Erectile dysfunction (ED) and low testosterone (also known as hypogonadism) are common health issues for aging men. Not only are ED and low testosterone related in that they both present in aging men, but low testosterone may contribute to ED and both have implications for overall cardiovascular health.
Important statistics regarding ED, hypogonadism and cardiovascular (CV) health:
- ED and sexual dysfunction is the most specific symptom of late-onset hypogonadism, which is associated with increased CV events and death [1,2]
- Normal sexual activity throughout adult life is associated with decreased CV events 
- ED precedes coronary artery disease in 50% of affected subjects, therefore ED indicates early heart disease 
- ED predicts CV disease and overall health independent of other known risk factors for CV disease 
Kevin Billups, MD, is the Director of the Men's Health and Vitality Program at Johns Hopkins. Dr. Billups is very aware of the relationship between ED, low testosterone and overall health. "The first thing I do," he says, "is point out that these problems don't occur in a vacuum. What else is going on?"
For example, if a man between 40 and 50 has ED, growing evidence suggests that he could have a nearly fifty-fold increased risk of developing heart disease over the next 10 years. Therefore, treating the ED is the equivalent of putting a band aid on a lacerated blood vessel – it does not treat the underlying issue and risks of subsequent serious health issues. Billups refers many of his patients to general urologists, primary care physicians, sleep specialists or preventive cardiologists for further testing when needed. "We're offering very integrated, multidisciplinary care." ED is the avenue to get these at-risk men into the doctor's office, from there these patients undergo a thorough risk assessment competing illnesses and can be directed to treat the underlying issues causing their ED.
Low testosterone is another cause of concern for many men. It doesn't help that many have seen advertisements for testosterone-boosting supplements promising to cure all—except, Billups notes, the underlying cause. "Men think it's just a sex drive thing, but a lot of what we see is related to other common chronic conditions. Treating that one symptom without finding out the whole story would not be a good idea." Diabetes or even prediabetes can lower testosterone; conversely better control of blood sugars in diabetic men can lead to improvements in testosterone levels. Other signs of metabolic syndrome including a large waist circumference, abnormal lipids and blood pressure can also affect testosterone. Having a big gut specifically plays a role, Billups adds. "Having a waist circumference greater than 40 inches lowers testosterone. Fat, especially belly fat, makes the enzyme aromatase, which converts testosterone to estrogen.
The most common symptoms of low testosterone are ED, fatigue, feeling sluggish, loss of strength or endurance, daytime sleepiness, even cognition issues. "We can document with a blood test that your testosterone is low, but what's going on with your cardiovascular status, your thyroid? Is there any depression going on? If a man has obstructive sleep apnea and low testosterone, he really needs to get the apnea addressed first, because that can make the testosterone worse."
The story was extracted from "Erectile Dysfunction and Low Testosterone Offer Gateway to Men's Health" in Johns Hopkins Urology: News for Physicians, Winter 2015 by Johns Hopkins Medicine.
 F.C. Wu, A. Tajar, J.M. Beynon, et al. Identification of late-onset hypogonadism in middle-aged and elderly men. N Engl J Med, 363 (2010), pp. 123–135.
 G. Corona, G. Rastrelli, M. Monami, et al. Hypogonadism as a risk factor for cardiovascular mortality in men: a meta-analytic study. Eur J Endocrinol, 165 (2011), pp. 687–701.
 S.A. Hall, R. Shackelton, R.C. Rosen, A.B. Araujo. Sexual activity, erectile dysfunction, and incident cardiovascular events. Am J Cardiol, 105 (2010), pp. 192–197.
 F. Montorsi, A. Briganti, A. Salonia, et al. Erectile dysfunction prevalence, time of onset and association with risk factors in 300 consecutive patients with acute chest pain and angiographically documented coronary artery disease. Eur Urol, 44 (2003), pp. 360–364
 A. Salonia, G. Castagna, A. Sacca, et al. Is erectile dysfunction a reliable proxy of general male health status? The case for the international index of erectile function-erectile function domain. J Sex Med, 9 (2012), pp. 2708–2715
 Ho CH, Jaw FS, Wu CC, Chen KC, Wang CY, Hsieh JT, Yu HJ, Liu SP. The Prevalence and the Risk Factors of Testosterone Deficiency in Newly Diagnosed and Previously Known Type 2 Diabetic Men. J Sex Med. 2014 Dec 2. doi: 10.1111/jsm.12777. [Epub ahead of print]