MS and low libido: why desire disappears and what actually helps
Low libido is one of the most common and least discussed symptoms of multiple sclerosis. Here are the three levels of causes — nerve damage, the knock-on effects of fatigue, spasms and medication, and the psychological side — and which of them can genuinely be treated.
At one of our group meetings, after an hour of talking about walking and treatments, a woman said quietly: "Does any of you still actually feel desire?" There was a silence, and then almost everyone spoke up. It turned out to be the topic we all keep quiet about and almost all of us have.
I have had MS since 2010, and I will say it plainly: sex was the first thing that vanished from my conversations with doctors. No neurologist ever asked me. I never asked them either. Yet it is a symptom like any other — with causes that can be named and, in large part, treated.
How common this is
Roughly half to three quarters of people with multiple sclerosis report sexual difficulties, and in some series more than 80% of men [1](#ref-1). In women the most frequent complaints are reduced desire, dryness and difficulty reaching orgasm; in men, erectile dysfunction and reduced desire [3](#ref-3), [4](#ref-4), [5](#ref-5). Recent systematic reviews find sexual function tracks with disability, fatigue and depression, but it also shows up in people with very mild disease [6](#ref-6).
Despite that, it is the least discussed item in the clinic. The appointment lasts fifteen minutes, it goes to legs and scans, and the topic is skipped — by both sides.
Three levels of causes — and why that split is useful
The literature divides sexual difficulty in MS into three levels [1](#ref-1), [8](#ref-8). This is not academic hair-splitting; it decides who you should see and what can be treated.
Primary causes come straight from nerve damage. Lesions in the spinal cord and brain interrupt the pathways that carry sensation and trigger response: reduced genital sensation, weaker erections, less lubrication, harder-to-reach orgasm and — very often — lower desire that has nothing to do with how you feel about your partner.
Secondary causes are other MS symptoms getting in the way: fatigue, spasticity and leg spasms, pain and unpleasant skin sensations, bladder and bowel problems, hand tremor, and medication side effects.
Tertiary causes are psychological and social: body image after catheterisation or a cane, fear of failing, depression, and the hardest one — when a partner becomes a carer and the roles at home shift so far that intimacy has nowhere left to sit.
> For most people it is not one level but all three at once. That is why a pill alone rarely solves it, and talking alone rarely fixes an erection.
Fatigue is probably the biggest silent culprit
If you are so drained that showering is a task, desire will not turn up. MS fatigue is not laziness and not lack of sleep, and it is the single most common reason people say they are "not in the mood" [2](#ref-2). Before chasing anything else, it is worth attacking fatigue properly — I wrote about that here: [fatigue in multiple sclerosis](/en/blog/fatigue-ms-therapies-strategies).
One practical change helps more than it sounds: move intimacy to the part of the day when you have energy. For most people with MS that is not eleven at night after a full day, but mid-morning or early afternoon.
Spasms, pain and the bladder
Spasticity in the legs and hips can make certain positions painful or impossible, and a sudden spasm at the wrong moment ends any desire. Treating spasticity is therefore part of treating the sexual problem, not a separate topic — more in the article on [spasticity and muscle spasms](/en/blog/spasticity-ms-happens-treat).
Fear of leaking urine is the other big brake. The fixes are simple and familiar from rehab: less fluid an hour or two before, emptying the bladder just beforehand, and for people who catheterise, a plan agreed with the urologist. None of it is romantic, but it removes the fear — and fear is the main enemy here.
Medications worth revisiting
Part of the problem often comes out of the pill box. SSRI antidepressants very commonly reduce desire and delay orgasm. Some bladder drugs, some antispasticity drugs and some pain medicines affect sexual function too [2](#ref-2).
That does not mean stopping them. It means that asking your doctor about the dose, the timing or a switch to a different drug is a legitimate request. For SSRIs there are alternatives with far less sexual impact; the decision belongs to a psychiatrist or neurologist, not the internet.
What actually has evidence behind it
For erectile dysfunction in men with MS, the best-studied drugs are the PDE5 inhibitors — sildenafil and tadalafil. They work well in MS and are first-line [2](#ref-2), [5](#ref-5). When tablets are not enough, vacuum devices and injectable treatments prescribed by a urologist are the next step.
In women the picture differs: the same tablets have not shown clear benefit. What helps is lubricants and vaginal moisturisers for dryness, vibrators for reduced sensation (stronger stimulation compensates for weaker signal transmission), treating pain during sex, and, after menopause, local hormone therapy assessed by a gynaecologist [3](#ref-3), [4](#ref-4).
Pelvic floor muscle training has shown benefit in several studies in women with MS — for bladder control and for sexual function [2](#ref-2). That is a job for a physiotherapist trained in pelvic health, not something to learn from a video.
Psychosexual counselling and couples therapy give the best results when combined with the medical measures. The 2024 international recommendations state explicitly that sexual health should be part of routine neurological follow-up, not a topic the patient has to raise alone [7](#ref-7).
Testosterone and hormones
Testosterone is given only when it has been measured and is genuinely low, and then it belongs to an endocrinologist. Low testosterone does occur in men with MS, but replacement without a confirmed deficiency is not a libido treatment and carries risks [5](#ref-5). The same goes for anything sold as a "natural booster" — there is no data there.
How to raise it with your doctor
The hardest part is the first sentence. What helped me was preparing it in advance and saying it without a run-up, at the start of the appointment rather than on my way out the door: "I have a problem with sexual function and I want it to be part of today's consultation."
If it is easier, write down what changed and when: desire, sensation, erection or lubrication, orgasm, pain. There are questionnaires designed for MS that your neurologist can hand you. If you meet a doctor who brushes the topic aside, find another — a urologist, gynaecologist, rehabilitation specialist or psychiatrist. One of them will take it on.
The conversation at home
Silence in a relationship almost always produces the wrong explanation. A partner who does not know the cause is neurological assumes they are no longer attractive or that you have drifted. One sentence — "this is a symptom of the disease, it is not about you" — often lifts years of tension.
What helps couples in practice: schedule time instead of waiting for spontaneity, widen what counts as intimacy (touch, massage, closeness with no goal), and separate the carer role from the partner role for at least part of the day. When the same person helps you stand up and shares your bed, that line has to be drawn deliberately.
It took me years to understand this is a symptom, not a shame. Had I asked the question in 2011 instead of 2019, I would have got the same answers — just eight years earlier.
This article is informational and does not replace a medical consultation. Decide any change of treatment, and any drug for sexual function, with your neurologist, urologist or gynaecologist.