The biopsychosocial screen before any treatment

The ISSWSH process of care is explicit: assess and modify the modifiable before any therapeutic intervention (Clayton et al., 2018). Most of what presents as "lost desire" has a driver you can name in one consultation. This page is the checklist.

Medications — ask "when did it change?"

• SSRIs and SNRIs — the most common and least-discussed cause. Sexual side-effects are dose-related and often under-reported; consider a switch (bupropion is not licensed for depression in the UK; mirtazapine and agomelatine have lower rates) or a dose review, in discussion with whoever prescribes it.
• Combined hormonal contraception — raises SHBG, lowering free testosterone; a minority of users report reduced desire. Timing relative to starting or switching is the clue.
• Antipsychotics (hyperprolactinaemia), opioids, beta-blockers, antiepileptics, GnRH analogues, aromatase inhibitors and tamoxifen.
• Alcohol and cannabis — chronic use lowers desire; ask quantity, not just yes/no.

Medical

• Thyroid — TSH. Hypothyroidism is a reversible cause.
• Prolactin — if galactorrhoea, amenorrhoea, headache, or an antipsychotic.
• Iron — ferritin in a menstruating or fatigued woman.
• Diabetes — HbA1c; vascular and neuropathic contributions to arousal.
• Menopause transition and after — declining oestrogen and testosterone; vasomotor symptoms and sleep disruption compound it. NICE NG23 covers the assessment of menopausal symptoms, including low sexual desire, and its treatment sequence (HRT first; see the testosterone page).
• Surgical or premature menopause — abrupt loss of ovarian androgen; a distinct and under-recognised group.
• Genitourinary syndrome of menopause and dyspareunia — treat pain and dryness first; desire cannot survive anticipated pain.
• Pelvic floor dysfunction, endometriosis, postnatal state, breastfeeding.

A minimal blood panel where indicated: TSH, ferritin, HbA1c, prolactin. Testosterone is measured at baseline only if testosterone therapy is being considered (see next page) — a low level does not diagnose HSDD, and a normal one does not exclude it.

Psychological

• Depression and anxiety — screen (PHQ-9, GAD-7). Low libido is a symptom of both; treat the mood disorder and re-assess. Be alert to the double bind: the SSRI that lifts mood may lower desire.
• Body image, history of sexual trauma, religious or cultural conflict — ask sensitively; refer to psychosexual therapy where these dominate.
• Sleep, stress, cognitive load — "you cannot want what your nervous system has no capacity for" is clinically as well as colloquially true.

Relationship and context

• Situational vs generalised — desire present with a partner or in solo activity but not in the primary relationship points to the relationship, not to a disorder.
• Partner sexual dysfunction (erectile dysfunction, premature ejaculation), conflict, infidelity, coercion. Screen for domestic abuse where the presentation or history suggests it.
• Life stage — new baby, caring responsibilities, bereavement.

Putting it together

If the screen finds a sufficient explanation, address it and review at three months before labelling the desire loss as a disorder. If it finds none — or finds contributors that have been addressed without recovery of desire — you are looking at generalised acquired HSDD, and the "When to refer" page applies.

Reflective learning

1. Which three investigations would you routinely request for a woman presenting with acquired low desire and no other symptoms?
2. Think of a patient on an SSRI who has stopped wanting sex. How did — or would — you raise it?
3. Where does your local psychosexual service sit, and what is its waiting time?

References

• Clayton AH et al. The ISSWSH Process of Care for Management of HSDD in Women. Mayo Clin Proc 2018;93:467–87. doi:10.1016/j.mayocp.2017.11.002
• NICE NG23. Menopause: identification and management. https://www.nice.org.uk/guidance/ng23