Windsock Man

Thanks to an aging population and a lot of direct-to-consumer advertising, many American men of a certain age know to ask about the “little blue pill” or similar medications if they develop erectile difficulties. But is an erectile dysfunction (ED) drug like sildenafil (Viagra) or its competitors always the best place to start? That’s an open question, especially among men with low levels of testosterone.

Testosterone first?

Before Viagra appeared on the scene in 1998 and transformed the treatment of erectile dysfunction, testosterone was an important medical therapy for it. Testosterone is central in the male sexual response, including the desire for sex and the mechanics of triggering an erection.

To be sure, getting more of this hormone isn’t a universal solution for ED. Some men with erectile problems have perfectly normal amounts of testosterone. Many doctors won’t consider prescribing testosterone unless certain other symptoms are also present, such as decreased desire for sex (libido) and fatigue. And boosting testosterone doesn’t always improve erections. But it is an option on the table for men with low testosterone.

“It’s well established that testosterone by itself, for men with sexual dysfunction that includes erectile dysfunction, can improve erections in the majority of men who take it, ” says Dr. Abraham Morgentaler, an associate clinical professor of urology at Harvard-affiliated Beth Israel Deaconess Medical Center.

Dr. Morgentaler is also the founder and director of Men’s Health Boston, which treats many men with low testosterone. At the clinic, “our first choice for men who have low testosterone and erection problems is to give them testosterone and not sildenafil, ” says Dr. Morgentaler, the author of Testosterone for Life. “Improved doesn’t always mean adequate, though, so, it is not unusual to add sildenafil or a similar medication if a man still is not satisfied with quality of his erection with testosterone therapy alone.”

One potential advantage to the “testosterone first” approach is that could make it unnecessary to take a pill in the anticipation of a sexual encounter. Also, men with low testosterone and symptoms may experience extra benefits of testosterone replacement, such as more “pep” and more desire for sex in the first place.