ED Medications vs. Testosterone Treatment: The Complete Utah Man's Guide to Reclaiming Sexual Performance

By Arsenal Men's Health | Medically Reviewed by Courtney LaSumner Bass, NP | 18-Minute Read

Understanding Your Options: When Two Powerful Treatments Target Different Problems

If you've noticed changes in the bedroom—difficulty getting or maintaining erections, decreased desire, or simply feeling like you're not performing at your best—you're not alone. An estimated 30 million American men experience erectile dysfunction, and the prevalence increases significantly with age [1]. For Utah men seeking solutions, the landscape can feel overwhelming. You've probably heard about medications like Viagra and Cialis. You've likely also encountered discussions about testosterone replacement therapy. But which approach is right for you?

The answer isn't always straightforward, and that's precisely why understanding the science behind each treatment matters. At Arsenal Men's Health, we believe every Utah man deserves to make informed decisions about his health—armed with the same clinical knowledge that guides our board-certified providers.

The Physiology of Erections: More Complex Than You Might Think

To understand why some treatments work for certain men and not others, we need to explore what actually happens when a man achieves an erection.

An erection is the result of a complex coordination between your nervous system, blood vessels, hormones, and even your psychological state [2]. When sexual arousal occurs, your brain sends signals through your nervous system to the blood vessels in your penis. These signals trigger the release of nitric oxide (NO), a molecule that causes the smooth muscle in the penile tissue to relax. As these muscles relax, blood rushes into the corpus cavernosum—the spongy tissue that fills the shaft of your penis—creating the firmness of an erection.

Here's where things get interesting: testosterone plays a critical role in regulating the nitric oxide system [3]. Research demonstrates that testosterone influences the expression of nitric oxide synthase (NOS), the enzyme responsible for producing nitric oxide in penile tissue. When testosterone levels decline—a common occurrence as men age—this entire cascade can be disrupted at its source.

Erectile Dysfunction: The Symptoms and Their Many Causes

Erectile dysfunction (ED) is defined as the consistent inability to achieve or maintain an erection sufficient for satisfactory sexual activity [1]. While occasional difficulty is normal, persistent ED often signals an underlying issue that deserves attention.

Common Causes of Erectile Dysfunction

Vascular Disease: The blood vessels that supply your penis are among the smallest in your body. Conditions that affect blood flow—including atherosclerosis, hypertension, and diabetes—often manifest as ED before they cause more severe symptoms elsewhere [4].

Neurological Conditions: Nerve damage from diabetes, multiple sclerosis, spinal cord injuries, or surgeries (particularly prostate surgery) can interrupt the signals necessary for erection [2].

Hormonal Deficiency: Low testosterone affects approximately 39% of men over 45 in the United States [5]. Beyond reducing libido directly, low testosterone impairs the biochemical machinery needed for erections.

Psychological Factors: Depression, anxiety, relationship problems, and stress all contribute to ED through complex neuroendocrine pathways.

Medications: Many common medications, including antidepressants, blood pressure medications, and antihistamines, can contribute to erectile difficulties.

Low Testosterone: More Than Just a Number

Testosterone deficiency, clinically termed hypogonadism, occurs when the body fails to produce adequate testosterone. The European Male Aging Study identified three cardinal symptoms most strongly associated with low testosterone: erectile dysfunction, reduced sexual desire, and loss of morning erections [6].

Clinical Thresholds for Testosterone Deficiency

• Total testosterone below 300 ng/dL: The Endocrine Society's threshold for considering testosterone replacement

• Total testosterone below 231 ng/dL (8 nmol/L): Generally requires testosterone replacement therapy

• Total testosterone above 346 ng/dL (12 nmol/L): Typically does not require treatment

• Levels between these thresholds: Clinical judgment based on symptoms

Beyond sexual function, men with low testosterone often experience:

• Decreased energy and fatigue

• Reduced muscle mass and strength

• Increased body fat (particularly abdominal)

• Mood changes, including depression and irritability

• Decreased bone mineral density

• Cognitive changes ("brain fog")

• Diminished sense of well-being

How PDE5 Inhibitors Work: The Science of ED Medications

Phosphodiesterase type 5 (PDE5) inhibitors—including sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Stendra)—represent the first-line treatment for erectile dysfunction [7]. These medications have revolutionized ED treatment since sildenafil's FDA approval in 1998.

The Mechanism

When nitric oxide triggers smooth muscle relaxation in the penis, it does so by activating an enzyme that produces cyclic guanosine monophosphate (cGMP). Think of cGMP as the "erection signal"—it keeps the smooth muscles relaxed and blood flowing in.

Normally, an enzyme called phosphodiesterase type 5 (PDE5) breaks down cGMP, eventually ending the erection. PDE5 inhibitors block this enzyme, allowing cGMP to accumulate and prolong its effects [8]. The result: stronger, longer-lasting erections.

Important Limitations

PDE5 inhibitors are considered highly effective, with success rates up to 76% in the general population [7]. However, these medications have a critical dependency: they require nitric oxide to be present in the first place. They amplify the erection signal—they don't create it.

This is where testosterone enters the equation. Research demonstrates that testosterone regulates PDE5 expression and functional activity in the penile tissue [3]. In men with testosterone deficiency, there may be insufficient nitric oxide production, rendering PDE5 inhibitors less effective. Studies indicate that approximately 30-35% of men don't respond adequately to PDE5 inhibitor treatment, and testosterone deficiency often explains this failure [9].

Comparing PDE5 Inhibitors

Medication Onset Duration Key Characteristics Sildenafil 30-60 min 4-6 hours Most studied; take on empty stomach Tadalafil 30-45 min Up to 36 hours "Weekend pill"; can be taken daily (2.5-5mg) Vardenafil 30-60 min 4-6 hours Similar to sildenafil Avanafil 15-30 min 4-6 hours Fastest onset; fewer food restrictions

Clinical evidence suggests that low-dose daily tadalafil may be more effective than high-dose on-demand tadalafil for some men [7]. Additionally, for men with severe ED, combining daily tadalafil with on-demand sildenafil has shown enhanced benefits.

Testosterone Replacement Therapy: Restoring Hormonal Foundation

Testosterone replacement therapy (TRT) aims to restore testosterone levels to the physiological range, addressing the hormonal foundation that supports sexual function [10]. Unlike PDE5 inhibitors, which provide symptomatic relief, TRT addresses an underlying cause when testosterone deficiency is present.

The TRAVERSE Trial: Landmark Evidence

The Testosterone Replacement therapy for Assessment of long-term Vascular Events and efficacy ResponSE in hypogonadal men (TRAVERSE) trial represents the largest and longest randomized controlled trial of testosterone therapy to date [11]. This study enrolled over 5,200 men aged 45-80 with documented hypogonadism.

Key findings from the Sexual Function Study nested within TRAVERSE:

• TRT significantly improved sexual activity compared to placebo, with effects maintained for 24 months

• TRT improved sexual desire and reduced hypogonadal symptoms

• Notably, TRT did not significantly improve erectile function as measured by the International Index of Erectile Function (IIEF)

This last point is crucial and often misunderstood. While TRT improves libido and overall sexual activity, it may not directly restore erections in men with established vascular or neurological causes of ED.

Methods of Testosterone Delivery

Injectable Testosterone (Cypionate or Enanthate): Administered every 1-2 weeks, injections provide predictable testosterone levels and remain cost-effective.

Transdermal Gels/Patches: Applied daily, these maintain more stable testosterone levels but require careful application to prevent transfer to others.

Subdermal Pellets: Implanted every 3-6 months, pellets provide consistent release without daily attention.

Oral Preparations: Newer formulations like testosterone undecanoate (Kyzatrex) and undecanoate (Jatenzo) offer oral alternatives, though they require multiple daily doses.

Nasal Gel: Applied three times daily, nasal testosterone offers an alternative for men who cannot use other forms.

Timeline for Benefits

Testosterone therapy is not an overnight solution. Clinical guidelines suggest:

• Sexual desire improvements: 3-6 weeks

• Erectile function improvements: 6-12 weeks (when testosterone is the limiting factor)

• Full benefits: 6-12 months for complete assessment [12]

The Critical Question: Will ED Medication Work if You Have Low Testosterone?

This is perhaps the most important question Utah men ask, and the research provides a nuanced answer.

The Evidence for Reduced PDE5i Efficacy in Hypogonadal Men

A 2021 comprehensive overview of systematic reviews published in Frontiers in Pharmacology examined the interaction between testosterone status and PDE5 inhibitor response [7]. The findings confirmed that combination treatment with PDE5 inhibitors and testosterone is both safe and effective compared to PDE5 inhibitor monotherapy in hypogonadal men.

Multiple mechanisms explain why PDE5 inhibitors underperform in men with low testosterone:

1. Reduced nitric oxide production: Testosterone regulates nitric oxide synthase expression; without adequate testosterone, less nitric oxide is available for PDE5 inhibitors to amplify [3]

2. Decreased PDE5 expression: Paradoxically, testosterone also regulates PDE5 itself—lower testosterone may mean fewer targets for the medication to act upon [3]

3. Impaired smooth muscle function: Testosterone maintains the structural integrity of smooth muscle in the corpus cavernosum [13]

4. Endothelial dysfunction: Low testosterone is associated with increased oxidative stress and subclinical inflammation, impairing blood vessel function [9]

The 2020 Meta-Analysis: Definitive Evidence

A systematic review and meta-analysis published in Translational Andrology and Urology examined 8 studies involving 913 patients [9]. The researchers found:

• Combination therapy (testosterone + PDE5 inhibitors) was significantly superior to PDE5 inhibitor monotherapy for erectile function improvement

• The pooled standardized mean difference was 0.663 (P<0.0001), indicating a moderate-to-large effect

• Adverse events did not differ significantly between groups

• PSA levels remained stable, with no patients experiencing increases above 4 ng/mL

The authors concluded: "TTh can enhance the reaction to PDE5-Is in men with ED and hypogonadism, but this effect also depends on the specific diagnosis and initial response to PDE5-Is."

The Power of Combination Therapy: When 1+1 Equals More Than 2

For Utah men with both low testosterone and erectile dysfunction, emerging evidence supports a synergistic approach.

Clinical Recommendations

Current clinical guidelines suggest that hypogonadal men with ED should typically begin with PDE5 inhibitor therapy due to its faster onset of action [6]. Testosterone's effects on erection require 6-12 weeks to manifest. However, for men who don't respond adequately to PDE5 inhibitors alone, adding testosterone therapy can "salvage" their response.

A 2023 scoping review published in Uro examined this salvage approach [13]. Key findings:

• TRT appears well-tolerated when added to PDE5 inhibitor therapy

• Men with mixed ED (multiple contributing factors) particularly benefit

• Men with very low testosterone levels show the greatest improvement

• Correcting profound hypogonadism improves response to PDE5 inhibitors

The TADTEST Study

The TADTEST study specifically examined men who failed to respond to tadalafil alone [14]. After adding testosterone gel to normalize testosterone levels, previously non-responsive men showed significant improvements in erectile function. This suggests that testosterone testing should be standard for all men with ED who don't respond to initial PDE5 inhibitor therapy.

Safety Profiles: Understanding the Risks

Every effective medical treatment carries some risk. Understanding these risks allows you and your provider to make informed decisions.

PDE5 Inhibitor Safety

Common Side Effects (occurring in >10% of users):

• Headache

• Flushing

• Nasal congestion

• Dyspepsia (upset stomach)

• Visual disturbances (particularly with sildenafil)

Serious Contraindications:

• Concurrent use with nitrates (e.g., nitroglycerin)—can cause life-threatening hypotension

• Alpha-blockers (use with caution; start with lower doses)

• History of heart attack, stroke, or unstable angina (relative contraindication)

• Severe hepatic impairment

Cardiovascular Safety: For men with stable cardiovascular disease who can tolerate moderate physical activity (equivalent to climbing 2 flights of stairs), PDE5 inhibitors are generally safe [7].

Testosterone Replacement Therapy Safety

Established Side Effects:

• Erythrocytosis (increased red blood cells)—requires monitoring

• Acne and oily skin

• Sleep apnea worsening (in predisposed individuals)

• Decreased fertility (reversible upon cessation)

• Testicular atrophy

Cardiovascular Concerns: The TRAVERSE trial specifically addressed long-standing concerns about cardiovascular risk [11]. The study found that testosterone therapy did not increase the incidence of major adverse cardiovascular events compared to placebo in men with hypogonadism and pre-existing cardiovascular disease or high cardiovascular risk.

Prostate Considerations: Despite historical concerns, recent meta-analyses demonstrate that TRT does not increase PSA levels, prostate volume, or prostate cancer risk in hypogonadal men [15]. However, monitoring remains essential:

• Baseline PSA before initiating therapy

• Follow-up PSA at 3-6 months

• Annual PSA and digital rectal examination thereafter

Combination Therapy Safety

The 2020 meta-analysis found no significant difference in adverse events between combination therapy and PDE5 inhibitor monotherapy [9]. Hematocrit increased slightly more in the testosterone group but remained below concerning thresholds (54%).

Who Should Consider ED Medications vs. TRT vs. Both?

Consider PDE5 Inhibitors Alone If:

✓ Your testosterone levels are normal (>346 ng/dL) ✓ You have situational ED (stress-related, new partner, etc.) ✓ Your ED began suddenly ✓ You have known vascular risk factors (diabetes, hypertension, smoking) ✓ You want rapid results for specific occasions

Consider Testosterone Therapy Alone If:

✓ Your primary complaint is decreased libido rather than ED ✓ Your testosterone is clearly deficient (<231 ng/dL) ✓ You have other symptoms of low testosterone (fatigue, mood changes, muscle loss) ✓ Your ED is mild and accompanied by multiple low-T symptoms ✓ You're interested in addressing underlying causes rather than symptomatic treatment

Consider Combination Therapy If:

✓ You have both documented low testosterone AND ED ✓ You've tried PDE5 inhibitors without adequate response ✓ Your testosterone is in the borderline range (231-346 ng/dL) with symptoms ✓ You want to address both immediate function and long-term hormonal health ✓ You have mixed ED with multiple contributing factors

The Arsenal Men's Health Approach: Personalized, Evidence-Based Care

At Arsenal Men's Health, we recognize that sexual health is deeply personal—and that cookie-cutter approaches often fail. Our board-certified nurse practitioner, Courtney LaSumner Bass, brings military-grade precision to men's health optimization.

Our Comprehensive Evaluation Process

Step 1: Confidential Consultation Every patient begins with a thorough review of symptoms, medical history, and lifestyle factors. We listen—because the details matter.

Step 2: Comprehensive Laboratory Testing We measure what matters:

• Total testosterone (morning draw)

• Free testosterone

• Complete metabolic panel

• Lipid profile

• PSA (when appropriate)

• Additional hormones as indicated

Step 3: Personalized Treatment Protocol Based on your unique physiology, symptoms, and goals, we develop a treatment plan that may include:

• PDE5 inhibitor therapy (sildenafil, tadalafil, or compounded options)

• Testosterone optimization (when clinically indicated)

• Lifestyle modifications that enhance treatment response

• Regular monitoring and protocol adjustments

Step 4: Ongoing Optimization Men's health isn't static. Regular follow-up ensures your treatment evolves with your needs.

Frequently Asked Questions

Can I take ED medication and testosterone together safely?

Yes, for most men. Clinical evidence demonstrates that combination therapy is both safe and effective when properly monitored. The key is working with a qualified provider who understands both treatments and monitors appropriately.

How quickly will I see results?

PDE5 inhibitors work within 30-60 minutes of the first dose. Testosterone therapy requires 6-12 weeks for effects on erectile function to manifest, though improvements in energy and mood may occur sooner.

Will my insurance cover these treatments?

Many Utah men choose Arsenal Men's Health specifically because our cash-pay model eliminates insurance hassles and provides transparent pricing. We accept HSA and FSA payments, making treatment accessible and straightforward.

Is there an age limit for these treatments?

Neither treatment has an upper age limit. The determining factors are your overall health status, symptom severity, and treatment goals—not your age.

What about natural alternatives?

While lifestyle modifications (weight loss, exercise, stress reduction, improved sleep) can meaningfully improve both testosterone levels and erectile function, they rarely provide complete resolution for men with significant deficiency or dysfunction. We view lifestyle optimization as foundational—but not a substitute for proven medical therapy when indicated.

Take the First Step Toward Optimal Performance

You've invested the time to understand the science. Now it's time to apply that knowledge to your own situation.

Whether you're experiencing the first signs of changes in the bedroom or have struggled for years without adequate answers, Arsenal Men's Health provides the expertise Utah men deserve. Our telehealth platform makes consultation discreet and convenient—no crowded waiting rooms, no awkward conversations, no judgment.

Ready to reclaim your confidence?

📞 Call: (385) 666-6292 📧 Email: info@arsenalmenshealth.com 📍 Location: 489 South Jordan Parkway, Suite #254, South Jordan, UT 84095

Hours: Monday-Friday 8:00 AM - 6:00 PM | Saturday 8:00 AM - 1:00 PM

References

1. Burnett AL, Nehra A, Breau RH, et al. Erectile Dysfunction: AUA Guideline. J Urol. 2018;200(3):633-641. doi:10.1016/j.juro.2018.05.004

2. National Institutes of Health. NIH Consensus Development Panel on Impotence. JAMA. 1993;270(1):83-90.

3. Traish AM, Park K, Dhir V, et al. Effects of castration and androgen replacement on erectile function in a rabbit model. Endocrinology. 1999;140(4):1861-1868. doi:10.1210/endo.140.4.6614

4. Vlachopoulos C, Jackson G, Stefanadis C, Montorsi P. Erectile dysfunction in the cardiovascular patient. Eur Heart J. 2013;34(27):2034-2046. doi:10.1093/eurheartj/eht112

5. Mulligan T, Frick MF, Zuraw QC, et al. Prevalence of hypogonadism in males aged at least 45 years: the HIM study. Int J Clin Pract. 2006;60(7):762-769. doi:10.1111/j.1742-1241.2006.00992.x

6. Wu FC, Tajar A, Beynon JM, et al. Identification of late-onset hypogonadism in middle-aged and elderly men. N Engl J Med. 2010;363(2):123-135. doi:10.1056/NEJMoa0911101

7. Pyrgidis N, Mykoniatis I, Haidich AB, et al. The Effect of Phosphodiesterase-type 5 Inhibitors on Erectile Function: An Overview of Systematic Reviews. Front Pharmacol. 2021;12:735708. doi:10.3389/fphar.2021.735708

8. Francis SH, Corbin JD. Phosphodiesterase-5 inhibitors and cGMP. Curr Top Med Chem. 2005;5(10):957-964.

9. Zhu J, Zhang W, Ou N, et al. Do testosterone supplements enhance response to phosphodiesterase 5 inhibitors in men with erectile dysfunction and hypogonadism: a systematic review and meta-analysis. Transl Androl Urol. 2020;9(2):591-600. doi:10.21037/tau.2020.01.13

10. Bhasin S, Brito JP, Cunningham GR, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018;103(5):1715-1744. doi:10.1210/jc.2018-00229

11. Pencina KM, Travison TG, Cunningham GR, et al. Effect of Testosterone Replacement Therapy on Sexual Function and Hypogonadal Symptoms in Men with Hypogonadism. J Clin Endocrinol Metab. 2024;109(2):569-580. doi:10.1210/clinem/dgad484

12. Corona G, Isidori AM, Buvat J, et al. Testosterone supplementation and sexual function: a meta-analysis study. J Sex Med. 2014;11(6):1577-1592. doi:10.1111/jsm.12536

13. Besiroglu H, Dursun M, Otunctemur A. Does Testosterone Salvage PDE5i Non-Responders? A Scoping Review. Uro. 2023;4(1):11. doi:10.3390/uro4010011

14. Buvat J, Montorsi F, Maggi M, et al. Hypogonadal men nonresponders to the PDE5 inhibitor tadalafil benefit from normalization of testosterone levels with a 1% hydroalcoholic testosterone gel in the treatment of erectile dysfunction (TADTEST study). J Sex Med. 2011;8(1):284-293. doi:10.1111/j.1743-6109.2010.02014.x

15. Chen X, Li H, Qiao Y, et al. An updated systematic review and meta-analysis of the effects of testosterone replacement therapy on erectile function and prostate. Front Endocrinol. 2024;15:1335146. doi:10.3389/fendo.2024.1335146

Disclaimer: This content is for educational purposes only and does not constitute medical advice. Treatment decisions should be made by a licensed medical provider based on individual evaluation. Arsenal Men's Health is a nurse practitioner-owned telehealth clinic serving Utah residents. All treatments are clinician-prescribed following comprehensive medical evaluation.

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