Excerpt from the book: Testosterone: A Man’s Guide

Most men find that their sexual desire increases after they start testosterone replacement. Sexual dreams and nighttime/morning erections may be more easily achievable, but in some cases testosterone alone does not make erections strong or lasting enough for successful intercourse. So, some men need some extra help to make sure that their improved sex drive matches an improved and hard erection.

Before we start covering other options for improving erections, let’s talk about steps you should take before you start combination therapy of testosterone plus other options. If erectile dysfunction or sex drive is not improved while on testosterone, ask your doctor about adjusting your dose of testosterone. Ensure that your total testosterone level is between 500 and 1000 ng/dL. Also, have your doctor check your blood levels of estradiol and prolactin. High estradiol blood levels caused by conversion of testosterone into this female hormone by the aromatase enzyme may cause sexual dysfunction (this can be treated with low dose anastrozole). So is high prolactin’s effect on erectile function. Low levels of thyroid hormone, infections, lack of sleep, alcohol, smoking, medications and depression also can cause erectile dysfunction in the presence of normal testosterone levels. Blood pressure medications are known to be one of the main causes of erectile dysfunction, so discuss the different type of medications to keep your blood pressure in normal ranges (high blood pressure is also a risk factor for erectile dysfunction). Last but not least, lack of attraction for our sexual partner can get in the way of achieving a strong erection. 

If high estradiol of over 40 pg/dl is found (by ultrasensitive testing), then anastrozole at 0.1-0.5 mg three times a week may be enough to bring it down to healthy levels. Remember that estradiol is important for men to keep healthy skin, hair, and brain function. High prolactin can be treated with cabergoline.

HCG

As mentioned before,human chorionic gonadotropin (HCG) mimics LH and stimulates the Leydig cells of the testicles to produce testosterone. HCG has been successfully used alone or in combination with testosterone replacement to normalize testicular size after long term anabolic steroid or testosterone use. It has also anecdotally helped men whose sexual drive does not improve on testosterone replacement alone. No published studies have been done on this benefit,however. Doses of 250-500 IU twice a week while on testosterone replacement are being prescribed by several physicians who report that their patients perceive improvements in sexual desire and erectile function on this regimen. We do not know if this effect lasts after long term HCG use or if it is better to cycle it on and off. 

Click here to hear Dr Saya discuss HCG:

PD-5 Inhibitors

For many older men the use of prescription phosphodiesterase type 5 inhibitor (PD-5) medications like Viagra, Cialis, and Levitra—may be needed in combination with testosterone replacement. However, some men do not respond well to these oral agents or have side effects such as headaches,nasal congestion, flushing,gut problems, and, in the case of Cialis, back pain. Cialis may last longer than the others (36 hours compared to 4 hours for Viagra or Levitra), but so may its side effects. Some men take Claritin and ibuprofen with these drugs to pre-treat nasal congestion and headaches, respectively.

Sildenafil (Viagra) was the first PDE5 inhibitor to enter on the market in 1998. The usual dose of sildenafil is 50 mg (25 to 100 mg) taken one hour before sex. The effects of sildenafil last for approximately four hours, and patients should be instructed to use no more than one dose within 24 hours. Fatty meals reduce the absorption of sildenafil; therefore, the drug should be taken on an empty stomach. This maybe an inconvenient factor that needs careful planning of which some patients are not aware.

Vardenafil (Levitra), the first second-generation PDE5 inhibitor to be developed, is given at a usual dose of 10 mg (2.5 to 20 mg) one hour before sex. Older men and those with moderate liver dysfunction should receive a lower initial dose of 5 mg. Vardenafil begins working within 30 to 45minutes after administration and lasts for about four hours. As with sildenafil, patients taking vardenafil should not use more than one dose within a 24-hour period. Patients should not take vardenafil within three hours of fatty meals, due to a reduction in absorption.

The newest PDE5 inhibitor is tadalafil (Cialis),which has a longer duration of action–approximately 36 hours–than sildenafil or vardenafil. In addition, the usual dose of 10 mg (5 to 20 mg) should be taken about 30 minutes before sexual activity. This shorter onset time can possibly allow patients more opportunity for spontaneity. Food intake does not appear to affect the absorption of tadalafil; this makes it very practical for men who do not plan ahead when they have sex. Cialis is approved for low dose daily use, but most insurance companies will not pay for it. If you want to try a 5 or 10 mg dose daily, you can get a free 30 day supply after getting a doctor’s prescription and taking the following voucher to your pharmacy after downloading it and printing it (you have to answer some questions online first). You are better off asking your doctor for a prescription for 10 mg per day and cut the pills in half for the first week to see if 5mg per day works well enough for you. If not, you can go up in dose.Here is the web site address to download the voucher:

Do you pay too much for Viagra and Cialis?

Both medications can be made into a tablet, capsule, or flavored sublingual troche. We have found that a combination of Sildenafil (Viagra) and Testosterone in Troche form works very well for both Men and Women who are seeking to improve their sexual performance.

Receive 3 free Viagra or Cialis with any order over $100.

  • Sildenafil 110mg (Viagra)- $9.00

  • Tadalafil 25mg (Cialis)- $10.00. 

Contact Defy Medical to request your prescription.

Though considered generally safe for most patients,including those taking multiple antihypertensives, PDE5 inhibitors are not a viable treatment option for every man with ED. They need to be used with careful monitoring in patients with a cardiovascular history that includes heart attacks or stroke (within the past two weeks) and hypotension (blood pressure <90/50 mmHg), Because PDE5 is inhibited in penile tissue as well as extra genital tissue, patients treated with PDE5 inhibitors may experience headache, facial flushing, nasal congestion, dyspepsia, and dizziness. Sildenafil also inhibits PDE type 6 in the retina.Therefore, patients treated with sildenafil may experience sensitivity to light, blurred vision,and loss of blue-green color discrimination, all of which are generally considered reversible. Tadalafil also inhibits PDE type 11 in skeletal tissue,possibly leading to back and muscle pain.

ED drugs are available by prescription and can be purchased at low cost through compounding pharmacies.  These pharmacies are able to make generic versions of these medications at a fraction of brand name cost. 

The following table shows how long each commercially available PD-5 drug starts working and how long they stay in your body. These numbers vary depending on the amount of food or alcohol you ingest before taking them, your body weight, and your liver metabolism.

If you are older than age 65, or have serious liver or kidney problems, your doctor may start you at the lowest dose (25 mg) of Viagra or any of the other two drugs.

Tell your doctor about all the medicines you take. ED drugs and other medicines may affect each other. Especially tell your doctor if you take any of these:

  • Medicines called alpha-blockers. These include Hytrin® (terazosin HCl), Flomax® (tamsulosin HCl), Cardura® (doxazosinmesylate), Minipress® (prazosin HCl), Uroxatral® (alfuzosin HCl), or Rapaflo® (silodosin). Alpha-blockers are sometimes prescribed for prostate problems or high blood pressure. In some patients the use of PDE5 inhibitor drugs with alpha-blockers can lower blood pressure significantly, leading to fainting. You should contact the prescribing physician if alpha-blockers or other drugs that lower blood pressure are prescribed by another healthcare provider
  • HIV protease inhibitors including Ritonavir (Norvir®) or indinavir sulfate (Crixivan®), saquinavir (Fortavase® or Invirase®) or atazanavir (Reyataz®)
  • Antifungals like ketoconazole or itraconazole (such as Nizoral® or Sporanox®)
  • Antibiotics like erythromycin or clarithromycin
  • Tell your doctor if you take medicines that treat abnormal heartbeat. These include quinidine, procainamide, amiodarone, and sotalol. Patients taking these drugs should not use ED drugs.

If you are taking HIV protease inhibitors your doctor may recommend the lowest dose of each ED drug to start with and work your way up if the starting dose does not provide the desire benefits.Norvir, part of HIV protease inhibitor regimens, can boost blood levels of Ed drugs by slowing down the liver’s clearance of those drugs, so lower doses are needed to achieve the desired effect with the fewest side effects.

In rare instances, men taking PDE5 inhibitors have reported a sudden decrease or loss of vision. It is not possible to determine whether these events are related directly to these medicines or to other factors. If you experience sudden decrease or loss of vision, stop taking PDE5 inhibitors and call a doctor right away.

Sudden decrease or loss of hearing has been rarely reported in people taking PDE5 inhibitors. It is not possible to determine whether these events are related directly to the PDE5 inhibitors or to other factors. If you experience sudden decrease or loss of hearing, stop taking the oral ED drug and contact a doctor right away.

If you have prostate problems or high blood pressure for which you take medicines called alpha blockers, your doctor may start you on a lower dose of ED drugs.

People who use recreational drugs called “poppers” like amyl nitrite and butyl nitrite should be careful while using ED drugs since a sudden decrease in blood pressure can occur.

Part 2: Check out our next newsletter which will feature more options available to treat ED.  Other options: penile injections and over the counter devices.  All articles are also archived here:

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