question from a user
In your experience, what are the usual reasons that men lose their libido after some time (2+ years) on TRT despite their numbers looking good, and no symptoms of high E2 etc? How have you typically resolved this? I.e his T, Free T, E2 etc all look good but he has no libido. Where do you look next / what do you test for next? DHT? DHEA? Pregnenolone? Other stuff like B12 Ferritin Folate? Where do you typically find the answer lies?
AlphaMD's Answer
This is a great question, and I hope you don't mind, but I'd like to copy/paste an answer we just gave because it's a good summary of this ebb & flow.
"Basically, if you had no libido prior to starting TRT, and TRT is not improving it at all, it suggests that you need to look for non-hormonal causes.
If you had no libido before TRT, then started TRT, and it came back, then you lost it again; this pattern is typical of a hormonal cause. Typically, adding in testosterone gets your libido back. But conversion of testosterone into estrogen is delayed, so estrogen levels creep up over several weeks and if they get too high, you can then lose the libido you just got back.
Also, some men on TRT can lose their libido because elevated levels testosterone can activate the autonomic nervous system. Basically, to have libido you need to be relaxed (the parasympathetic nervous system), but if testosterone is too high, it can activate the sympathetic nervous system (fight-or-flight). This constant adrenaline release means your body cant relax enough to have interest in sex. https://academic.oup.com/cardiovascres/article/53/3/678/328102?login=false
Another thing to consider is your prolactin level. High prolactin can drop your libido into the gutter. Many men who have low testosterone, it is due to a prolactinoma (a benign tumor on the pituitary that releases too much prolactin). Getting your prolactin tested can rule out this diagnosis easily."
In this context, it is often that these other values are having a delayed response & becoming an issue. It's easier to pin down if you had libido, then it left, rather than it never returning on TRT. If anything, that's a good sign that point to there being a solution. We would also want to rule out lifestyle changes. Although TRT does help with limiting the impact of lifestyle changes, enough could cause a need to adjust doing. Very often we find someone is going through extreme stress, has stopped working out/gained weight, or has encountered mental health issues/started depression medication (this has a direct impact on libido). In those cases, we can test or change doses to better address what probably needs to be tweaked once we know.
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