MARGARET PYKE TRUST

Sexual dysfunction and testosterone level are important markers of sexual health but also cardiovascular (CV) health, was the central message to a talk by Consultant Endocrinologist at St. George’s University Hospital NHS Foundation Trust, London, Dr Leighton Seal.

“When a man presents with sexual dysfunction, not only do you have to assess his sexual dysfunction, but you also need to assess cardiovascular risk,” he emphasised. “Erectile dysfunction precedes cardiac disease by an average of three years, which provides an opportunity to intervene in cardiovascular risk level,” he added.

Testosterone deficiency affects genital dysfunction. In men, testosterone deficiency decreases production of nitric oxide, which is responsible for causing the erection and leads to fibrosis in the erectile tissue. In both men and women, it reduces vaso-restrictive responses, thereby reducing clitoral erections too, explained Dr Seal.

He also stressed the importance of dealing with testosterone before starting with drugs designed to alleviate sexual dysfunction. “If you give PDE5 (phosphodiesterase type 5) inhibitors to treat erectile dysfunction you could end up with failure,” he said, adding that, “We know hypogonadism causes PDE5 failures, and we also know that 60-70% of erectile dysfunction returns to normal with testosterone replacement.”

Often, a man tells the general practitioner (GP) that they are struggling to get an erection, and it is easy to tell the man to go to the pharmacy and get Viagra (or similar) over the counter, Dr Seal points out. “This might put a plaster on it for a while, and I’m concerned with the ease of availability of Viagra online or in pharmacies. In these cases, how much of a cardiovascular assessment is made?”

A major function of primary care, currently, is CV risk intervention, so the GP should do a proper CV risk assessment including lipid profile, blood pressure, evidence of diabetes and history of heart problems. If there is cause for concern then the patient might benefit from referral to a specialist, or they might feel that various interventions, for example, cholesterol-lowering drugs, might be appropriate.

Regarding risk groups, Dr Seal referred to data suggesting that the correlation with CV disease is higher the younger the man is. “Men with erectile dysfunction from 35-45 years, have around a 40-fold increase in heart disease, compared to men in the 50-60 years age bracket, this risk becomes three to four-fold increased. The younger the man is, the stronger erectile dysfunction is as a marker of CV disease.”

For women, testosterone deficiency is often unrecognised. “Female sexual dysfunction is much more complex than in the male, but in women with testosterone deficiency, including lack of libido with tiredness, testosterone replacement is safe and effective and there should be a strong call for having effective female testosterone products available. We shouldn’t have to adapt products designed for men,” highlighted Dr Seal. “Many women get sent off for a talking therapy when actually they need a medical therapy.”

An old myth around testosterone is that it governs libido, and if libido is maintained than there is no need to check testosterone level, but that is wrong, stated Dr Seal. “Testosterone needs to be checked in all men presenting with libido problems [and] men with erectile dysfunction should have a CV assessment,” he stressed.

Finally, he added that testosterone has non-sexual advantages as well, so hypogonadal men are fatter around the middle, with higher metabolic risk. This higher metabolic risk is restored by testosterone replacement, which in turn improves insulin sensitivity.