Erectile dysfunction (ED) is highly prevalent, affecting up to half of men in their 50-70s. General interest toward ED has exploded since the introduction of “phosphodiesterase type 5 inhibitor” (PDE5i) drugs such as sildenafil (Viagra®). In the last decade, the time lapse between first symptoms of sexual disorders and seeking of medical advice has greatly decreased. However, none of the PDE5i drugs are curative, but only treat the symptoms of ED.

ED is associated with unhealthy lifestyles, such as smoking or overweight, and other health problems such as hypertension, diabetes mellitus, and neurological disorders. It is well accepted that testosterone levels are a good marker of sexual and physical health, and lower levels of testosterone often correlate with poor health. However, several other hormones, including LH, prolactin, TSH, and FT4 are involved in sexual functioning and should be investigated in men with ED.4

In contrast to women who experience a sudden drop in estradiol levels around the time of menopause, the age-related drop in testosterone in men is more gradual at 0.5–2.0% per year from early adulthood onwards. Sex hormone binding globulin (SHBG) binds hormones, and as levels of SHBG rise with age by 1–2% per year, the decline in free testosterone (the active form) is 2–3% per year.5

Male hypogonadism (low testosterone levels), caused by problems within the hypothalamic-pituitary-testicular (HPT) axis that regulates testosterone production, is an under-diagnosed condition. By contrast, late onset hypogonadism (LOH), where low testosterone levels are associated with age-related illness, may be less common than previously believed. Testosterone levels are commonly lower in men with metabolic syndrome, type 2 diabetes mellitus, obesity, depression, obstructive sleep apnea, chronic kidney disease or anorexia nervosa. In addition, certain medications, in particular cortisone-like drugs and opiolds (painkillers such as morphine, oxycodone or methadone), reduce testosterone levels. It is important to consider other hormones and cortisol, along with stress evaluation, to have a complete picture of factors contributing to sexual dysfunction.6

Testosterone replacement is recommended for treatment of symptoms of testosterone deficiency, after the physician excludes contraindications following physical examination and lab work. Men with low testosterone levels typically respond very well to testosterone replacement therapy and show a marked improvement in sexual function, sense of well-being and energy levels, and maintenance of secondary sexual characteristics.

Testosterone therapy may suppress sperm production. When male fertility is a concern, the following approaches may be considered:

•Change in lifestyle to include weight management, strength training, a healthy diet, and decreased consumption of alcohol and nicotine
•Use of aromatase inhibitors such as anastrazole, chrysin, resveratrol and/or zinc to decrease aromatase activity and decrease conversion of testosterone to estradiol, simultaneously affecting two potential causes of male infertility
•Use of 5-alpha-reductase inhibitors such as progesterone and/or saw palmetto

Our compounding pharmacist will work together with each patient and practitioner to customize therapy to meet individual needs.

References

1 J Sex Med. 2014 May;11(5):1262-70.
2 http://www.medscape.com/viewarticle/769813
3 J Sex Med. 2013 Oct;10(10):2443-54.
4 Endocrine. 2014 Aug;46(3):423-30.
5 Aust Fam Physician. 2014 May;43(5):277-82.
6 Fertil Steril. 2013 Jun;99(7):1814-20.