Does testosterone supplementation help Erectile Dysfunction?

Marc Darrow, MD, JD.

In this article we will review the research on the benefits of testosterone for improving sexual health in men with a focus on erectile dysfunction.

For decades, doctors and researchers have speculated on, debated, on and remain divided on the role of testosterone in reversing problems of erectile dysfunction. Doctors have long noted that among the issues that cause erectile dysfunction, hormonal deficiency may be at the bottom of causes. More to the point, is testosterone deficiency, by itself, a cause of erectile dysfunction?

Let’s review that last twenty years of research and see where 2024 brings us.

Erectile function is more likely to improve with testosterone therapy in patients with severe degrees of hypogonadism

A May 2006 paper in the American Journal of Medicine (1) examined the role of testosterone and erectile dysfunction. Nasser Mikhail, MD, MSc wrote: “Despite the well-established role of testosterone in enhancing libido, its exact contribution to erections in men remains unclear.” The paper’s main objective was to “clarify the role of testosterone in erectile function and evaluate its therapeutic value in men with erectile dysfunction (ED).” The findings were “Erectile function is more likely to improve with testosterone therapy in patients with severe degrees of hypogonadism. Further: “Available data suggest that in most men circulating levels of testosterone, well below the normal range, are essential for normal erection and that higher levels of serum testosterone may not have major impact on erectile function. Screening for hypogonadism in all men with ED is necessary to identify cases of severe hypogonadism and some cases of mild to moderate hypogonadism, who may benefit from testosterone treatment.”

A 2011 study in the Journal of Sexual Medicine (2) suggested that low testosterone levels would impair the body’s mechanism to relax the arteries to the penis (the inability to relax the arteries would prevent blood from collecting in the penis that is needed to maintain an erection). Normal erectile function (EF) involves a coordinated relaxation of the arteries that supply the penis and the corpus cavernosum smooth muscle (CCSM), resulting in expansion of the sinusoids and increased intracavernous pressure.

A 2014 study in the journal European Urology (3) writes: “Testosterone modulates nearly every component involved in erectile dysfunction, from pelvic ganglions (nerve centers that send signals into the penis) to smooth muscle and the endothelial cells of the corpora cavernosa (the vessels and muscles of the penis). It also regulates the timing of the erectile process as a function of sexual desire, coordinating penile erection with sex. Epidemiologic studies confirm the significant overlap of hypogonadism and erectile function. . . ”

An August 2016 study in the Journal of Sexual Medicine (4) “Despite controversies concerning testosterone with regard to sexual function, basic science studies provide incontrovertible evidence for a significant role of testosterone in sexual function and suggest that properly administered testosterone therapy is potentially advantageous for treating male sexual dysfunction.”

Does Testosterone make Phosphodiesterase 5 Inhibitors (PDE5Is) work better?

A December 2024 study in the journal Aging Male (5) writes Phosphodiesterase 5 Inhibitors (PDE5Is) have a record of good safety and effectiveness in treating erectile dysfunction, however, older, low-testosterone level men typically have more complex health issues than those with normal testosterone levels. Further the older men have a reduced responsiveness to Phosphodiesterase 5 Inhibitors (PDE5Is). In this case, published research suggest a combination therapy with testosterone and Phosphodiesterase 5 Inhibitors (PDE5Is) be recommended as a safe and effective erectile dysfunction treatment for older men.

Testosterone replacement therapy is thought to provide health benefits in aging and elderly men

In general, as stated in this March 2022 paper in the International journal of molecular sciences (6) testosterone replacement therapy is thought to provide health benefits in aging and elderly men. “Testosterone is the most important hormone in male health. Aging is characterized by testosterone deficiency due to decreasing testosterone levels associated with low testicular production, genetic factors [such as high cholesterol], adiposity [body fat], and illness. Low testosterone levels in men are associated with sexual dysfunction (low sexual desire, erectile dysfunction), reduced skeletal muscle mass and strength, decreased bone mineral density, increased cardiovascular risk and alterations of the glycometabolic profile (glucose, blood sugar levels). Testosterone replacement therapy shows several therapeutic effects while maintaining a good safety profile in hypogonadal men.”

An October 2023 paper in the The lancet. Healthy longevity (7) medical journal wrote of the results of over 5000 patient data reviews : “In men aged 40 years or older with baseline serum testosterone of less than 12 nmol/L, short-to-medium-term testosterone treatment could provide clinically meaningful treatment for mild erectile dysfunction, irrespective of patient age, obesity, or degree of low testosterone. However, due to more severe baseline symptoms, the absolute level of sexual function reached during testosterone treatment might be lower in older men and men with obesity.”

“Many physicians have achieved positive results for their patients.”

An October 2023 paper in the World Journal of Men’s Health (8)  writes: “Although the causal relationship between hypogonadism (low-testosterone) and erectile dysfunction in elderly men remains unclear, many physicians have achieved positive results after implementing exogenous testosterone supplementation therapy in patients with normal or slightly low blood testosterone.”

To better understand patient outcomes, the researchers examined patient data from five random control studies. The researchers found only intramuscular injection of 1,000 mg testosterone significantly improved sexual function of the elderly suggesting: “The injection formulation resulted in a significant sexual function improvement.”

Let’s explore the conflicting research on testosterone replacement therapy and erectile dysfunction treatment

Should testosterone be recommended for men with already healthy testosterone levels? 

A January 2024 review study (9) examined clinical practice guidelines for testosterone replacement therapy for men with sexual dysfunction and testosterone deficiency. the researchers suggest doctors be attuned that men who already have good testosterone levels may not derive extra benefit from testosterone replacement therapy.

Testosterone replacement therapy provides good benefits for erectile dysfunction.

A January 2024 study in The Journal of clinical endocrinology and metabolism (10) evaluated the effectiveness of testosterone replacement therapy in improving sexual function and hypogonadal symptoms in men with hypogonadism and whether effects are sustained beyond 12 months.

  • Among 5204 men in this study, testosterone replacement therapy was associated with significantly greater improvement in sexual activity than placebo at 6 and 12 months. While testosterone replacement therapy improved hypogonadal symptoms and sexual desire, it faired no better than placebo in improving erectile function.

Summary

A November 2022 paper in the International journal of impotence research (11) offers this summary: “The randomized controlled trial data for the efficacy of testosterone replacement as mono- or combination therapy to treat erectile dysfunction has been conflicting. Positive results were frequently not clinically meaningful. . . Consensus is still lacking in several areas, such as the threshold of low testosterone severity for which replacement therapy is most beneficial; the timing for initiating combination therapy; and the duration of treatment.”

 

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References

1 Mikhail N. Does testosterone have a role in erectile function?. The American journal of medicine. 2006 May 1;119(5):373-82.
2 Zhang XH, Melman A, DiSanto ME. Update on corpus cavernosum smooth muscle contractile pathways in erectile function: a role for testosterone?. The journal of sexual medicine. 2011 Jul;8(7):1865-79.
3 Isidori AM, Buvat J, Corona G, Goldstein I, Jannini EA, Lenzi A, Porst H, Salonia A, Traish AM, Maggi M. A critical analysis of the role of testosterone in erectile function: from pathophysiology to treatment—a systematic review. European urology. 2014 Jan 1;65(1):99-112.
4 Podlasek CA, Mulhall J, Davies K, Wingard CJ, Hannan JL, Bivalacqua TJ, Musicki B, Khera M, González-Cadavid NF, Burnett AL. Translational perspective on the role of testosterone in sexual function and dysfunction. The journal of sexual medicine. 2016 Aug;13(8):1183-98.
5 Wang C, Zhang H, Wang F, Guo J, Yuan J, Hou G, Gao M, Li Z, Zhang Y, Marco Polo Study Group on Sexual Health (MAPS-GOSH). Efficacy and safety of PDE5 inhibitors in middle-aged and old patients with and without hypogonadism. The Aging Male. 2024 Dec 31;27(1):2288347.
6 Barone B, Napolitano L, Abate M, Cirillo L, Reccia P, Passaro F, Turco C, Morra S, Mastrangelo F, Scarpato A, Amicuzi U. The role of testosterone in the elderly: what do we know?. International journal of molecular sciences. 2022 Mar 24;23(7):3535.
7 Hudson J, Cruickshank M, Quinton R, Aucott L, Wu F, Grossmann M, Bhasin S, Snyder PJ, Ellenberg SS, Travison TG, Brock GB. Symptomatic benefits of testosterone treatment in patient subgroups: a systematic review, individual participant data meta-analysis, and aggregate data meta-analysis. The Lancet Healthy Longevity. 2023 Oct 1;4(10):e561-72.
8 Yang HJ, Kim KH, Kim DS, Lee CH, Jeon YS, Shim SR, Kim JH. The Effect of Testosterone Replacement on Sexual Function in the Elderly: A Systematic Review and Meta-Analysis. The World Journal of Men’s Health. 2023 Jan 1;41.
9 Oh CK, Lee S, Yu HS, Lim JS, Kim HW, Walsh T, Kim MH, Jung JH, Dahm P. Testosterone replacement in men with sexual dysfunction. Cochrane Database of Systematic Reviews. 2024(1).
10 Pencina KM, Travison TG, Cunningham GR, Lincoff AM, Nissen SE, Khera M, Miller MG, Flevaris P, Li X, Wannemuehler K, Bhasin S. Effect of testosterone replacement therapy on sexual function and hypogonadal symptoms in men with hypogonadism. The Journal of Clinical Endocrinology & Metabolism. 2024 Feb;109(2):569-80.
11 Onyeji IC, Clavijo RI. Testosterone replacement therapy and erectile dysfunction. International journal of impotence research.

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