Testosterone, often referred to as the male hormone, is key to sexual health, particularly in terms of libido and erectile function. Lower than normal testosterone levels can cause erection problems and loss of sex drive, and may also indicate progressive erectile dysfunction. Understanding the relationship between testosterone and erectile dysfunction can help you choose the right treatment option.
Testosterone is the basis of men's sexual health. It gives you a boost of energy, helps you produce sperm, and plays a role in getting and keeping an erection. This hormone is mainly produced in the testicles and reaches its highest levels in men in their late teens and twenties. After the age of 30, it gradually declines by about 1% a year[1]. This slow but steady decline may not always be noticeable at first, but for some people the symptoms of low testosterone, can have a significant impact on their quality of life.
One of the most common symptoms of low testosterone is a reduced sex drive (low libido). This decrease in libido often translates into difficulty getting or maintaining an erection. It's also important to understand that erectile dysfunction (ED) is a complex issue that can be influenced by different factors, including vascular, neurological and psychological elements. While low testosterone certainly exacerbates existing ED, it's not always the primary cause. Thanks to modern pharmacological solutions, testosterone deficiency and ED can be effectively treated. Testosterone replacement therapy (TRT) and erection pills are the first line of treatment.
Blood tests are essential to determine whether a man's testosterone levels are normal. These tests measure testosterone in the blood and results are usually given in nanograms per decilitre (ng/dL). In adult men, normal levels are typically between 300 and 900 ng/dL[2]. Blood samples are generally taken in the morning, when testosterone levels are highest[3], and sent to a laboratory for analysis.
Testosterone levels can vary depending on factors such as age, health and medication, so these should be considered when interpreting the results. Low testosterone levels below 300 ng/dL may indicate hypogonadism, a condition in which testosterone production is low. Symptoms include fatigue, low sexual desire, erection disorders and muscle loss. High testosterone levels may indicate hypergonadism, a condition where testosterone production is excessive. Symptoms include aggression, acne and enlarged prostate. In these cases, further assessment is needed to determine the cause and the best course of treatment.
Research suggests that ED becomes more apparent when testosterone levels fall below a certain threshold, typically around 300 ng/dL[4]. Below this level, the lack of the hormone can affect sexual arousal and cause impotence.
Low testosterone influences the release of nitric oxide (NO) in blood vessels, a signalling molecule that helps relax the smooth muscles in the walls of blood vessels, allowing them to expand and increase blood flow, a process called vasodilation. Testosterone plays an important role in this mechanism by increasing the activity of nitric oxide synthase (NOS), the enzyme responsible for producing NO. Without sufficient NO, the blood vessels cannot fully relax, impairing the ability to achieve or maintain an erection.
For men with ED related to low testosterone, exogenous androgens (steroid hormones) or TRT may provide relief. These treatments can restore normal testosterone levels, improve libido and also improve erectile function.
Sometimes restoring optimal testosterone levels can be achieved through lifestyle changes. Regular exercise, especially resistance training, has been shown to boost testosterone naturally. Getting enough sleep, managing stress and eating a balanced diet rich in zinc, magnesium and healthy fats can also help with hormonal health. However, for men with clinically significant testosterone deficiency, these measures will not be enough.
The best natural testosterone boosters for ED (those that claim to boost testosterone and potency) often promise big results, but rarely deliver. Ingredients such as tribulus terrestris and fenugreek may have some effect on libido, but there isn't enough solid scientific evidence to show that they can significantly increase testosterone levels[5]. In contrast, clinically available testosterone preparations such as injections, patches, gels, or pellets are highly effective for men diagnosed with low testosterone.
For men with clinically low testosterone, there are several options for TRT, each with unique advantages and disadvantages.
Oral options, such as 17α-alkylated methyltestosterone (10-40 mg daily), are less commonly used because they are metabolised directly by the liver and can cause liver stress.
Transdermal preparations, including the scrotal patch (Testoderm, 5 mg daily) and the non-scrotal patch (Androderm, 5 mg daily), deliver testosterone steadily through the skin. Skin gels, such as Androgel, are easy to use and help your body absorb the hormone evenly.
Testosterone injections are often the first treatment for ED in men with low testosterone levels. The best testosterone injections are Cypionate and Enanthate because they're effective, affordable, and convenient. These long-acting esters are usually injected into the muscle every 1–2 weeks, which keeps hormone levels constant. Testosterone undecanoate is a very long-acting ester that offers the advantage of fewer injections (every 10–12 weeks) and stable levels, but it's more expensive. Short-acting options such as testosterone propionate work quickly, but you need injections every 2–3 days, so they're not ideal for long-term use.
TRT can restore normal testosterone levels and relieve symptoms such as erection problems, low libido and mild ED. However, TRT should be monitored by a doctor to avoid potential side effects such as an increased red blood cell count, acne or an enlarged prostate.
If ED is severe and doesn't improve with lifestyle changes or TRT, medical intervention may be needed. The most commonly prescribed treatments for ED are drugs such as sildenafil (Kamagra), tadalafil (Tadalis) and vardenafil (Valif).
These drugs belong to a class called phosphodiesterase type 5 (PDE5) inhibitors. They work by increasing blood flow to the penis. Sildenafil is known for its relatively fast onset and short duration of action, making it suitable for occasional use. Tadalafil, on the other hand, has a longer half-life, which means it can be used more spontaneously as it can remain effective for up to 36 hours. Vardenafil strikes a balance between the other two, with a moderate onset time and the mildest side effects.
Although these medications are very effective for many men, they have some limitations. They only work if you're sexually stimulated, and they're less effective if you've already suffered damage to your blood vessels or nerves. In these cases, other options such as penile injections, vacuum erection devices or even surgical implants may be worth considering.
Testosterone is a key factor in men's health, affecting everything from energy levels to libido and erection. While low testosterone can contribute to ED, it is only one piece of a complex puzzle that includes physical, hormonal and psychological factors. Currently, available TRTs can help restore hormonal balance and improve overall quality of life. However, some cases of ED, especially the more severe ones, may require additional treatments such as PDE5 inhibitors. With the right approach, men can regain their sex drive, energy and healthy erections. It just goes to show that age and hormonal changes don't have to be insurmountable barriers to a fulfilling lifestyle.
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