Low Testosterone and ED

Understanding Low Testosterone

For most men, low testosterone is not the cause of their erectile dysfunction (ED). 

What is Testosterone?

Testosterone is a naturally produced androgen hormone in both males and females, and it is the primary sex hormone in men. It is primarily produced by the testicles and is regulated by the pituitary gland and the hypothalamus. Testosterone is the hormone responsible for the development of male sex organs during the fetal stage and it drives the physical changes and transitions that occur during male puberty. In adult men, testosterone controls and maintains typical adult male characteristics and physical features.

  • Sex hormone produced in testes (reproductive glands)

  • Participates in modulation of sperm production

  • Maintains adult male characteristics and physical features

  • Affects sex drive and feelings of sexual desire

  • Impacts mood, energy level, muscle mass, and bone strength

The Myth of Low Testosterone and Erectile Dysfunction (ED)

Often, erectile dysfunction (ED) or male impotence is misdiagnosed as a testosterone-driven problem. While androgen does play a role in erections, there is a lack of clinical evidence linking low testosterone level to the inability to achieve or sustain an erection. Erectile dysfunction is most often a vascular problem, not a hormonal issue. More recently several well designed prospective studies have shown that even when replacing testosterone in men with ED and “low or borderline levels”, no improvement of erectile function occurs.

Research has proven two significant facts dispelling the direct correlation between low testosterone and ED problems:

  1. Normal erections do not require normal testosterone levels

  2. Increasing testosterone level does not increase frequency or strength of erections

Many times the reduced sexual desire that accompanies ED is misconstrued as low testosterone by a patient or his physician. It is common for men who experience prolonged sexual potency problems or erection difficulties to become disinterested in sex out of depression or avoidance, not a low level of testosterone. A state of resignation sets in men’s minds expressed by the following words: “Why bother…”

Further, age may be a factor in the hasty connection made between ED and low testosterone. As man ages, his testosterone level naturally declines by 1-2% each year. Likewise, aging can play a role in diminished sexual potency and the ability to achieve an erection. While these occurrences may be simultaneous, there is no proof that one causes the other.

Approximately 2% of total testosterone exists in the free or unbound form, and approximately 40% is tightly bound to sex hormone–binding globulin (SHBG). The remaining testosterone is weakly bound to albumin and other proteins. Free and albumin-bound testosterone are considered the active or bioavailable testosterone. Several medical conditions may cause free testosterone to be low when total testosterone appears to be normal. Also total testosterone may be low and free testosterone levels normal. When evaluating and treating men for low testosterone levels it is therefore important to measure both the free and total testosterone before initiating testosterone replacement therapy. Because testosterone levels vary greatly in the same individual depending on when it is measured therapy should not be initiated until several measurements are made.

Normal Verses Low Testosterone Levels

It is important to understand that testosterone is measured as a range, not a scale. Testosterone level is determined through a simple blood test and, since levels fluctuate throughout the day, a true reading can only be achieved with multiple tests on different days at varying times.

Normal male testosterone levels range from 300 to 1,200 nanograms per decileter. If your testosterone level tests at the lower end of this range it does not mean you have a low testosterone level. Again, these numbers are to be used as a range, not a scale, and testosterone level can very significantly by man and even by time of day.

Men are far more likely to have non-problematic, low-normal testosterone than they are to have true low testosterone, below 300 ng/dL.

Symptoms of Low Testosterone

Symptoms of low testosterone can only be diagnosed by a medical professional, but one suffering from a deficiency may notice erectile dysfunction, depression, anxiety, low sex drive, high cholesterol, weight gain, or problems concentrating. However, these symptoms are not specific for low testosterone levels and can be caused by many other factors. If it is determined that the patient is suffering from androgen deficiency, long term TRT may be initiated. Testosterone can be administered in gels, creams, pills, injections, or through an implant underneath the skin. Receiving the hormone orally is generally not the preferred route of delivery, as it is not well absorbed and may lead to complications in other organs such as the heart and liver. Transdermal delivery is currently the best way to replace testosterone.

Low testosterone, registering below 300 ng/dL, can be indicated by any number of the following symptoms:

  • Excessive tiredness and easy fatigue with exertion or exercise

  • Reduced sex drive

  • Fertility issues as the result of lowered sperm count

  • Irritability, moodiness, and depression

  • Body hair reduction

  • Reduced bone strength and/or muscle mass

  • Weight increase and/or increased body fat

  • Hot flashes or excessive sweating

It is important to remember that many symptoms of low testosterone are common aging symptoms, as well associated with conditions such as diabetes, heart disease, and primary depression, the metabolic syndrome, renal disease and hypertension.

What Causes Low Testosterone?

Low testosterone, confirmed through a blood test, can be caused by a variety of medical issues. Prior to beginning any treatment, your physician will attempt to rule out disease or another serious medical problem as the cause.

Testosterone levels can be lowered by:

  • High blood pressure

  • High cholesterol

  • History of pituitary or thyroid issues

  • Kidney problems

  • Obesity

  • Osteoporosis

  • Pulmonary disease or asthma

  • Steroid exposure

  • Type 2 diabetes

Testosterone Replacement Therapy

Unfortunately, testosterone supplementation does not exist. Studies repeatedly show Androgen Replacement Therapy (ART), also called Testosterone Replacement Therapy (TRT) or Hormone Replacement Therapy (HRT), is an ineffective form of ED treatment.

Men with confirmed low testosterone levels may be advised to begin a testosterone replacement regimen. Treatment choices include topical gels, pills, injections, and patches. Topical gels, such as AngroGel, Testim or Axyron are most often prescribed and are applied to the shoulders and upper body, allowing the testosterone to be absorbed through the skin.

Whenever testosterone is added to the male human body, it causes a cessation of ones natural testosterone, shrinkage of testicle and sterility. Therefore this should never be given to young men contemplating fatherhood, as the effects of long-term therapy may be permanent.  

Small subsets of men actually choose to undergo testosterone replacement therapy, which for some patients restores energy and sex drive. It is important to note that testosterone replacement therapy, or TRT, should only be reserved for the most severe of cases, and this treatment option should always be discussed with Dr. Eid, who can properly diagnose you with a deficiency.

At our office, we will measure the total and free testosterone in your blood, and will likely measure prolactin (to assess the function of the pituitary gland), as well as SHBG, FSH, LH, and thyroid levels. Testosterone levels normally falls between 250-800 nanograms per deciliter of blood. However, this level will vary even for the same person, depending on exercise and time of day, as well as other factors. 

Dangers of Testosterone Replacement Therapy

Currently, testosterone cannot be supplemented. Low testosterone treatments are designed to replace the body’s natural production of testosterone and could permanently cease the body’s ability to produce testosterone naturally. Unfortunately, extensive marketing from the pharmaceutical industry encourages the widespread use of testosterone replacement. The aggressive pressure they place on physicians to prescribe testosterone borders on medical irresponsibility. The long-term dangers of inappropriate testosterone use could be far more severe than we know today.

The potential, negative side effects of testosterone treatment should be discussed in detail with your physician. Men must carefully weigh the benefits and risks prior to beginning treatment.

Immediate physical reactions may include:

  • Increased appetite

  • Mood alterations

  • Nausea

  • Vomiting

Note: Men often mistake the increased energy and improved mood they experience while using testosterone replacement as proof of its effectiveness. In reality, the steroidal nature of testosterone is what causes these changes. Once the treatment is stopped, men can experience withdrawal and severe depression, as well as the permanent inability to naturally produce testosterone.

Longer-term effects may include:

  • Permanent dependence on testosterone replacement therapy

  • Difficulty urinating

  • Increase in red blood cell count and thickening of blood

  • Fluid retention, liver problems, blood clots, and stroke

  • Increased growth of prostate tissue

  • Prostate cancer tumor growth

  • Sperm count reduction leading to permanent infertility

  • Permanent irreversible suppression of natural production of testosterone

  • Shrinking of the testicles

  • Increased resistance to testosterone replacement

More severe side effects include priapism (an erection that does not go away, and requires medical attention), liver damage, and swelling. In addition, TRT should be used cautiously, and is not the ideal treatment for most healthy adult men with low normal testosterone levels. It should not be used in patients with heart disease or prostate cancer, those with known prostate problems, or men with high cholesterol. In addition, treatment with testosterone may activate prostate cancer in men with undiagnosed cancer. So men considering this treatment should be screened for prostrate cancer, as well as have future screenings.

Once started, it is extremely difficult to stop testosterone therapy. In essence, complete dependence or even addiction to it may occur over time. The long-term effects of testosterone therapy are continually being studied.

Results and efficacy

Almost all of the clinical trials studying TRT have been inconclusive or have not followed patients long-term, so this treatment option is still a bit experimental in practice, and the treatment should not be administered to anyone not deemed an exceptional candidate. Because of the serious nature of TRT, patients with less severe testosterone deficiencies may look into safer, alternative treatment options. Any man currently taking TRT needs to see their doctor regularly for checkups, and should report any medical issues immediately. In addition, prostate screenings are essential.