Low Testosterone and Erectile Dysfunction with Dr. Robert Segal

Erectile Dysfunction Radio Podcast

Dr. Robert Segal joins the Erectile Dysfunction Radio Podcast to discuss Low Testosterone and Erectile Dysfunction. Dr. Segal is a urologist in Maryland who specializes in male sexual medicine.

The Erectile Dysfunction Radio Podcast is dedicated to educating and empowering men to address erectile dysfunction, improve confidence, and enhance the satisfaction in their relationships. This podcast is hosted by certified sex therapist, Mark Goldberg, LCMFT, CST.

Transcript of Episode 16 – Low Testosterone and Erectile Dysfunction with Dr. Robert Segal

MARK: Welcome to another episode of the Erectile Dysfunction Radio podcast. Today we are joined by Dr. Robert Segal. Dr. Segal is a urologist who has completed a fellowship in male sexual medicine at Johns Hopkins. He practices general urology and male sexual medicine.

Dr. Segal specializes in male sexual dysfunction, including hypogonadism, which is low testosterone, and the topic of tonight’s podcast, premature ejaculation, Peyronie’s disease and erectile dysfunction.

Dr. Segal has conducted research and is an author of multiple articles on these topics. Welcome, Dr. Segal.

DR. SEGAL: Thank you very much. Happy to be here.

MARK: So our topic today, Dr. Segal, is going to be low testosterone and erectile dysfunction. I’d like to get started by helping our listeners understand what it means when somebody has low testosterone?

DR. SEGAL: Testosterone is the hormone that gives a man his vitality. Energy level, libido, it contributes to a sense of well-being, good mood. It’s produced, for the most part, by the testicles, so about 95% of the testosterone in the body comes from the testicles, so if someone has low testosterone, it means that there is insufficient production of testosterone.

Typically, the clinical symptoms associated with it include low sex drive, low energy level, the inability to exercise or to perform a great deal of physical activity, it can be associated with depression, with erectile dysfunction as well. It’s diagnosed with a blood test that would be ordered on the basis of the patient having these symptoms.

MARK: Okay. So testosterone goes way beyond just sexual function. It includes also mental health, other areas of general function, energy levels. Is that correct?

DR. SEGAL: I would say that’s very true. One of the difficult things associated with assessing for low testosterone and potentially managing it, is that a lot of the symptoms that I mentioned to you are relatively nonspecific, and so just because someone has one or more of these symptoms, does not automatically mean that they have low testosterone.

Sometimes you can have men who have low testosterone, who have these symptoms, who, when you treat them and get their testosterone levels normalized, they are still symptomatic, which implies that their symptoms are related to something else other than the low testosterone.

MARK: There’s a lot of complexity with low testosterone, the symptoms, not always a simple fix the low testosterone and everything’s going to be okay.

DR. SEGAL: Exactly. The one other thing I think is important to mention is that low testosterone is also associated with some other issues throughout the body.

It can be associated with a cardiovascular disease, and men with low testosterone may be at higher risk of cardiovascular outcomes such as heart attack or stroke. It can be associated with weak bones, otherwise called osteopenia or osteoporosis.

Those are two of the big ones that we hadn’t touched upon before. And so I have some patients who may not derive benefit in terms of their sexual symptoms, for example, with replenishing testosterone, but because they want to keep these other body systems healthy, they will continue testosterone replacement just for the ancillary benefit, so to speak.

MARK: Got it. Okay. Now, when you were talking about conditions that are associated, one of the things that I think will also be very important for our listeners to understand are what are some of the most common causes of low testosterone?

DR. SEGAL: So it’s a good question, and this can sometimes, in fact, many times, be difficult to ascertain. You could make the argument that, in some cases, it may not even entirely matter what the cause is, because if the end result is having low testosterone, and the treatment, for the most part, is the same, i.e., replacing testosterone with different medical options, then finding the exact cause may not be possible or may not be that important.

The two kind of principal views of it are that it could relate to the testicle not producing enough testosterone, and this is something that it’s kind of hard to pinpoint exactly why. Certainly, certain things, such as if the patient has needed one or both of the testicles removed for other reasons, then that’ll contribute to it.

If they have a testicular cancer, that can potentially suppress testicular function, if the testicles have been exposed to radiation, for example. Trauma can affect testicular function, meaning trauma to the testicles.

In the older days, one of the common sources of testicular dysfunction would be mumps, which you can get an infection of the testicle called mumps orchitis, which can result in kind of a lasting testicular dysfunction.

Most of the guys we see with low testosterone don’t have any of these risk factors, and so it can be hard to potentially delineate why. You can argue that probably the most common type of low testosterone that we see is associated with aging, and that could be, just as the patient ages, the testicle stops functioning optimally.

That may also relate to the other cause of low testosterone, which is what we call hypogonadotropic hypogonadism.

So basically, the brain, which is responsible for releasing a hormone or several hormones to stimulate the testicle to produce testosterone, the brain is deficient.

If the brain can’t produce these hormones, then the testicles aren’t stimulated to produce testosterone. And sometimes, again, guys who’ve had certain brain tumors, that’s… it can be related, if they’ve had radiation to the brain because of again, a brain tumor, for example, that could be related.

Again, trauma, there are other more rare congenital syndromes that may contribute to this.

MARK: Just to clarify, though, for our listener. In the vast majority of situations where a man is experiencing low testosterone, would you say that some of these factors, such as a brain tumor, are likely to be involved, or is it most likely not the case?

DR. SEGAL: It’s most likely not the case. Whenever we interview a patient, we ask about some other symptoms that could be concerning, for example, do they have frequent headaches, do they have changes in their vision.

Those affirmative answers may lead us to think we need to get imaging of the brain to confirm that everything is normal, or sometimes even we just look at the testosterone level. If the testosterone level is very low, that may indicate to us, okay, maybe we need to just make sure that the hormones that are produced by the brain are normal to help us delineate exactly the source.

MARK: Got it. So in short, there could be a whole number of causes?

DR. SEGAL: Absolutely.

MARK: For low testosterone. In the vast majority of instances of low testosterone, the treatment is largely going to be the same, certainly as it pertains to erections. Is that correct?

DR. SEGAL: I’d say that’s true. In the rare event that we identify one of these more uncommon causes like a brain tumor, then treating that cause will potentially help to improve the testosterone.

One other thing that I didn’t mention, and this sometimes is poorly understood by the patient. Obesity or increased fat mass can also result in low testosterone. The reason why is because there is an enzyme produced by fat tissue called aromatase. And the function of aromatase is to breakdown testosterone.

Someone who is very obese, their body may be producing sufficient testosterone, but if they have all this fat tissue that’s metabolizing or breaking down the testosterone, then their levels may be low.

Certainly in men who are obese, who come in with a low testosterone, the first recommendation that I’m giving them is they need to lose weight, because even if I replace their testosterone, that enzyme is still going to be very active because of all the fat tissue, and so that’s just potentially providing more testosterone to be broken down by that enzyme.

MARK: Yeah. So a lot of causes and a lot of potential solutions with that.

DR. SEGAL: Yes.

MARK: So let’s pivot, Dr. Segal, to understand a little bit about the role of testosterone in erections.

DR. SEGAL: So this is, in my mind, not that straightforward. If you read any textbook on low testosterone, one of the main symptoms is erectile dysfunction, which I think is not untrue, but it’s not mutually exclusive.

You can have men who have erectile dysfunction with normal testosterone, you can have men with low testosterone who do not have erectile dysfunction. For those men who have both, the erectile dysfunction may not be a consequence of the low testosterone. It can be very complex.

The way the erection works is it’s increased blood flowing to the penis, and the penis’ ability to trap blood in the penis. So the blood flow allows you to get the erection, the trapping of the blood allows you to keep the erection or maintain the erection.

Testosterone in itself does not substantially affect blood flow. If you have someone who’s obese, who has diabetes, who has coronary artery disease, which are all risk factors for erectile dysfunction, you give them testosterone, that may help their other symptoms, like low sex drive, low energy for example, but it may not improve the erections, because they have other risk factors for erectile dysfunction.

MARK: So just to clarify, the testosterone itself doesn’t directly impact the blood flow. Is that correct?

DR. SEGAL: It can. And so again, it’s complicated, and I’m sorry if I’m not committing to a definitive answer, but again, that’s why they call it the art of medicine, right?

There’s no absolutes. So it is possible that if men have very low testosterone, you replace their testosterone, their erections do get better, but it’s not necessarily guaranteed.

MARK: Got it. And we can definitely appreciate the complexity, certainly when we talk a lot about the role of the brain, which adds a whole other layer to the erection process. How is low testosterone treated?

DR. SEGAL: We already talked about the lifestyle changes that would be important, so men who are overweight should lose weight, men who drink a lot of alcohol should know that may contribute to low testosterone.

Having one or two drinks a day is probably not anything too concerning, but certainly if you’re drinking five or more drinks a day, which would be considered alcohol abuse or dependence, that’s an important lifestyle modifier to consider.

However, if you make the diagnosis in someone who doesn’t have any of these risk factors, who is symptomatic, you’re then talking about testosterone replacement. There are different ways of doing it.

We may come to this a little bit later, but one of the big side effects of testosterone replacement is that it can affect a man’s fertility, meaning it can drop the sperm count. So for men who wish to preserve their fertility, testosterone replacement may not be appropriate.

There are other treatments. There’s, for example, an off-label treatment called clomiphene citrate, which is a category of medication called a selective estrogen receptor modulator that works by blocking the estrogen receptor, so it basically makes the brain think that there’s less circulating estrogen.

That ramps up the brains production of hormones, which in turn stimulates the testicle to produce more testosterone, and hence, the levels go up. For men in whom fertility is not a concern to be preserved, there are a variety of different ways of providing exogenous or outside testosterone that will increase the levels in the blood, but it’s not a consequence of the increase in the body’s production of testosterone.

MARK: Got it. So either some of the treatments will stimulate the body to try to produce naturally the testosterone, or the other line of treatment is to externally feed the body with testosterone to try to raise those levels. Is that correct?

DR. SEGAL: Correct. Yes.

MARK: Okay. I know you touched on this a little bit earlier, but I want to kind of clarify this just a little bit more. When testosterone levels return to within that normal range, what is the expected impact on erections?

DR. SEGAL: So that depends. If men don’t have erectile dysfunction in spite of having low testosterone, we wouldn’t really expect it to change.

I always counsel the patient that if they have concomitant erectile dysfunction with low testosterone, that my hope, my expectation would be that the erections would improve, but if it doesn’t, not to fret, because there are dedicated treatments for erectile dysfunction that we can use at the same time.

MARK: Okay. I’ve worked with a number of men who have undergone treatment for low testosterone, and they’ve seen their levels improve, but they do continue to struggle with erections. Is that common?

DR. SEGAL: I would say it is common. I see that a lot as well. And it again, it kind of alludes back to the comment that you made before about how the brain can add a layer of complexity to managing this. So an erection, as I mentioned before, is blood flow to the penis and blood trapping in the penis, and so again, if one or both of those mechanisms are not working, then testosterone on its own may not be able to enhance the erection.

On top of that, if men have other issues that can contribute to erectile dysfunction, what I would call, and what you would call psychogenic erectile dysfunction, meaning, their penis works, but they are anxious, they are depressed, that will potentially not resolve, even though you’re giving testosterone.

Men who are tired because they work two jobs and they don’t sleep well, for example, they may not be able to get erections when the time is needed, even though their testosterone has been normalized. So there’s a lot that goes into erectile dysfunction beyond simply low testosterone.

MARK: So to that end, I know that the role of the brain is something that the podcast is focused on, and that I tend to focus on, but I do like to get a medical perspective, maybe some of the things that you’ve heard from patients in terms of what are some of the thoughts, beliefs that they may be holding that might be contributing to not being able to gain or maintain an erection despite that testosterone treatment.

DR. SEGAL: I see a lot of men, erectile dysfunction is associated with aging, which is not to say that young men and young healthy men do not get erectile dysfunction, they do, but certainly the risk and the prevalence of it goes up as men age. The first thing I’m asking them about are these other risk factors that I mentioned to you before.

Do they have coronary artery disease? And how that works is, the plaque that blocks the arteries that feed the heart, for example, the same process occurs in the penis, but the arteries that supply the penis are a lot smaller. So you can get erectile dysfunction way before developing cardiac symptoms.

And related to that would be, do they have high blood pressure? Do they have high cholesterol? Do they have diabetes? Do they smoke? For example, I treat, obviously, a lot of men with prostate cancer, and so that treatment can impact on the erection.

A lot of men who come to see me with low testosterone have one or more of these associated risk factors as well, and so I try to educate them that the low testosterone is kind of in one silo, let’s say, the erectile dysfunction is in a different silo.

Just because the symptoms could be related, doesn’t mean the treatment of one will result in improvement in both of these conditions. That can sometimes be a little hard for patients to understand or to grasp.

There is this misconception about testosterone that it’s this kind of wonder drug and it’s an anti-aging solution, for example. I would say that there is a lot of less than reputable clinics, for example, who will tout testosterone replacement as improving many problems, and I’ve seen patients who have normal testosterone who have been put on testosterone replacement by these practitioners.

Whether that’s because they’re just trying to make a buck at the expense of a patient, or maybe they don’t fully grasp the condition, I don’t know, but that’s certainly not appropriate. If you look at any kind of medical guideline relating to low testosterone, treatment would only be appropriate in men who are symptomatic who have low testosterone.

Men who have normal testosterone, studies actually show that they do not benefit from treatment. And certainly, if the testosterone goes above what would be considered the normal range, that can also be dangerous for patients.

I think good clinicians kind of know when it’s appropriate to treat and when it’s not, and that can be difficult for patients to grasp sometimes, because they come in, they’re feeling tired, they’re feeling depressed, they have no sex drive, they have no energy, so it’s hard for them to appreciate that their testosterone is normal.

And thus, giving them testosterone may not help them. It’s easy if you diagnose them with low-t and they have these symptoms, it’s most of the time an obvious solution, but for those men who are kind of looking for a quick fix, sometimes it’s not there for them.

MARK: And it makes complete sense. Now, do you see increased levels of anxiety, worry, concern, do men bring factors that we know will impact the brain’s ability to facilitate gaining and maintaining an erection? Do you see that in particular with the men who have been diagnosed with low testosterone?

DR. SEGAL: I would say I definitely see it. I don’t know if men who have low testosterone are at a greater likelihood of having anxiety, for example, associated with their erectile dysfunction. A lot of men are perturbed by their ED, and that in itself is a cause for consternation or anxiety, and that’s when I’m sending them to you, because they can kind of get in their own heads, and it becomes a vicious cycle.

They have erectile dysfunction, so they worry about their next encounter. They know that, or they feel like they may be frustrated, and that kind of turns them off.

You can sometimes see guys who have a low libido even though their testosterone is normal, just because they have erectile dysfunction. Sometimes, if you can improve the erections, their libido gets better, and it wasn’t because they have low testosterone.

MARK: And that kind of speaks again to that complexity of the role of the brain, which I will continually come back to, because that is the focus of what I do, and I appreciate you having that viewpoint.

I assume that you see a decent amount of men who are experiencing erection problems and have low desire. How often does a man experiencing both of these symptoms actually have low testosterone?

DR. SEGAL: It’s not uncommon, but again, it’s not always. I just mentioned, guys who have low libido, it may relate to anxiety, it may relate to depression, it may relate just to the erectile dysfunction, but certainly low libido is a hallmark symptom of low testosterone.

So someone who comes in to see me, if they have erectile dysfunction, one of my first questions is going to relate to low libido. If someone comes to see me with ED, but they don’t have any of the other low testosterone symptoms, I’m not always checking their testosterone, but if they have low libido, I am definitely going to check their testosterone, because if it’s low, then my hope is, that by replacing their testosterone, that one or both of those issues will be improved.

MARK: Got it. If a man has both erectile dysfunction and low libido, you would be looking  to test those testosterone levels to see where they are, but erectile dysfunction by itself with a healthy, normal baseline libido for that patient, would not necessarily indicate a testosterone issue? It may not be where you would start? Is that correct?

DR. SEGAL: That’s correct. And I can only speak for my practice. I guarantee you there are experts out there who, any man who comes in with erectile dysfunction, irrespective of their other symptoms, they aren’t getting their testosterone checked.

As I mentioned, low libido is not the only symptom. If someone comes in with ED, their libido is normal, but they tell me they’re very tired all the time, they need to take naps in the afternoon, that would be a reason for me to check their testosterone, even though they may not have an issue with their libido.

MARK: And that makes sense. And I think it’s just a very helpful clarification for our listeners, and I appreciate you mentioning that other people may practice a little bit differently, but your perspective is certainly important.

As I mentioned at the beginning, one of the goals of this podcast is to empower men with good information, good education about the erection process, so they can seek out the best treatment possible. I really appreciate you joining us on the podcast. This has been extremely informative, and I have no doubt will be of extreme value to the people that are listening to our podcast.

If men wants to get in touch with you or your practice, is it okay if we go ahead and leave a link at the bottom of this podcast to get in touch?

DR. SEGAL: Yeah, by all means. I think that this is a great idea for a podcast. Men, in general, tend to not be very vocal about their symptoms.

Very often, men come in and I ask them, “Okay, well, why are you here?” And they say, “Oh, well, look, my wife told me to come.”

A lot of men are pretty stoic about their problems, whether it’s because they’re ashamed or they’re not aware of the condition or the treatments, who knows, but I think it’s great to empower people with information, and the good news is, there are treatments available for a lot of sexual dysfunction issues. And so, hopefully, by arming men with this information, it leads them to seek out the appropriate care.

My practice is in Baltimore. We have many offices, and there are experts in every office, so you can find a practitioner close to you that’ll be able to help you, for sure.

Learn more about Dr. Segal and his practice by visiting the Chesapeake Urology website.

Subscribe to our Podcast

All ED Radio Podcast episodes are available on this website, ErectionIQ.com. You can also find and subscribe to it for free on Apple Podcast/iTunes, Spotify and YouTube.

Ready to Learn More?

To start your in-depth approach to resolving ED, try our online learning course called BEYOND THE LITTLE BLUE PILL, The Thinking Man’s Guide to Understanding and Addressing ED. 

Ready to talk to an ED expert? Erection IQ founder Mark Goldberg helps men resolve erectile dysfunction. He offers individual, one-on-one services to men throughout the world through a secure, telehealth platform. It’s 100% confidential. You can visit the Center for Intimacy, Connection and Change website to
Schedule A Consultationwith Mark.