What is the role of androgens in the treatment of erectile dysfunction (ED)?

Updated: Oct 14, 2020
  • Author: Edward David Kim, MD, FACS; Chief Editor: Edward David Kim, MD, FACS  more...
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Men who present with diminished libido and ED may be found to have low serum testosterone levels (hypogonadism). Hormone replacement may benefit men with severe hypogonadism and may be useful as adjunctive therapy when other treatments are unsuccessful by themselves. Libido and an overall sense of well-being are likely to improve when serum testosterone levels are restored to the reference range. [89, 90, 91, 92, 93, 94] However, a meta-analysis by Corona et al found that the positive effect of testosterone therapy on erectile function and libido was significance only in randomized controlled trials partially or completely supported by pharmaceutical companies. [95]

Meta-analyses suggest that the combination of testosterone and PDE5 inhibitors yields more effective results, but in noncontrolled versus controlled studies. However, adverse effects, especially in older frail men, require consideration. [96]

Replacement androgens are available in the following four forms:

  • Oral
  • Injectable
  • Gel
  • Transdermal

Oral therapy is rarely used; of the available approaches, it is the least effective and the most likely to be associated with hepatotoxicity, even though the risk is relatively small.

Parenteral therapy is the approach most likely to restore androgen levels to the reference range, but it requires periodic injections (usually every 2 weeks) to sustain an effective level. Measurement of peak and trough levels can help avoid symptomatic troughs and supernormal peak levels, though such measurement is rarely done in clinical practice. Typically, a level is obtained 1 week after an injection. Weekly injections using lower doses can be used to minimize the wide swings in blood levels noted with less frequent dosing.

Skin patches deliver a sustained dose and are generally accepted by patients. Testosterone gels are available for daily topical use to treat male hypogonadism and have the advantage of minimizing the peaks and troughs associated with the use of injectable agents. However, these gels require daily application and are relatively expensive.

Implantation of longer-acting testosterone pellets has become increasingly popular. The pellet is placed during an office visit. The advantage of this approach is the infrequency of pellet placement (only every 3-6 months).

The use of exogenous androgens suppresses natural androgen production. Elevation of serum androgen levels has the potential to stimulate prostate growth and may increase the risk of activating a latent cancer. Periodic prostate examinations, including digital rectal examinations, prostate-specific antigen (PSA) determinations, and blood counts (ie, complete blood count [CBC]), are recommended in all patients receiving supplemental androgens. Obtaining a testosterone level during therapy is necessary for optimizing the dosage.

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