargy, weight changes, menstrual issues	Both
HbA1c / Fasting Glucose	Screen for diabetes	Obesity, polyuria, FHx of diabetes	Both
Lipid Profile	Evaluate cardiovascular risk	Hypertension, smoking, erectile dysfunction	Both
Liver Function Tests (LFTs)	Detect liver dysfunction	Alcohol excess, jaundice	Both
Serum Ferritin / Iron Studies	Check for iron deficiency ↓ or overload ↑	Fatigue, anaemia on FBC	Both
Total Testosterone	Screen for hypogonadism	Low energy, ED, ↓ muscle mass	Male
SHBG (Sex Hormone Binding Globulin)	Calculate free testosterone	Borderline testosterone, obesity	Male (± Female)
Prolactin	Identify hyperprolactinaemia	Galactorrhoea, irregular menses, antipsychotic use	Both
FSH / LH / Estradiol	Assess ovarian function, menopause	Irregular periods, menopausal symptoms	Female
Androgens (FAI, etc.)	Evaluate androgen insufficiency ↓	PCOS, hirsutism, post-menopause	Female

Principles of Management for Loss of Libido (LOL) in Primary Care

Aligned with RCGP curriculum, BSSM (2018), and NICE guidelines, management of LOL in UK primary care uses a biopsychosocial, patient-centered approach.

Principle	Strategies	Key Guidelines/Notes
Holistic Assessment	- Explore biological, psychological, social factors - Use shared decision-making - Respect cultural beliefs	RCGP, Natsal-3 (2013)
Treat Reversible Causes	- Manage hormonal imbalances (e.g., TRT for men, HRT for women) - Optimize chronic disease care - Review medications	BSSM 2018, NICE NG23 (2015)
Psychological Support	- Screen for depression/anxiety (PHQ-9, GAD-7) - Refer to IAPT or counselling - Encourage CBT, mindfulness	NICE CG90 (2009)
Relationship & Social Factors	- Provide relationship counselling - Refer for psychosexual therapy - Address social stressors	Natsal-3 (2013), COSRT
Lifestyle Changes	- Promote healthy weight, exercise, ↓ alcohol, smoking cessation - Improve sleep hygiene	BSSM 2018, NICE 2020
Pharmacological Options	- PDE-5 inhibitors for ED - Testosterone for postmenopausal women (off-label, specialist-led) - Avoid unproven treatments	NICE CKS 2021, BSSM 2018
Specialist Referral	- Endocrinology, sexual health, psychiatry, gynaecology when indicated	RCGP 2020
Education & Empowerment	- Explain test results & treatment rationale - Signpost reputable information sources - Encourage partner communication	Natsal-3 (2013), NHS resources
Safeguarding & Ethics	- Screen for domestic abuse - Maintain confidentiality - Respect patient autonomy	RCGP, GMC guidelines
Follow-Up	- Review in 4–6 weeks - Use patient-reported outcomes - Adjust care plan or refer	RCGP: Continuity of care principle

By addressing loss of libido - with empathy, thorough assessment, and tailored interventions, GPs can improve patients’ quality of life, relationships, and overall well-being, aligning with the RCGP’s commitment to holistic, equitable care.

 References and Citations

1. Mercer, C. H., et al. (2013). Sexual function in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). The Lancet, 382(9907), 1817–1829.

2. British Society for Sexual Medicine (BSSM). (2018). Guidelines on the Management of Sexual Problems in Men and Women.

3. National Institute for Health and Care Excellence (NICE). (2015). Guideline NG23: Menopause – Diagnosis and Management. Available here: https://www.nice.org.uk/guidance/ng23

4. NICE Clinical Knowledge Summaries (CKS). (2021). Erectile Dysfunction. Available here: https://cks.nice.org.uk/topics/erectile-dysfunction

5. NICE. (2009, updated 2011). Guideline CG90/CG91: Depression in Adults – Recognition and Management. Available here: https://www.nice.org.uk/guidance/cg90

6. Royal College of General Practitioners (RCGP). (2020). Curriculum: Sexual Health. Available here: https://www.rcgp.org.uk/getmedia/4b80030b-5994-4299-9f4e-a2a0b07469f1/Sexual-Health-SCCG-2025.pdf

7. Byrne, M., et al. (2015). Discussing sexual dysfunction with patients in primary care: a qualitative study. BMJ Open, 5(11), e008779.

8. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

9. Patient.info. Loss of Libido: Causes and Treatment. Available here: https://patient.info/doctor/loss-of-libido

10. NHS UK. Loss of Libido. Available here: https://www.nhs.uk/symptoms/loss-of-libido

11. Royal Australian College of General Practitioners (RACGP). (2023). Male Sexual Dysfunction: Clinical Diagnosis. Available here: https://www1.racgp.org.au/ajgp/2023/january-february/male-sexual-dysfunction

12. Royal United Hospitals Bath NHS Foundation Trust (RUH NHS). Primary Care Management of Erectile Dysfunction. Available here: https://www.ruh.nhs.uk/For_Clinicians/departments_ruh/Urology/documents/Primary_Care_Management_of_Erectile_Dysfunction.pdf

13. Northern Lincolnshire NHS. (2024). Amber 1 Guidance: Topical Testosterone for Low Libido in Women. Available here: https://www.northernlincolnshireapc.nhs.uk/wp-content/uploads/2024/10/Amber%201%20guidance%20testosterone%20for%20low%20libido.pdf?_t=1728310649&UNLID=9747740192025416926

14. European Association of Urology (EAU). Guidelines on Sexual and Reproductive Health - Male Hypogonadism. Available here: https://uroweb.org/guidelines/sexual-and-reproductive-health/chapter/male-hypogonadism