Loss of Sex-Drive
Loss of sex-drive can be a daunting presentation for established GP and registrar alike. This universal problem spans adulthood in both sexes. Conventional medical school teaching seems to fail to prepare the generalist; however, the didactically taught approach of systematic enquiry and examination is the key to successful management.
Differential diagnosis
Common Diagnoses
- Depression
- Relationship Problems
- Perimenopause
- Excess Alcohol Intake (and Cirrhosis in Men)
- Ageing
Occasional Diagnoses
- Low Testosterone in Men
- Hypothyroidism
- Antihypertensive Treatment in Men
- Hyperprolactinaemic Drugs in Men (e.g. Phenothiazines, Haloperidol)
- Anti-Androgenic Drugs in Men (e.g. Cimetidine, Finasteride)
- Anti-Androgenic Drugs in Women (e.g. Cyproterone)
Rare Diagnoses
- Hypothalamic/Pituitary Disease
- Renal Failure
- Primary Testicular Disease or Damage
- Adrenal Disease (Cushing’s and Addison’s Diseases)
- Feminising Tumours in Men: Testis or Adrenal Gland
Ready reckoner
Key distinguishing features of the most common diagnoses
| Depression | Relationship Problem | Perimenopause | Alcohol | Ageing | |
|---|---|---|---|---|---|
| Excessive Fatigue | Yes | Possible | Yes | Possible | Possible |
| Irrational Mood Swings | Yes | Possible | Yes | Possible | No |
| Facial Flushing | No | No | Yes | Possible | No |
| Alters with Different Partner | Possible | Yes | No | No | No |
| Otherwise Well | No | Yes | Possible | Possible | Yes |
Possible investigations
Likely: None.
Possible: FBC, U&E, LFT, TFT.
Small Print: Hormone profile.
- FBC: May show evidence of general disease; MCV raised with significant excess alcohol.
- U&E: Check for renal failure. Na+ and K+ deranged in adrenal disease.
- LFT and γGT: Should reveal hard evidence of excess alcohol.
- TFT: Will demonstrate hypothyroidism.
- Hormone profile: FSH/LH, prolactin, oestradiol and testosterone may be useful in both sexes. Altered by primary endocrine disease, drugs and alcohol.
Top Tips
- This is often a ‘by the way’ or ‘while I’m here’ symptom. It may be tempting to ask the patient to return for a further appointment, but bear in mind that this may mean a lost opportunity to help the patient.
- General examination is important to detect rare causes. This also demonstrates that the problem is being taken seriously.
- Avoid over-medicalising the situation if it is clearly a relationship problem.
- Be prepared to revise or augment your diagnosis – the problem is often multifactorial.
- Don’t forget iatrogenic causes and be prepared to undertake a trial without treatment.
Red Flags
- Loss of sex drive may be the tip of the iceberg of significant pathology, such as depression or alcoholism – don’t be distracted into a superficial approach.
- Depression and relationship difficulties can cause each other and coexist. A careful history will reveal whether antidepressants and/or psychosexual counselling is appropriate.
- Investigations don’t often help – but lower your threshold for blood tests if the patient seems generally unwell and isn’t obviously depressed.
- Early hypothyroidism closely mimics depressive illness.