Erectile Dysfunction and Testosterone Replacement Therapy

Testosterone replacement therapy works best for men with ED who have been diagnosed with hypogonadism (low testosterone levels). Men who have ED and normal testosterone levels are not likely to benefit from testosterone therapy. Studies indicate that testosterone therapy can modestly improve erectile function and libido.

Forms of testosterone therapy include:
•    Muscle injections using testosterone enanthate (such as Andryl or Delatestryl) or cypionate (Andro-Cyp, Depo-Testosterone, or Virion).
•    Skin patch (Testoderm, Testoderm TTS, Androderm). Depending on the brand, patches may be applied daily to the skin of the scrotum or to the abdomen, back, thighs, or upper arm.
•    Skin gel (such as Androgel or Testim). The gel is applied only to the shoulders, upper arms, or abdomen, not directly to the penis. It is extremely important that men thoroughly wash their hands with soap and water after applying the gel, and cover the application site with clothing once it dries. Testosterone gel has caused serious side effects (premature development, genital enlargement) in children who have come in contact with it through secondary exposure. Pregnant women must avoid contact with the gel because the testosterone can harm the fetus.
•    Oral forms of testosterone are not recommended because of the risk for liver damage when taken for long periods of time.

Side effects may include acne, breast enlargement, headache, and emotional instability. Testosterone therapy may increase the risk for the following serious side effects:
•    Rapid growth of prostate tumors in men with existing prostate cancers. (Taking testosterone does not appear to increase the risk for prostate cancer, but doctors remain concerned.)
•    Benign prostatic hyperplasia (BPH), enlargement of the prostate gland
•    Liver disease and possibly liver cancer
•    Worsening of sleep apnea, especially in men who are obese or who have lung conditions

An alternative to testosterone is clomophine citrate, which is especially useful in younger men with testosterone deficiency with FSH and LH blood tests in the low or normal range. Use of clomiphene can raise testosterone blood test values and avoid potential testicular atrophy and infertility. Another strategy to raise testosterone, especially in men with high estradiol, is to give an aromatase inhibitor.
•    While long-term testosterone therapy was less common in the past, a large number of aging men now include testosterone therapy as part of their daily regimen.
•    Dehydroepiandrosterone (DHEA) is synthesized at a much greater amount than testosterone. DHEA has many actions in a man’s body, especially including acting on vascular smooth muscle DHEA receptors inducing smooth muscle relaxation. Low DHEA values herald vascular disease in aging men. A typical dose to replace DHEA is 25 - 50 mg/day. 

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