Table 8.1
Prevalence of hypogonadism in screening of American population
Age | <40 years | 40–50 years | 50–70 years | >70 years |
|---|---|---|---|---|
% Hypogonadism (T <8.0 nmol/l) | 7.7 | 11.7 | 17.4 | 26.0 |
Symptomatic hypogonadism with an onset after the age of 40 is referred to as symptomatic late-onset hypogonadism (SLOH) (Morales et al. 2006). In medical practice this is by far the most common form of hypogonadism. Common risk factors are: chronic disease, type II diabetes mellitus, metabolic syndrome (MetS)2 and depression (Joshi et al. 2010).
Because SLOH often occurs alongside other (chronic) conditions (comorbidity), the causal direction is often difficult to establish; hypogonadism, hypoactive sexual desire and a (chronic) condition are, after all, age-related conditions that are themselves interrelated. That is to say that hypogonadism may lead to hypoactive sexual desire but, inversely, that visual erotic stimulation may lead to an increase in T levels (Carani et al 1990). Moreover, disease causes a decrease in T levels and vice versa (Corona et al. 2006; Guay and Jacobson 2007). But also disease itself can be a causal factor of the decreased sexual desire (Fig. 8.2).
Fig. 8.2
The relationship between hypoactive sexual desire, hypogonadism and comorbidity
The use of some drugs (medications) can reinforce this mechanism. One example is the use of antipsychotic medication, as a result of which 30–60 % of patients experience hypoactive sexual desire and SLOH. Especially antipsychotics with a high antagonistic affinity for dopamine receptors and/or antipsychotics that strongly raise prolactin levels are notorious in this respect (Knegtering et al 2007). The drugs described in the current literature as (possible) risk factors for decreasing T levels are listed in Table 8.2.
Table 8.2
Drugs which inhibit the production and/or action of testosterone
Spironolactone | Progesterone |
Chemotherapeutics | Estrogens |
Ketoconazole | GnRH agonists, antagonists |
Metronidazole | Prolactin |
Flutamide | Phenothiazine |
Bicalutamide | Tricyclic antidepressants |
Cimetidine | Reserpine |
Cyproterone | Opioids |
Cocaine | Anabolic steroids |
Alcohol | Risperidone |
In contrast to the gradually increasing SLOH in men over 40, the symptoms of hypogonadism in younger men who had a normal pubertal development are much more severe and the course is more abrupt. In addition, the above-mentioned comorbidity is usually absent in these men. They present with severe sexual dysfunction, such as the complete absence of sexual desire, and erectile and ejaculatory dysfunction up to and including anorgasmia. On testing they often prove to have extremely low T levels. Due to their inability to ejaculate intravaginally, their request for care is often related to the desire to have children. The cause is almost always a pituitary tumour which, through its volume and possible secretion of prolactin, leads to hypopituitarism and hypogonadism. Furthermore, the increased prolactin levels themselves have an inhibitory effect on sexuality through the depression and anxiety which they can cause.
Men with congenital hypogonadism such as M. Klinefelter,3 Kallmann syndrome4 or bilateral testis atrophy with onset in childhood, such as can occur after a bilateral testicular torsion, usually seek help in or before puberty due to the lack of development of secondary sex characteristics.
8.4.3 Relational Problems and Psychiatric Disorders
Comorbid psychiatric problems and relational problems are frequently encountered in men with hypoactive sexual desire, just as other sexual disorders, such as erectile dysfunction and premature ejaculation (Segraves and Segraves 1991). Cause and effect are sometimes difficult to distinguish, especially in long-standing complaints.
8.4.3.1 Relational Problems
A man may find it difficult to acknowledge his lack of sexual desire when there are serious relationship problems or if he finds his partner less physically attractive. Myths about masculinity in many cultures dictate that a man is always prepared to have sex, even under such adverse circumstances. On the other hand he may conclude that the fact that he has little desire to have sex with his partner must prove that his love for her is over.
This implies that in men with decreased sexual desire, in whom relationship problems are not evident, the sexual history needs to be thorough and assessment without the partner present are necessary. Anger and rage can inhibit sexual desire and excitement (Bozman and Beck 1991). There are indications from experimental research in women that both anger and fear can reduce sexual desire, but the effect of anger seems to be strongest. In men the same effects were found, but with less difference between fear and anger. More women than men indicate they would discontinue lovemaking if feelings of anger or rage arise (Beck and Bozman 1995).
8.4.3.2 Psychiatric Disorders
Hypoactive sexual desire is the most common sexual problem in individuals with psychiatric disorders. In most cases the cause of the sexual difficulties is multidimensional: the psychiatric problem in itself and the pharmacological treatment both play a part, besides other possible physical factors. Hypoactive sexual desire is most often reported by men with a psychotic disorder. The highest prevalence is found in schizophrenic patients with chronic neuroleptic use; sexual dysfunction occurs less frequently in medication-free schizophrenic patients (Knegtering et al. 2003; Kockott and Pfeiffer 1996). A large part of the antisexual side effects of these antipsychotic drugs can be explained by their prolactin-increasing effect (Knegtering et al. 2008).
Hypoactive sexual desire occurs in more than 40 % of men with depressive disorders (Kennedy et al. 1999; van Lankveld and Grotjohann 2000). However, Bancroft and colleagues (2003a, c, 2004) discovered that in a minority of heterosexual (9.4 %) and homosexual (16 %) men, hyperactive sexual desire occurred in depression. According to Bancroft and colleagues, this increase in sexual desire in reaction to depression can be explained by the fact that in men with a lower tendency toward sexual inhibition and a stronger tendency toward sexual excitement, the depressed mood occurs in conjunction with an increased need for intimacy and self affirmation. Sexual contact can provide this. Heightened sexual activity can also be the consequence of reduced concern about sexual risks, brought about by the depressive state. In cross-sectional research, increased sexual desire during depressed mood coincided with a higher frequency of risky sexual behaviour (Bancroft et al. 2003b, 2004). Men with a strong dispositional tendency toward inhibition see their sexual desire decreased when in a depressed mood. Bipolar (manic-depressive) disorder is characterised by hypersexual desire, especially during manic episodes.
Sexual dysfunctions are a well-known side effect of antidepressant medication. Although depressed patients attach importance to their sexual functioning, they can be reluctant when it comes to taking the initiative to mention decreased desire to their health-care professional. Most likely decreased sexual desire is underreported and this could result in undisclosed lack of medication compliance with possible relapse into depression as a result (Finn et al. 1990).
The sexual side effects of different antidepressants vary strongly and in the literature this is often neglected. For example, the tricyclic antidepressants, SSRIs and venlafaxine cause sexual side effects more often than bupropion, reboxetine, mirtazapine or agomelatine (Coleman et al. 2001; Hindmarch 1998; Schweitzer et al. 2009; Waldinger 1999).
If the intake consult reveals that a man with hypoactive sexual desire has a depressive disorder, this needs to be prioritised and treated first (with medication or cognitive behavioural therapy). In case of depressive symptoms or dysthymia without a full-blown major depressive episode, it should be discussed with the patient and his partner (if present) which concerns carry more weight.
8.4.4 Other Sexual Dysfunctions
Hypoactive sexual desire in men often occurs concurrent with other sexual dysfunctions, especially with erectile dysfunction and orgasmic disorder (Segraves and Segraves 1991). The relationship between cause and effect is unclear.
8.4.5 Physical Factors and Disease
As described above age, especially in combination with comorbidity, is an important risk factor for the complaint hypoactive sexual desire. From the age of 40 onward, sexual desire in men decreases slowly and sometimes unnoticeably. Although aging men usually do not have the strong sexual interest they felt at a younger age, most men retain a recognisable level of sexual desire (Schiavi and Rehman 1995). However, decreased or absent sexual desire is often reported by men with chronic physical diseases such as cardiovascular disease (Bernardo 2001), diabetes, kidney failure and HIV (Dove et al. 2009). It is not always clear whether this change should be contributed to the disease, the treatment with medication, chemotherapy or radiation therapy, hypogonadism or to the changes that occur in the relationship during sickness. Three quarters of the men with an HIV infection experience a sexual problem after they start treatment; in 9 out of 10 patients this includes low sexual desire (Lallemand et al. 2002). Men with a chronic kidney disease often complain of a lack of sexual desire but they sometimes attribute it to their fatigue and exhaustion (Toorians et al. 1997). Men with kidney failure who are being treated with haemodialysis (56 %) or peritoneal dialysis (48 %) were shown to have decreased sexual desire more often than men who had undergone a kidney transplant (41 %) or male rheumatoid arthritis patients (Diemont et al. 2000). Hyperactive sexual desire is a common but not always recognised side effect of the treatment of Parkinson’s disease with dopamine agonists, especially levodopa. This side effect is not life-threatening but can strongly influence the quality of life of the patient and his or her partner. The effect can probably be attributed to the dopaminergic effect (Jimenez-Jimenez et al. 2002; van Deelen et al. 2002). Men often experience decreased sexual desire after a cortical cerebral infarction (Duits et al. 2009); however, case reports describe that some men with a comparable affliction have hypersexual episodes (Monga et al. 1986). Patients with isolated symmetrical amygdala damage, including the cortical connections, can, besides other complaints, exhibit hypersexual behaviour, such as occurs in the Kluver-Bucy syndrome. This syndrome is characterised by behavioural disorders due to damage of the right and left medial temporal lobes of the brain. This behavioural change comprises among other features, including changes in eating pattern (bulimia or the eating of inedible objects), strong oral fixation and neuropsychological disorders such as the inability to recognise familiar faces. This clinical pattern of behavioural changes suggests a role for the amygdalae in both hemispheres (Hayman et al. 1998).
Absent sexual desire is seen relatively frequently in body builders and men with eating disorders (Mangweth et al. 2001). The eating and exercising routines of body builders can be as obsessive as that of men with an eating disorder, but their goal is build-up of muscle mass and not weight loss as in an eating disorder.
8.5 Specific Diagnostics
Hypoactive sexual desire has a broad range of biological and psychological causes (Rosen 2000). There are various questionnaires that can quantify the problem, such as the Sexual Desire Inventory (King and Allgeier 2000; Spector et al. 1996) and the International Index of Erectile Function (Rosen et al. 1997); however, at present there is no gold standard for the diagnosis of hypoactive sexual desire in men (Rosen et al. 2002). In most cases health-care professionals can only identify hypoactive sexual desire if they ask their patients or clients direct and clear questions about their sexual desire and motivation. Often they will only reveal sexual difficulties if they ask supplementary questions (Meuleman and van Lankveld 2005; van Lankveld and van Koeveringe 2003).
Examples of questions from the Questionnaire for Screening of Sexual Dysfunctions (QSSD, Vroege 2003) on problems with sexual desire are:
1.
Do you ever find someone (your partner or someone other than your partner) sexually attractive?
2.
Do you ever come across something while reading or watching television which sexually arouses you?
3.
Do you ever seek out things (situations, images etc.) which sexually arouse you?
4.
Do you ever have sexual fantasies or sexual daydreams?
If these questions indicate the presence of low sexual desire and sexual activity both with a partner and masturbation, a physical exam and laboratory testing is indicated. The doctor inspects the habitus and the external genitalia for possible signs of hypogonadism (secondary sex characteristics, muscle atrophy, testicle and penis size). Laboratory testing of the T levels and, if these are too low, measuring the prolactin level is also indicated.
As described, in older men with evident hypoactive sexual desire, distinguishing between the causes of the deterioration of sexual function, including (1) physiological aging, (2) hypogonadism, (3) comorbidity (e.g. metabolic syndrome or depression), chronic disease, medication or a combination of these factors, is often difficult. In clinical practice it is important to address all these factors in the diagnostic process and the management plan.
8.6 Management
There is a range of intervention options to choose from. The PLISSIT model (Annon 1974) can be used a guideline, see Table 8.3. This is in accordance with a stepped-care approach to sexual health care, which starts with care of limited intensity that requires a maximal effort on the part of the individual and his own problem-solving capacities. When this has insufficient effect, a more intensive (and therefore often more expensive) kind of management is indicated. The PLISSIT model distinguishes, in order of intensity, permission and psycho-education (PLI: permission and limited information), specific advice (SS: specific suggestions) and intensive therapy (IT: intensive therapy).
Table 8.3
Summary of diagnostics and interventions in decreased sexual desire
Process | Intervention | Result | |
|---|---|---|---|
Step 1 Intake diagnostics | Determining the complaints and focus of the request for help and the causative and sustaining factors | Patient history: direct questions concerning all the aspects of sexual functioning and perception, including relationship satisfaction, comorbid psychological/psychiatric and somatic problems | Complaints and focus of the request for help have been clarified |
Physical examination: in complete absence of desire and activity – inspection of external genitalia for signs of hypogonadism | Diagnosis made according to the DSM-IV-R and/or description of predisposing, triggering and sustaining factors | ||
Questionnaire: QSSD, GRISS, IIEF | |||
Laboratory testing: T and prolactin levels | |||
Assessment | Formulate working hypothesis | Management | |
Discussion of the findings and treatment options | Referral: in case of comorbid physical (i.e. DM) or psychiatric problems – referral to adequate care. In case of stable chronic comorbid problems – consultation with treating health-care professional for possible adjustment of medication | ||
Establishing management plan | |||
Step 2 Permission and Limited Information (PLI) | Normalise | Psychoeducation sexuality: explain the circular model of sexuality; existence of proactive and reactive sexual desire; if applicable the roll of hormones, chronic) disease, psychological and relationship problems and psychiatric medication | Dysfunction resolved |
Permit | Dysfunction unresolved | ||
Inform | |||
Step 3 Specific Suggestions (SS) | Modification of important sustaining or causative factors in case of little or no comorbidity | Counselling | Dysfunction resolved |
Lifestyle adjustments | Dysfunction unresolved | ||
Psychoeducation sexuality and communication | |||
Simple medication interventions: in established hormonal disorders – T therapy, prolactin decreasing medication (i.e. bromocriptine) (first: MRI sella turcica to exclude prolactinoma) | |||
Step 4 Intensive Therapy (TT) | Modification of complex interdependent sustaining or causative factors | Sex therapy | Dysfunction resolved |
CBT | Dysfunction unresolved | ||
Psychotherapy | |||
Relationship therapy: targeted at communication about emotions, sexual preferences and boundaries, negotiating, power struggle | |||
Medication interventions: (i.e. T substitution in T deficit, prolactin decreasing medication; antidepressants + PDE-5 inhibitor in depressive disorder) | |||
Step 5 Evaluation | Evaluation and redefining goal | Psychotherapy | Acceptance of the dysfunction |
Practical support | Start treatment of other problem | ||
Pharmacotherapy: in established medication effects re-evaluation, medication adjustment, possibly temporary medication cessation, supporting pro-sexual medication; continuous monitoring of sexual side effects |
8.6.1 Permission and Psycho-education
By giving ‘permission’, i.e. reassuring the man that hypoactive sexual desire is not an abnormal complaint, the health-care professional can reduce insecurity and tension. This includes explanation on what is normal, what one can expect in case of disease, grieving, medication or depression. The reversibility of decreased sexual desire, once the inhibiting factor is removed, can also be discussed. In addition, the information that sexual desire can follow sexual arousal by erotic stimuli, instead of preceding it, can be discussed.
The help seeker can be stimulated to gather further adequate information on the subject through books and websites.
8.6.2 Specific Suggestions and Advice
This part comprises among other things, simple interventions from sex therapy. The man can, for example, be given an exploration exercise to discover new kinds of erotic stimulation and rediscover forgotten ones.
Against the backdrop of the hypothesis that sexual desire can arise secondarily to, or can increase as a response to rewarding experiences with sexual arousal, simple touching and caressing exercises with the partner can be advised.
8.6.3 Intensive Therapy
This step can be applied when simpler, short-term and less demanding interventions produce insufficient results. Psychological interventions, medication or treatment with a combination of both is possible.
8.6.3.1 Hormonal and Drug Therapy
Classic indications for treatment with T are Klinefelter’s syndrome, Kallmann syndrome, idiopathic hypogonadotropic hypogonadism, anorchism and pituitary disorders. Because treatment with testosterone inhibits the spermatogenesis through a negative feedback mechanism to the pituitary (T is used as a contraceptive in males) (Mommers et al. 2008), patients with a dysfunction of the hypothalamus or pituitary who want to reproduce are temporarily treated with gonadotropin (hCG/hMG) or pulsatile GnRH. When pregnancy is achieved the treatment regimen can be readjusted to treatment with T (Depenbusch et al. 2002). Although there is general agreement that patients with classic types of hypogonadism should be treated with T, the question whether the same should apply to older men with sexual complaints and SLOH cannot yet be answered decisively: firstly, because the symptoms are difficult to distinguish from the signs of physiological aging and secondly because the long-term side effects of treatment with T are not yet well known (Barrett-Connor and Bhasin 2004; Kaufman and Vermeulen 2005; Liu et al. 2004; Snyder 2004).
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