When searching for solutions to improve erectile function, it is easy to feel overwhelmed by the vast array of treatments promising to fix your issues. Two of the most prominent options are prescription erectile dysfunction (ED) medications and testosterone treatment.
However, before you choose, it is crucial to understand that these two interventions work very differently. The best option for you depends on your specific symptoms, the underlying cause of your condition, and your health history. While ED and low testosterone (low T) share some similarities, they are distinct conditions requiring separate approaches.
This guide explains the causes of both, how they are related, and which treatment is best for your situation.
The basics: Erectile dysfunction and low testosterone
First, know that if you are experiencing erectile dysfunction, you are not alone. Research suggests that about 40% of men have some form of ED by age 40, rising to an estimated 70% by age 70. Causes range from psychological issues like performance anxiety to vascular factors like heart disease.
Regarding low testosterone, the American Urological Association defines low T (or male hypogonadism) as a total testosterone level below 300 nanograms per deciliter (ng/dL). Low T is also common, especially in older men, affecting up to 40% of men over 45.
To pinpoint the cause of low testosterone, doctors must determine if the issue originates in the testicles (primary hypogonadism) or the brain (secondary hypogonadism). Causes can include genetic abnormalities, pituitary disorders, diabetes, and more.
How low testosterone impacts sexual function
Testosterone plays a vital role in sexual health. It helps regulate sexual desire; brain scans show that regions responding to sexual cues are influenced by androgens like testosterone.
Beyond desire, normal testosterone levels sustain sexual arousal, influence spontaneous erections (like morning wood), and enable stimulated erections.
When testosterone is deficient, various sexual dysfunctions can occur, including:
- Lack of sexual desire
- Significant decrease in sexual activity
- Decreased quality of erections
- Delayed ejaculation or difficulty reaching orgasm
Can low testosterone cause ED?
Testosterone supports erectile function by helping the body synthesize, store, and release pro-erectile neurotransmitters like dopamine, nitric oxide, and oxytocin in the central nervous system. It also controls the nerves and muscles involved in achieving an erection. Without sufficient testosterone, these muscles may weaken, and nerve signaling may decline, making erections harder to achieve or sustain.
However, while low testosterone can contribute to ED, it is rarely the sole cause. ED causes are widespread and can be both physical and psychological, including:
- Vascular issues (heart disease, atherosclerosis, high blood pressure, high cholesterol)
- Metabolic syndrome
- Diabetes
- Chronic kidney disease
- Obesity
- Nerve disorders (multiple sclerosis, spinal cord injuries)
- Enlarged prostate
- Peyronie’s disease
- Certain medications (antidepressants)
- Mental health issues (depression, anxiety)
- Lifestyle habits (inactivity, poor sleep, substance abuse)
Shared risk factors between ED and low T
Both ED and low testosterone are more common in aging men. However, age is not the only similarity. Shared causes and risk factors include:
- Obesity
- High blood pressure
- High cholesterol
- Metabolic syndrome
- Environmental toxins
- Poor diet
- Lack of exercise
- Sleep issues
- Substance use
- Genetic conditions (e.g., Klinefelter syndrome)
- Testicular injuries or abnormalities
- Pituitary disorders
- Cancer treatments
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How ED medications work
The most common ED medications are phosphodiesterase type 5 (PDE5) inhibitors, such as sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®), and avanafil (Stendra®).
These medications work by inhibiting the enzyme PDE5. This allows blood vessels to widen, increasing blood flow to the penis—a crucial component for getting an erection. These drugs do not increase testosterone levels.
Instead, the goal of ED medications is to increase blood flow to help you achieve and maintain an erection with sexual stimulation. Studies show oral ED medications are highly effective, with success rates up to 76%.
While some research suggests tadalafil might increase testosterone in diabetic rats, it is unclear if this applies to humans.
Will ED medication work if you have low testosterone?
Research suggests that PDE5 inhibitors are less effective in hypogonadal men (men with low testosterone). PDE5 inhibitors like sildenafil often fail in men with low T because their efficacy depends on nitric oxide, which is regulated by testosterone.
However, testosterone supplementation may restore normal levels in men with low T and improve their response to sildenafil. In fact, combining ED medications with testosterone therapy may be even more effective for men with low T.
How testosterone treatments work
One of the most common treatments is testosterone replacement therapy (TRT), which uses synthetic testosterone to replace low natural levels. It is available as an injection, patch, pellet, pill, or gel. TRT can resolve common symptoms of low testosterone, such as:
- Low sex drive
- Erectile dysfunction
- Fatigue
- Decreased bone density
- Loss of muscle mass
- Increased body fat
- Decreased body hair
- Mood changes
- Memory trouble
- Breast growth
- Reduced red blood cell count (anemia)
Some benefits of TRT may be noticeable within weeks, while others may take several months or even a year to fully set in.
Another option is enclomiphene citrate, a selective estrogen receptor modulator (SERM) that promotes your body’s natural testosterone production. This compounded medication has been shown to increase testosterone levels in as little as 14 days, though more research is needed on its symptom-reduction capabilities.
Do testosterone treatments help erectile function?
TRT has been shown to improve ED and low libido in hypogonadal men, but not in men with normal testosterone levels who have ED. Studies support that testosterone therapy is most effective for mild to moderate ED and may not work as well for severe cases.
As mentioned, TRT may also enhance the response to ED medications like sildenafil and tadalafil, particularly in men with very low testosterone.
For men with slightly low levels (300 to 400 ng/dL), adding testosterone treatment for a short time can help if ED medications fail, provided it is safe.
Regarding SERMs like enclomiphene, there is not enough evidence that it improves ED on its own. However, combining enclomiphene with ED medication may be a game-changer. noRxClinic offers access to a 2-in-1 Testosterone Rx with Enclomiphene & Tadalafil to support both testosterone levels and sexual function. Schedule a consultation to test your levels at home and see if you qualify.
Combination therapy with TRT and ED medication may also improve erectile function in men with low T and other medical issues who do not respond to testosterone alone. However, in men without other medical problems, testosterone monotherapy can sufficiently improve ED.
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Risks and side effects of each approach
Like any medication, PDE5 inhibitors and testosterone treatments carry risks of side effects and drug interactions.
Side effects of ED medications
Common side effects include:
- Headaches
- Dizziness
- Flushing
- Upset stomach
- Nasal congestion
- Back pain
- Vision changes
Rare, serious side effects include vision or hearing loss, priapism (prolonged erection), and dangerously low blood pressure.
Important: Do not mix ED medications with nitrates, nitroglycerin, or alpha blockers. You may not be a candidate if you have a history of heart attack, stroke, arrhythmia, unstable angina, or extreme blood pressure issues.
Side effects of TRT
Potential side effects include:
- Skin irritation (for topicals and injections)
- Testicular shrinkage
- Infertility
- Worsened sleep apnea
- Breast growth
- Increased red blood cell count
While historical studies linked TRT to prostate cancer risk, more recent research refutes this connection.
Side effects of enclomiphene
Unlike TRT, enclomiphene does not reduce sperm count or compromise fertility. However, it may cause side effects in some users:
- Nausea
- Muscle spasms
- Headaches
- Hot flashes
- Aggression
- Blurred vision
- Increase in estradiol (a form of estrogen)
Rarely, enclomiphene may increase the risk of blood clots, cardiac issues, increased red blood cells, increased PSA, eye disorders, or psychiatric disorders.
Who should consider ED meds vs. TRT?
ED medications (Viagra, Cialis, etc.) are best for:
- Men with normal testosterone levels who have trouble getting or maintaining an erection
- Men whose ED is primarily due to blood flow or psychological issues (not low T)
- Men seeking a fast-acting solution for ED during sexual activity
- Men without significant contraindications (e.g., not on nitrates, no recent heart attack/stroke)
Note: ED medication may not work well if you have low testosterone, as testosterone helps regulate the nitric oxide needed for these drugs to function.
TRT may be a good choice for:
- Men diagnosed with low testosterone (typically <300 ng/dL)
- Men dealing with typical low T symptoms (low libido, fatigue, muscle loss, fat gain, testicular shrinkage)
- Men whose ED is caused by hormonal deficiency rather than just blood flow issues
- Men who don’t respond well to ED medication alone and have confirmed low T
Note: TRT takes weeks or months to work and is not a “quick fix” like ED medication. It is most effective for mild to moderate ED.
Differences between ED medication and testosterone treatment
| Feature | ED Medications | Testosterone Treatment |
|---|---|---|
| How it works | Blocks PDE5 enzyme to increase blood flow to the penis. | Increases testosterone levels using synthetic hormones (injections, gels, etc.). |
| Purpose | Helps achieve/maintain an erection for sex. Does not increase T levels. | Resolves low T symptoms and may improve sexual function over time. |
| Who it’s for | Men with normal T levels and vascular/psychological ED. | Men with low T symptoms and/or confirmed low T diagnosis. |
| Effectiveness | Success rate up to 76%. | Most effective for mild/moderate ED due to low T; less effective for severe ED. |
| Risks | Headaches, dizziness, upset stomach. Rare: vision/hearing loss, priapism. | Infertility, skin irritation, testicular shrinkage, breast growth. |
ED medication vs. testosterone treatment: A final word
Erectile dysfunction and low testosterone are highly prevalent, especially among aging men. While related in some cases, they do not require the same treatments.
Here is what we know:
- Different goals: ED medications improve blood flow and are best for men with normal T levels. TRT is best for men with clinically low testosterone and addresses symptoms like low libido, fatigue, and mild to moderate ED.
- Low T reduces ED med effectiveness: PDE5 inhibitors may be less effective in men with low T because testosterone regulates the nitric oxide these drugs need to work.
- Combination therapy works: For men with both low T and other medical issues (like diabetes), TRT alone may not be enough. A combination of TRT and ED medication is often more effective.
For more support, explore natural ways to increase testosterone and consult a healthcare provider to determine if you are a good candidate for ED medication or testosterone therapy.
noRxClinic offers at-home testing and email consultation to help you find the right path forward.
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