The most prevalent symptoms of hypogonadism in ageing men are reduced libido, reduced sexual activity, and ED. The International Society for Sexual Medicine 2018 guidelines state that:

• Sexual symptoms are a prominent presenting feature for men with testosterone deficiency (TD).
• Testing for TD should be performed in men with decreased libido, ED and difficulty achieving orgasm.

“Testosterone therapy (TTh) may improve libido, erection quality and other sexual symptoms,” and “TTh may salvage erectile function in men who have failed PDE-5 inhibitors.”

According to Morgentaler et al’s Updated Recommendations From the Lisbon 2018 International Consultation for Sexual Medicine, T treatment in hypogonadal men with low libido is associated with significantly greater improvement in libido, erectile function and sexual activity vs placebo. T does not significantly improve sexual function and activity in men who do not have low T concentrations.

According to the American Urological Association 2018 guidelines, the main purpose of TTh is to achieve therapeutic
T levels and provide relief of symptoms with minimal side effects.

Data from clinical trials in men with hypogonadism demonstrate that using TTh leads to statistically significant improvements in ED and sex drive.

Patients should be informed that TTh may result in improvements in erectile function, low sex drive, anaemia, bone mineral density, lean body mass, and/or depressive symptoms.

TTh can improve body composition, bone mineralisation, signs of metabolic syndrome, male sexual problems, diabetes parameters, memory and depressive symptoms. In hypogonadal men with ED, start with a PDE-5 inhibitor as first-line treatment and add testosterone in case of a poor response to PDE-5 inhibitors.

Key takeaways

• Sexual dysfunction is a common sign of hypogonadism in men, with up to one-third of men with symptoms also having hypogonadism.
• Current guidelines recommend that men presenting with sexual dysfunction should be evaluated for low T levels, and TTh and PDE-5 inhibitor use should be considered if appropriate
• Data from randomised controlled trials, meta-analyses and observational and registry studies show that in men with hypogonadism, TTh significantly improves sexual symptoms, including ED, decreased libido and sexual activity, orgasm and poor erection quality.

References available on request.