Treating Erectile Dysfunction with Hormone Therapy: Research and Results

Highlights

• Testosterone is not the only hormone involved in attaining and maintaining erections.
• Testosterone replacement therapy (TRT) is controversial when used for erectile dysfunction without hypogonadism (low testosterone, or low T), a common cause of ED.
• Hypogonadism is almost always the cause of a hormone deficiency or imbalance that affects erectile function.
• hCG and pituitary hormones may present less risk than testosterone when used to treat hypogonadism.
• Bioidentical hormones (BHRT) are exactly like the natural hormones in the human body and considered safe by the FDA, but compounded forms of BHRT are not FDA-approved.
• The fertility drug clomiphene citrate (Clomid) is sometimes used off-label to improve sexual function in men.
• Combination therapies of hormone treatment — such as testosterone with PDE5 inhibitors or hCG — are used to treat ED in some men.

“You eat enough garlic, and it will stand up every time.” ― Alberto Vitale

If only treating ED were that simple! The truth is, many hormones are involved in healthy erections (but thankfully, garlic isn’t one of them!). TRT has been the most common form of hormone therapy for ED, but research has found that the risks can be high for some men.

Fortunately, there are other hormonal treatments for low T/ED. These include pituitary hormone replacement, human chorionic gonadotropin (hCG) supplementation, selective estrogen receptor modulators (SERMS), bioidentical hormones, aromatase inhibitors, and combination therapies.

Read on to learn about recent research on hormonal treatments for hypogonadism and ED.

Testosterone Replacement Therapy

There are two types of hypogonadism: primary and secondary. Both can cause erectile dysfunction. Primary hypogonadism is caused by testosterone deficiency, while secondary hypogonadism results from problems with the hypothalamus or pituitary hormones.

For primary hypogonadism, the most common form of hormone therapy has been testosterone replacement. But depending on the reason for the ED, testosterone supplementation may not solve the problem. If a man’s testosterone level is normal, for example, replacement likely won’t help him attain or maintain erections.

TRT in men with normal T has become controversial in recent years. Researchers are finding possible connections between TRT and prostate cancer, cardiovascular events, low sperm count, and infertility. The American Urological Association now recommends that TRT be prescribed only for men who have symptoms of testosterone deficiency and whose testosterone levels are below 300 ng/dL (nanograms per deciliter).

However, even men with normal T can have symptoms of testosterone deficiency but not meet TRT guidelines. Other forms of hormone treatment might make sense for them.

Other Hormone Treatments for Hypogonadism and ED

Hormones play an essential role in the reproductive system. Testosterone is the most significant, but other hormones are necessary for normal sexual function. The following are examples of hormonal alternatives or adjuncts to TRT.

Human Chorionic Gonadotropin (hCG)

Though hCG is often called “the pregnancy hormone,” hCG injections can also help with low T symptoms. It’s safer than TRT for men who want to preserve their fertility, as testosterone therapy can lead to azoospermia (lack of ability to produce sperm). hCG works by stimulating the testicles to produce more testosterone. It can also restore fertility in men with azoospermia while increasing testosterone production.

hCG is also safe and effective treatment for ED in men with testosterone levels above 300 who may not meet TRT guidelines, according to a 2016 study.

hCG is a safe and effective treatment for ED in men with testosterone levels above 300 who may not meet TRT guidelines.

Pituitary Hormones

In secondary hypogonadism (hypogonadotropic hypogonadism), hypothalamus or pituitary gland problems cause hormone deficiencies and low T. These hormones can include thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), antidiuretic hormone (ADH), growth hormone, cortisol, and prolactin.

Medication in injection or pill form is the usual treatment for hormonal deficits.

Selective Estrogen Receptor Modulators (SERMs)

Clomiphene citrate (Clomid) is the most-studied SERM sometimes prescribed for men whose ED is caused by hypogonadism. Clomid causes the pituitary gland to release the hormones needed for healthy sexual function. Clomid does not affect testosterone levels or fertility. Though it is not FDA-approved for use in men, it has been safely used off-label for this purpose since the 1970s.

Bioidentical Hormones

Bioidentical hormones are made from plant extracts and designed to be molecularly identical to the body’s natural hormones. They have been used for decades to treat many medical problems, including low T. Bioidentical hormones are available in patches, pills, gels, creams, injections, and implanted pellets.

Researchers warn that while some BHRT products are FDA-approved, many others are not.

Researchers warn that while some BHRT products are FDA-approved, many others are not. These include compounded bioidentical hormones, meaning that two or more hormones are combined into one product. These compounded bioidentical hormones (cBHRT) are considered supplements rather than drugs, so the FDA does not regulate them. However, the FDA does not recommend their use for most men, and the Endocrine Society has recommended FDA oversight of these compounds, as their safety and efficacy have not been proven.

Aromatase Inhibitors

Aromatase inhibitors (such as anastrozole and letrozole) are not hormones, but they directly affect testosterone levels. Their use is off-label for this purpose, but they are considered a safe and effective alternative to testosterone replacement. Aromatase inhibitors are also more convenient, as they are taken in pill form.

Combination Therapies 

Several TRT treatments are used in combination to treat men who have ED caused by low T. Here are just a few examples:

Testosterone and PDE5 inhibitor:  A 2020 study concluded that many men who use a PDE5 inhibitor for ED (Viagra, Levitra, Cialis, or Stendra) could safely and effectively enhance their reaction to the medication by supplementing with testosterone. The study reported only mild side effects.

Testosterone and hCG:  hCG can be used to reduce the side effects of testosterone. It can prevent testicular atrophy, maintain the body’s response to testosterone therapy, and protect sperm production. Adding hCG to testosterone is especially helpful for athletes with hypogonadism due to anabolic steroid use.

Conclusion

For erectile dysfunction with no other symptoms, PDE5 inhibitors are usually the first-line treatment. However, in men who experience ED due to low T (and in some cases with normal T), hormonal therapy might make sense. Testosterone is the most common form, but because of its risk profile, some men may want to speak to their doctors about testing for other hormone deficiencies.

If you’re experiencing low libido or problems maintaining an erection, you may benefit from a PDE5 inhibitor like Viagra or Cialis. Click to speak with one of our trusted online pharmacists.