Erectile Dysfunction and Testosterone: The Heart of the Matter

Erectile dysfunction (ED) is one of the most common reasons that male patients seek

treatment. Often, they also have low energy, less sexual desire and drive, and they are

easily fatigued. This is a common cluster of symptoms which occur from numerous

causes, including: poor or inadequate sleep; excessive and unmanaged stress; poorly

regulated blood sugar; insufficient adrenal function; compromised cardiovascular

function; or low testosterone. While any one of these factors, or a combination, needs

to be assessed, most are looking for testosterone. And why not? Testosterone is the

“thing” these days in men’s health. But, it’s only part of the ED story.

Erectile dysfunction can occur due to problems in the circulatory, nervous, or endocrine

(hormonal) systems, or secondary to stress or emotional challenges. These

considerations are directly aligned with the potential causes noted above. In my

practice, circulatory (aka vascular) problems are about twice as common as low

testosterone (Low-T) as the underlying cause of erectile issues, which we will get to

shortly.

Often when patients have low, but still within normal range, testosterone levels, they

have other stress-related hormone effects, including adrenal and thyroid concerns. To

get a clear picture, it is important to check total and free testosterone as well as

metabolic, thyroid, and cholesterol labs. Patients who bring labs from other doctors

typically only have total testosterone values as part of their evaluation. This seems to

be a very common practice but is inadequate for a full understanding of the treatment

options. When both are low, pharmaceutical support, including but not limited to

testosterone replacement, is certainly indicated. Even then, the bigger hormone picture

and vascular contributions are evaluated and incorporated into treatment. In short, we

still treat whole person even when clinically low testosterone is identified.

Now, let’s get to the heart of the matter (pun intended), which is vascular health. As I

mentioned, vascular dysfunction is a common cause of ED, particularly in men is their

30s and 40s. And guess what, this is a target market for testosterone clinics, online

men’s “health” influencers, and (most recently) the United States military. And, this is a

big problem, in my opinion. Pushing testosterone when it is not actually needed is

irresponsible, and has negative health consequences, including infertility and testicular

shrinkage. But, perhaps more importantly, ED can be an early warning sign of heart

disease and gets over-looked because of the fixation on testosterone.

Men at any age may may notice a decline in sexual performance before heart problems

appear. ED and heart disease, as well as other peripheral vascular concerns, are

problems of blood flow, with erectile difficulties appearing between two and four years

before heart symptoms occur. It is believed this is due to cholesterol build up

(atherosclerotic plaquing) in the smaller vessels of the penis, which leads to reduced

blood flow and less firm erections. Damage to the vessels in the heart (coronary

arteries) occur later because they are larger and it takes longer for plaque to

accumulate before the effects are noticed. While this vascular process is a

consideration for all men who experience ED, and warrants an examination of other

cardiovascular risk factors as well as cholesterol, it is often overlooked in younger men

who are influenced by marketing campaigns about “Low-T.” Bottom line: If you are

young and otherwise healthy, but have erectile problems that developed gradually,

check in with a doctor, for a holistic evaluation that includes a cardiovascular

assessment, before hopping on the Low-T train.