On at least five occasions every week, urologist Jesse Mills, M.D., has a man come into his office with low libido and normal testosterone. Sometimes they even have high testosterone and low libido. Otherwise-healthy men tell him their erections are fine, but they don't have the same sex drive they used to have. They ask Mills what's wrong.
The first question the director of the Men's Clinic at UCLA in Los Angeles asks is, "When was the last time you had a vacation?" And then, "Were you having sex like a honeymoon on that vacation?"
It could be that they're stressed. After all, stress is a libido killer.
"You put your two kids to bed, it's 11:30 [p.m.], your partner is exhausted and you've got nothing left in the tank, even though your testosterone is fine," Mills said. "That doesn't mean your libido is completely tied into that testosterone level. There's certainly a huge mental health component to libido."
On the other hand, some men have low testosterone but maintain a strong sexual desire. So high testosterone and low libido can coexist.
The normal range of testosterone is between 300 and 1,000 nanograms per deciliter (ng/dL) of blood. Regardless of age or other factors, a level within this range is considered normal.
"Imagine if you're a 22-year-old college student and you're having sex two to three times a day and your doctor checks your testosterone and it's 800. It's great," Mills said. "Imagine you're that same college student and now you're 42 and you've got two kids and a mortgage. And you have a boss that keeps jumping up your a-- every time you don't hit your sales metrics, and your testosterone is 400."
That testosterone level is still within the expected range, but it's half of what it was 20 years ago. This begs the question: What is a normal testosterone level for a man?
Testosterone is not the only driver of libido
Mills checks a patient's pituitary gland, which helps control testosterone production. If the testosterone is within a normal range but his pituitary gland is overactive—if it's signaling the testicles to make more testosterone to return to the levels he had when he was 22—Mills has a clue that maybe the "normal" testosterone level is not "normal" for him.
"It is usually a deeper dive into figuring out what is the right level for that individual," he said.
What's most important to note is that libido is typically multifactorial and usually cannot be linked to testosterone alone. Lael Stieglitz, M.D., a urologist at Baptist MD Anderson Cancer Center in Jacksonville, Florida, said she has never treated a case of high testosterone levels and low libido.
When low libido is the issue, Stieglitz finds it's often not related to testosterone. However, she said some studies suggest that when you replace testosterone, libido responds well, more so than erectile function.
"Libido is playing to so many things, that's why it's really hard to put testosterone on it," she said. "A lot of times, it's situational. There's trouble at home, there's trouble with the partner, there's anxiety."
Stieglitz thinks the COVID-19 pandemic has impacted the sexual function and sexual health of many American men.
"There's been so much more anxiety," she said. "I have a lot of really young guys who come in to see me and they think they have low libido and erectile dysfunction, and they're like 27. You don't have any of this. It's all in your head. It's hard to tell someone that. That's the hard part about libido."
How much testosterone is too much?
Many people believe high testosterone levels are good, and when they're in the normal range, they usually are. But there's a cap, according to T. Mike Hsieh, M.D., a professor of urology and the director of the Men’s Health Center at UC San Diego Health (University of California).
When you go beyond the normal testosterone range and get up to 2,000 or 3,000, similar to bodybuilders who are taking anabolic steroids to increase muscle mass, it's not exponentially better.
"'If I feel good at 800, I'll feel 10 times better at 8,000.' That's not true," Hsieh said. "When you have too much testosterone, there are other problems, specifically for libido."
For example, when you have too much testosterone, some of it gets metabolized to estrogen, Hsieh explained.
"That usually is done in the fatty tissues of our body," he said. "Your estrogen level can go up. It's not just testosterone goes up and your estrogen stays the same; they actually go up proportionally. Men need estrogen in their body, too. When a guy has too much estrogen, that can start having some psychological impacts. Sometimes people can be more emotional. They also can have sexual health problems when they have too much estrogen in their body."
Weaker erections and poor libido are potential consequences of an elevated estrogen level, which results from too much testosterone in men's bodies. Other general well-being issues that high testosterone levels can cause for men include:
- They don't feel well
- They retain fluid
- Their hands and feet are swollen
- They may gain weight
Dealing with low libido
Usually, Mills wants men to look internally and ask themselves, "When was the last time my libido was great?" Are they stressed? Are there relationship woes?
"Is it a libido mismatch? The partner is horny all the time, and the patient is not that interested in sex but they're still having sex three or four times a week," Mills said. "That, to him, is a low libido because his partner wants it eight times a week."
In addition to stress reduction, Mills recommended finding something, such as a new sex position, that can spice up the relationship. It's important to have a conversation with your partner about why your libido may be low.
Stieglitz employs some "low-level counseling" when talking with patients about their low libido. She asks if they've had any recent life changes or major stressors. She also reviews their list of medications.
"Antidepressants will mess with their head in general," she said. "It will cause erectile dysfunction. A lot of times I find that the ones who come in with ED, if I get them better on their erections, then they have more confidence and the libido comes back. It's not usually just testosterone replacement."
When men seek medical advice and she can help them restore their sexual confidence, it can significantly improve their libido, Stieglitz said.
"Usually, it's not just libido by itself," she said. "There's other stuff involved."