Testosterone is the primary male sex hormone in humans. While men have far higher blood levels of the hormone, which for them is produced primarily in the testicles, women also produce testosterone (in the ovaries), although at far lesser levels than men.
As the main male sex hormone, testosterone plays a role in almost every aspect of male sexuality, but its role in erectile function has been the subject of considerable debate in recent years.
Judging by the flood of print and broadcast advertisements for testosterone replacement therapy, one might mistakenly assume that men with low-T can overcome all problems related to sexual dysfunction — and overall health — by boosting their blood levels of the hormone.
Testosterone’s Role Unclear
Sadly, that just isn’t true. In fact, although medical science acknowledges that testosterone plays some sort of role in erectile function, that role is not fully understood nor necessarily straightforward, according to WebMD.
Most erection problems stem from a lack of adequate blood flow to the penis, a condition that is known to accompany a number of other diseases and disorders, including atherosclerosis, diabetes, high blood pressure, or elevated levels of cholesterol in the blood.
Cause and Effect?
But wait, you say, pointing out that low testosterone levels are widely known to accompany some of the same chronic health conditions that are blamed for erection problems. Doesn’t that suggest a cause-and-effect link between the two?
While it’s true that men suffering from heart disease, obesity, or type 2 diabetes may be suffering from both low-T and erection problems, the concurrent presence of these two conditions doesn’t necessarily prove a direct link between low testosterone and impotence.
Some men with relatively low serum levels of testosterone manage to achieve and maintain erections with no apparent problem, while others with normal T-levels may be having erection problems. So it’s fairly clear that testosterone alone may not end symptoms of impotence.
What Is Hypogonadism?
Hypogonadism is a condition in which the body’s sex glands — testes in men and ovaries in women — produce little or no hormones. When used in reference to men, hypogonadism means that the testes aren’t cranking out anything approaching normal levels of testosterone.
In the opening to his review of relevant literature about the link between hypogonadism and erectile function, urologist Jacob Rajfer, M.D., states categorically that ¨disorders of the endocrine system are the rarest¨ among major causes of erection problems. He goes on to say, however, that within this overall category of hormonal problems, hypogonadism is the most common cause of impotence.
Dr. Rajfer, who is on the staff of UCLA Health’s Frank Clark Urology Center in Los Angeles, is credited with making UCLA ¨one of the top basic science research centers in the field of impotence,¨ according to UCLA Health’s online profile of the doctor.
Aging Not Sole Cause
Noting that most men experience a gradual lowering of testosterone levels as they age, Dr. Rajfer says that this natural phenomenon is not sufficient in and of itself to cause erection problems. Hypogonadism, as previously noted, represents a state in which sex hormone production is extremely low to nonexistent.
For patients who have been tested and found to be suffering from hypogonadism, Dr. Rajfer suggests that they be treated with testosterone replacement therapy if there are no other health reasons that would make this treatment unwise. However, while this form of treatment should produce clinical improvement in the signs of hypogonadism, says Dr. Rajfer, there is no guarantee that hormone replacement therapy will improve erectile function.
If testosterone replacement therapy fails to produce any improvements in sexual function after ¨a finite time of treatment,¨ Dr. Rajfer suggests that patients be tested for other causes — including vascular and/or neurologic — of erection problems.
Other Ills Linked to Hypogonadism
Erection problems are not the only reason that doctors might choose to begin testosterone replacement therapy in men diagnosed with hypogonadism, notes Dr. Rajfer. For example, men with hypogonadism are at higher risk for cardiovascular events.
Looking back at the history of impotence treatment before the introduction of the PDE5 inhibitors, Daniel Pendick, executive editor of Harvard Men’s Health Watch, recalls a time when testosterone supplementation was one of the most popular modes of treatment.
While this form of hormone replacement therapy remains an option for men who’ve been diagnosed with abnormally low levels of testosterone, Pendick says that it is by no means ¨a universal solution¨ for erection problems.
Not all medical professionals agree on the efficacy of testosterone replacement as a treatment for erection problems. Pendick cites urologist Abraham Morgentaler, M.D., as one who takes a ¨testosterone first¨ approach to treating impotence.
Dr. Morgentaler, an associate clinical professor of urology at Harvard-affiliated Beth Israel Deaconess Medical Center, is also founder and director of Men’s Health Boston, which specializes in testosterone replacement therapy. Dr. Morgentaler says that ¨it’s well-established that testosterone by itself . . . can improve erections in the majority of men who take it.¨
In treating patients that have low testosterone and erection problems, Men’s Health Boston’s first choice generally ¨is to give them testosterone and not sildenafil [Viagra],¨ says Dr. Morgentaler. While this may produce some improvement in erectile function, ¨improved doesn’t always mean adequate, though, so it is not unusual to add sildenafil or a similar medication if a man still is not satisfied with the quality of his erection with testosterone therapy alone.¨
For men whose testosterone levels are normal or better, WebMD says raising the levels further through testosterone replacement therapy, or TRT, ¨probably won’t help¨ ease their erection problems. Chances are better that some improvement will be realized when TRT is used to treat men diagnosed with low levels of testosterone. And, notes WebMD, TRT can help to revive a man’s sex life by ¨restoring his libido and brightening his mood, thereby renewing his interest in sex,¨ even if it doesn’t resolve his erection problems.
Dangers of TRT
In the flood of advertising about the benefits of TRT, it is easy to lose sight of the fact that this form of treatment can have some adverse effects. Endocrinologist Carl Pallais, M.D., an assistant professor of medicine at Harvard Medical School, warns that ¨men should be much more mindful of the possible long-term complications¨ of TRT.
Dr. Pallais cites some studies showing that men on TRT are more likely to have cardiovascular problems, such as heart attacks, strokes, and heart failure. Other doctors have voiced concern that TRT could stimulate the growth of prostate cancer cells. While other studies have come to contradictory conclusions, says Dr. Pallais, men should take a cautious approach in the face of such uncertainty.
“I can’t tell you for certain that taking testosterone raises the risk of heart problems and prostate cancer, or that it doesn’t,” Dr. Pallais says. “We need a large study with multiple thousands of men followed for many years to figure it out.”
Don Amerman is a freelance author who writes extensively about a wide array of nutrition and health-related topics.
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