ED Medication vs. Testosterone Treatment: What’s Right for You?

When you’re looking for solutions to improve your erectile function, it’s easy to get overwhelmed by the vast array of treatments available that promise to fix the issues you’re experiencing.

Two prominent options are prescription erectile dysfunction (ED) medications and testosterone treatment. But, before you pick, it’s important to understand that these two interventions work very differently. The one that’s best for you ultimately depends on your symptoms, the underlying cause of your symptoms, and your health history, among other factors. That’s because while ED and low T may share some similarities, they’re ultimately different and require separate interventions. 

Below, learn what causes both ED and low testosterone, how they’re related, and which treatments are best for each situation.

First, know that if you’re experiencing some form of erectile dysfunction (ED), you’re hardly alone. Research suggests that about 40 percent of men have some form of erectile dysfunction by age 40, and that number rises to an estimated 70 percent by age 70. There are a number of causes for erectile dysfunction, including psychological issues (like performance anxiety) and vascular factors (like heart disease).

Regarding low testosterone, the American Urological Association defines low T (or male hypogonadism) as having a total testosterone level below 300 nanograms per deciliter (ng/dL). Low levels of testosterone are also common, especially in older men. Low T affects up to 40 percent of men over 45, and also becomes even more common with age.

To pinpoint the cause of low testosterone, you first need to decipher whether the issue originates in the testicles (primary hypogonadism) or the brain (secondary hypogonadism). From there, you can consider the presence of various causes, like genetic abnormalities, pituitary disorders, diabetes, and more.

How Low Testosterone Impacts Sexual Function

Testosterone plays an important role in sexual health. For one, the hormone helps regulate sexual desire. Brain scans have shown that some regions of the brain light up in response to sexual cues, and these areas are affected by androgens like testosterone.

In addition to regulating sexual desire, having normal testosterone levels sustains sexual arousal, potentially determines spontaneous erections (like morning wood), and enables stimulated erections.

When there is testosterone deficiency, a variety of 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 at the central nervous system level.

The sex hormone also helps control the nerves and muscles involved in achieving and maintaining an erection. Without sufficient testosterone, these muscles could weaken, and nerve signaling may decline, making erections more difficult to achieve or sustain.

However, though low testosterone can contribute to ED, it may not be the sole cause.

The causes of ED are widespread, and can be both physical and psychological.

Causes and risk factors of ED include:

• Vascular issues, such as cardiovascular disease, heart disease, atherosclerosis, high blood pressure, and high cholesterol

• Metabolic syndrome

• Diabetes

• Chronic kidney disease

• Obesity

• Chronic obstructive pulmonary disease

• Nerve disorders, like multiple sclerosis and spinal cord injuries

• Enlarged prostate

• Peyronie’s disease

• Certain medications, like antidepressants

• Mental health issues like depression and anxiety

• Lifestyle habits like inactivity, poor sleep, and substance abuse

Shared Risk Factors Between ED and Low T

Both ED and low testosterone are more common in the aging male. However, age isn’t the only similarity between the two issues. Other shared causes and risk factors of low testosterone and ED include:

• Obesity 

• High blood pressure

• High cholesterol

• Metabolic syndrome

• Environmental toxins 

• Poor diet

• Lack of exercise

• Sleep issues

• Substance use

• Genetic conditions, like Klinefelter syndrome 

• Testicular injuries or abnormalities

• Pituitary disorders

• Cancer treatments

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 effects of the enzyme phosphodiesterase type 5 (PDE5). This allows for widening of the blood vessels, allowing for an increased blood flow to the penis—a crucial component to getting an erection. These medications are not aimed to increase testosterone levels.

Rather, the goal of ED medications is to increase blood flow to the penis, helping you achieve and maintain an erection with sexual stimulation. The goal is not to restore normal testosterone levels. Studies show oral ED medications are highly effective, with a success rate of up to 76 percent. 

Though some research shows that the PDE5 inhibitor tadalafil can increase testosterone and luteinizing hormone (LH) levels in diabetic rats, it’s unclear if the same results would occur in humans.

Research suggests that PDE5 inhibitors are less effective in hypogonadal men (men with low testosterone) for the treatment of erectile dysfunction.

PDE5 inhibitors like sildenafil often don’t work in men with low testosterone because the efficacy of the medications depend 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, research supports that combining ED medications with testosterone therapy may even more effectively increase testosterone levels in men with low T.

Testosterone replacement therapy (TRT) is a treatment used to restore testosterone levels in men with low T. The therapy typically uses synthetic testosterone to make up for low levels of the natural hormone in your body.

Available as an injection, patch, pellet, pill, or testosterone gel, TRT can resolve some of the most 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)

One review analyzing the onset of effects of testosterone treatment found some benefits to be noticeable within weeks. By contrast, others may require several months or even a year to fully set in.

Yes, TRT may improve ED and low libido in hypogonadal men—but not men who have normal testosterone levels but do have ED. However, studies support that testosterone therapy is most effective in men with mild and moderate ED symptoms, and may not work as well for men with severe ED.

As previously mentioned, TRT may also enhance the response to ED medications like sildenafil and tadalafil, particularly among men with very low levels of testosterone.

In men with slightly low testosterone levels (300 to 400 ng/dL), adding testosterone treatment for a short time can help if ED medications don’t work on their own, as long as it's safe for them to take testosterone.

Combination therapy with TRT and ED medication can also improve erectile function in men who have low testosterone and other medical issues if they don’t respond to testosterone alone. However, in men without other medical problems, testosterone monotherapy can sufficiently improve ED.

As is true with any medication, PDE5 inhibitors and TRT each come with a risk of side effects and potential drug interactions.

Side Effects of ED Medications

Side effects of ED medications can include:

• Headaches

• Dizziness

• Flushing

• Upset stomach

• Nasal congestion

• Back pain

• Vision changes

Rarely, more serious side effects can occur, including vision and hearing loss, priapism, and dangerously low blood pressure.

You shouldn’t mix ED medications with nitrates, nitroglycerin, or alpha blockers. And you may not be a suitable candidate for PDE5 inhibitors if you have a history of heart attack, stroke, arrhythmia, low or high blood pressure, heart failure, or unstable angina.

Side Effects of TRT

Side effects of TRT can include:

• Skin irritation (for topicals and injections)

• Testicular shrinkage

• Infertility

• Worsened sleep apnea

• Breast growth

• Increased red blood cell count

Though some historical studies show a link between TRT and an increased risk of prostate cancer and enlarged prostate, more recent research refutes this.

ED medications like Viagra and Cialis are best for:

• Men with normal testosterone levels who have trouble getting or maintaining an erection

• Men whose ED is primarily an issue with blood flow or a psychological issue (not due to low testosterone)

• Men who want a fast-acting solution for ED during sexual activity

• Men who don’t have significant contraindications (e.g., not on nitrates or alpha blockers, no recent history of heart attack or stroke)

Remember, ED medication may not work as well if you have low testosterone. That’s because testosterone helps regulate the nitric oxide needed for these drugs to work.

TRT may be a good choice for:

• Men diagnosed with low testosterone (typically lower than 300 ng/dL on a blood test)

• Men dealing with typical symptoms of low T, such as low libido, fatigue, loss of muscle mass, increased body fat, and testicular shrinkage

• Men whose ED might be caused by hormonal deficiency, not just blood flow issues

• Men who don’t respond well to ED medication alone and have confirmed low testosterone

Remember, TRT can take weeks or even months to work and is not a “quick fix” for erection problems, like targeted ED medication. While testosterone treatment may help with mild to moderate ED, it may not be as effective for severe ED.

From their mechanism of action to their side effects and beyond, there are a variety of differences between ED medication and testosterone treatment.

Erectile dysfunction and low testosterone are highly prevalent, especially among aging men. These conditions are related in some cases, but that doesn’t mean they require the same treatments. Here’s what we know:

• ED medications and TRT have different goals. ED medications improve blood flow to the penis and are best for men with normal testosterone levels. TRT is best for men with clinically low testosterone and addresses symptoms like low libido, fatigue, and mild to moderate ED due to testosterone deficiency.

• Low testosterone can lower the effectiveness of ED medications. PDE5 inhibitors may be less effective in men with low T because testosterone helps regulate nitric oxide, which is crucial for these drugs to work.

• Combination therapy may be more effective than either treatment alone. For men with both low testosterone and medical issues (like diabetes or heart disease), TRT on its own may not be enough to alleviate erectile dysfunction. A combination of TRT and ED medication may be more effective in such cases.

For more support, check out how to increase testosterone naturally, and get medical advice from a healthcare provider today to find out if you’re a good candidate for ED medication or testosterone therapy.