The approach to sexual problems is no different from other common conditions managed in primary care. Most cases can be managed by the primary care team without the need for secondary referral. There are different approaches required according to gender.
Establishing the diagnosis
History
First, establish whether the patients have gone off sex because they are no longer able to perform. In men, failure to get and maintain an erection (ED) or premature ejaculation (PE) may often lead to avoidance behaviour because of fear of failure. The patient or their partner may prefer to present this problem as lack of desire or interest. Find out precisely what happened with recent sexual attempts.
Ask whether the problem is lifelong (primary) or acquired/secondary, global or situational as acquired or situational causes are much easier to treat than lifelong situation that occur on each and every occasion. Always ask men about morning erections or erections with stimulation as the absence of these strongly suggests predominant organic disease.
Patients are often confused by the term libido. Always ask what they mean and use terms like ‘thinking about sex’ or ‘feeling randy’ as these are terms that might be better understood. This often encourages them to open up and give a fuller history. Ask who initiates sex, although usually the male, establish whether 50/50 or 70/30. In the case of a woman, ask if she never initiates sex, does she respond, does she get pain, and does she get aroused, lubricated and reach orgasm, even if infrequently. This will distinguish whether she has an arousal disorder and avoids sex because it is not enjoyable as opposed to a primary problem with lack of desire (hypoactive sexual desire disorder).
Ask whether they feel that anything has provoked the issue or caused it to persist, for example, illness, medication, a distressing life event, pregnancy, relationship or partner problem. Ask whether they are in a relationship, as the lack of a supportive partner will make the problem much more difficult to resolve.
Depression is a common cause of loss of sexual desire and may require a HADS or PHQ9 to confirm the diagnosis, especially in men, as undiagnosed depression often results in poor response to other interventions. However, SSRI antidepressants are a common cause of low sexual desire, arousal and orgasm difficulties.
Always remember that more than one problem may be present and sexual problems are more likely to be present in the partner.
Examination
If the history suggests that a man might have ED, check his BP and perform a detailed genital examination to reveal abnormalities of the foreskin, deformity of the shaft or diminished or absent testes which might suggest hypogonadism. Generalised obesity or lack of mobility in either partner may lead to less enjoyable intercourse and a focus on lifestyle but this should not detract from investigation to exclude other treatable causes.
Investigations
In all men with low desire and especially if ED is suspected, lipid profile, fasting glucose, HbA1c, thyroid function and morning testosterone should be measured. Obese men, those with type 2 diabetes, those on long-term analgesics and anticonvulsants are at particularly high risk of testosterone deficiency. Women require thyroid function tests, and possibly SHBG and free testosterone if they are on combined oral contraception or HRT. SHBG levels are raised by HRT and testosterone is selectively bound, lowering free testosterone, contributing to low sexual desire.
Diagnosis
A clear history will have defined whether lack of the desire is primary or secondary to another sexual problem and depression needs to be diagnosed and treated. ED or PE will need to be addressed in addition to managing the desire problem. As with other conditions, it is important to manage all the co-morbidities. Psychological issues will usually be present along with physical factors and it is advisable not to focus on a single cause, especially psychological. A full explanation of the importance of managing the co-morbidities as well as the presenting problem, ideally with the partner present, is vital to successful outcome.
Management
Counselling (particularly couple therapy) should be the primary treatment, where the history suggests predominantly psychological factors and should ideally be combined with medical treatment.
In men, testosterone deficiency syndrome is the most common and most treatable medical cause of low desire. Reduced sexual desire is likely to occur at total testosterone levels around 11nmol/l and a recent large European study showed that the triad of low sexual desire, ED and loss of morning erections strongly predict the likelihood of testosterone deficiency.1 If symptoms are supported by low morning testosterones on two or more occasions, then a trial of testosterone therapy of at least six months is recommended by most guidelines as this may correct all aspects of sexual function, not just erection.2
In women, arousal problems, often secondary to vaginal dryness, especially in peri-menopausal woman are easily treated with prescribable water-based lubricants or vaginal oestrogens. Other menopausal problems might require conventional HRT, especially in premature or surgically induced menopause. Where combined oral contraceptives are associated with high SHBG and low FT, the patient may wish to stop the combined pill but they need to be told that it might take up to 12 months for SHBG levels to recover.
Resources
- Sexual Advice Association - 020 7486 7262 www.sda.uk.net/
- College of Sexual and Relationship Therapists. www.cosrt.org.uk for leaflets and advice on sexual problems and to find a fully qualified certified therapist in your area
- www.relate.org.uk for local counselling on sexual matters
- THE BSSM Guidelines on Erectile Dysfunction and Androgens in Men and Women at www.bssm.org.uk
Professor Geoffrey Hackett is consultant in sexual medicine at Good Hope Hospital and visiting professor in men’s health at University of Bedfordshire
Competing interests: Professor Hackett is an occasional speaker for Lilly and Bayer
References
1. Wu FC, Tajar A, Beynon JM et al. Identification of late onset hypogonadism in middle-aged and elderly men. N Engl J Med 2010;363:123-35.
2. Hackett G, Kell P, Ralph D et al. British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction. J Sex Med 2008;5:1841-6.
