Erectile dysfunction – when more testosterone doesn’t help
By Erica Zelfand

The role of cardiovascular health on male sexual function – and what to do about it

“I’m taking testosterone and anastrazole. I’m lifting more weight than the other guys at the gym. I look amazing. I have tons of energy – so much I can’t fall asleep at night – but I still can’t get hard enough to have sex. What the @#&* is wrong with me?”

I counsel countless men* who have stories like this one.

Typically, these fellows come to see me after trying one or two “Low T” clinics and attempting various dose ranges of hormones and hormone precursors. From testosterone creams to shots, to HCG (human chorionic gonadotropin), to breast cancer drugs and beyond, hormone treatments do, indeed, help some men with erectile dysfunction – but certainly not all.

Erectile dysfunction (ED, impotence) is a fairly common medical condition, characterized by the inability to achieve and maintain a penile erection firm enough for satisfying sexual intercourse.1

I often explain to my exasperated clients with ED that testosterone is just one piece of the puzzle. Aside from hormone levels, ED can also be caused by dysfunctions in the nervous system (including mental health), in the adrenal glands, in metabolic function, and in the endothelium (the inner lining of the blood vessels). The latter is a commonly overlooked aspect of sexual health and the focus of this article.

The mechanics of erection: it’s all about blood flow

Tumescence (penile erection) is all about blood flow. During healthy sexual response, blood flows into the penis through the arteries. At the same time, there is decreased blood outflow through the veins.2,3 This circulatory one-two-punch effectively traps blood in the area, allowing for sustained erection.

The issue with ED tends to be with the first part of this process – the delivery of blood into the penis. The integrity of the circulatory system – the system of “highways” that circulates blood throughout the body – is therefore very important for male sexual performance and satisfaction.4

A key ingredient for a healthy circulatory system lies in a special little gas called nitric oxide.

Nitric oxide gets the blood flowing

Nitric oxide (NO) is a tiny gas molecule that works throughout the circulatory system, causing muscle relaxation and vasodilation (the widening of blood vessels), thus allowing for the passage of more blood.5,6 With regard to male sexual function, nitric oxide (NO) relaxes the cavernous smooth muscle of the penis, allowing for penile engorgement and subsequent erection.

NO levels can become reduced, however, by inflammation – specifically inflammation of the endothelium (lining of the blood vessels).7 Vascular inflammation and the NO deficiency it causes are also to blame for other cardiovascular problems, like angina (chest pain), heart attacks, and strokes.

Erectile dysfunction can be a warning sign of other impending diseases

The vessels of the penis are relatively small – even in “well endowed” men. Their small size as compared to other parts of the body makes the penile blood vessels relatively fragile and sensitive to injury. The penis can thus be the first place in the body where cardiovascular disease symptoms can show up. I refer to cases of ED linked with poor vascular health as “endothelial ED.”

If left untreated, the vascular inflammation and NO dysfunction associated with endothelial ED may lead to more serious cardiovascular diseases.8 Guys can develop ED before they have even so much as a high blood pressure reading!9

Angina (recurrent chest pain or tightness) is a common, unpleasant symptom of coronary artery disease. Angina is caused by the restriction of blood flow of an artery of the heart. People who experience angina are at a significantly high risk of having a heart attack or stroke.

We can think of endothelial ED as “penile angina” – a restriction of blood flow to the penis.10

A whopping 70% of men with coronary artery disease report that they had ED long before they developed any symptoms of cardiovascular disease.11 ED can therefore serve as a warning sign of poor vascular function and impending heart problems.6,11–13

ED and CAD share many of the same risk factors. All of these risk factors are also associated with poor NO activity:6,13–15

  • Obesity
  • Sedentary lifestyle
  • Smoking
  • Diabetes
  • Hypertension (high blood pressure)
  • Hyperlipidemia (high cholesterol)
  • Metabolic syndrome

NO production declines with age (as do testosterone levels), which may explain why older men tend to struggle with endothelial ED more than younger ones.16 But younger and younger guys are struggling too: 40% of men above the age of 40 are now estimated to have some degree of ED.13 While an estimated 152 million men worldwide had ED in 1995, that number is expected to swell (no pun intended) to over 320 million people by 2025.17,18

Conventional treatments of ED

Drugs like sildenafil (Viagra) and tadalafil (Cialis) are commonly used by men with ED. These drugs fall into the class of phosphodiesterase type 5 inhibitors (PDE5i)19 and serve as short-term methods to increase penile blood flow. Part of how they work, in fact, entails NO-mediated pathways,20 though these effects are transient. PDE5i’s don’t really solve the problem in the long run, though: Men need to continue taking these drugs every time they want to have sex.

When PDE5i’s fail to work, conventional medicine offers vacuum devices, injections into the penis, and prosthesis implants. None of these methods addresses the real causes of endothelial ED, however – plus they’re highly unpleasant for the patient!

As more guys develop ED, “Low T” clinics have cropped up, comprising a multi-billion dollar industry.21,22 But does testosterone replacement therapy (TRT) really solve the problem?

Won’t more testosterone help?

If the true cause of a man’s ED is low testosterone, then yes, doing things to raise sex hormone production and/or administering testosterone replacement therapy will absolutely help improve his sexual function.

Testosterone plays an important role in sexual function via several mechanisms, including the stimulation of NO release,23 but it’s unlikely to control endothelial ED on its own for very long.

For some people with endothelial ED, testosterone replacement may help, but not sufficiently unless the dosage is ramped up high – too high. Guys on too much testosterone might be happy with their sexual function, but they’ll likely complain of irritability, anxiety attacks, insomnia, or any of the other symptoms of testosterone overdose. More seriously, because of testosterone’s influences on red blood cell (RBC) production, these guys are at high risk of having too many RBCs floating around their bloodstreams, placing them at risk of life-threatening events like blood clots, chest pain, heart attacks, and strokes. While many men enjoy the increase in muscle mass that comes with testosterone, men overdosed on the hormone tend to have acne, “backne” (acne on the back), a reddish complexion, and/or a puffy appearance – effects that look handsome on just about nobody (except for maybe the Kool-Aid Man).

For other guys, though, all the testosterone in the world won’t cause a healthy erection. And that does not mean that the guy’s penis is broken. It just means that testosterone isn’t the real (or only) cause of his ED.

What to do if you have endothelial ED

If you have endothelial ED, it’s important to understand how and why your blood vessels are dysfunctional. Yes, there are of course nutritional supplements you can take to enhance nitric oxide production, but they’re unlikely to give you the best outcomes unless you’re also taking care to stop the cause(s) of your vascular inflammation. This is where diet and lifestyle become non-negotiable.

Not all guys with ED have endothelial ED, to be clear – though a whopping percentage of them do. Nevertheless, just about everyone can likely benefit from these suggestions:

Eat your veggies!

Diets rich in vegetables support heart health24,25 and lower the risks of high blood pressure, heart attack, and stroke.26–28 If you’re not eating vegetables – start eating them now. Aim for at least half of your plate at every meal to be comprised of greens (spinach, kale, chard, etc.) and/or brightly colored vegetables like purple cabbage, onions, tomatoes, carrots, red or orange bell peppers, broccoli, etc. Beets (beetroot) are particularly amazing at increasing NO levels in the body.29–31 If you often eat on the run, consider a powdered greens and/or powdered beetroot supplement, and choose organic produce whenever possible.

Enjoy berries.

Berries like blueberries, cherries, and goji berries are fantastic for vascular health because they’re rich in flavonoids and antioxidants. Antioxidants, such as those found in berries, green tea, and dark chocolate (I said dark chocolate!) can inhibit oxidative stress, heal vascular endothelial dysfunction, and ward off cardiovascular diseases (and other diseases too!).32

Steer clear of mouthwash and stomach-reducing medicines.

After you finish eating those veggies, your body will then convert the nutrients they contain into NO. In order to do this, healthy bacteria in the mouth and an acidic environment in the stomach are required.33 That’s why I recommend most people avoid antiseptic mouthwashes, as they kill the good bacteria in the mouth. I also typically advise my clients to stay away from TUMS, omeprazole (Prilosec), and other medications that dampen stomach acid production.34–36 (If you have acid reflux and think you need acid-reducing drugs, read this.)

Avoid refined sugars and refined carbohydrates.

Foods like commercial pastries, candy, candy bars, sodas, most juices, breads, pastas, cereals, crackers, and potato chips all increase blood glucose (sugar) levels and drive inflammation in the body and blood vessels. It’s no coincidence that men with diabetes and pre-diabetes are more likely to have ED than other guys.37,38

Quit smoking and drinking.

You know that smoking and drinking are harmful for your health, as does everybody else under the sun. These habits also create very high levels of inflammation and oxidative stress in the body, thus wrecking havoc on the circulatory system.8,39


Beyond blood vessel dilation, NO’s other benefits include immune function support and nervous system balancing.40 NO helps us feel more relaxed, and relaxation helps support NO production.41 Experienced meditators were found to have higher levels of NO precursors in their blood than non-meditators in one study.9

Get up off that thing!

(And dance ‘til you feel better…) A sedentary lifestyle is a significant risk factor for ED and other cardiovascular diseases,6 and the number one lifestyle factor most strongly correlated with erectile health is exercise.42,43

A review of 10 studies found that moderate to vigorous aerobic exercise (four times weekly for six months) improves erectile function in men who have ED caused by sedentary lifestyle, obesity, high blood pressure, cardiovascular disease, and/or metabolic syndrome.6

Physical activity is an effective way to prevent – and likely treat – ED because it increases NO levels and improves vascular function.43 Considering that exercise helps with a wide array of other health conditions, physical activity should be a basic treatment guideline for just about every patient.

Consult a Naturopathic Doctor (ND)

There are a variety of nutritional supplements, herbs, and natural products that can further calm endothelial inflammation and increase NO production. I strongly advise working with a naturopathic doctor (ND) or other healthcare provider trained in integrative healthcare to create a targeted treatment plan customized to your unique chemistry.


During male sexual arousal, nitric oxide delivers blood to the penis, resulting in erection. Erectile dysfunction may therefore be a symptom of poor circulatory health, high vascular inflammation, and low nitric oxide levels – all of which can predispose a man to more serious problems like heart attack and stroke. ED can therefore serve as an important warning signal of bigger problems to come – problems that may very well be avoided with proper care and treatment.

Simple, natural strategies can make all the difference – like eating green vegetables, beets, and berries; drinking green tea; avoiding antiseptic mouthwashes; finding natural ways to treat reflux instead of using stomach-acid-depleting therapies; quitting smoking; avoiding alcohol; meditating; and exercising. Working with an integrative healthcare provider who will listen to you and mindfully choose the right vascular support strategy for you will also help take your health (and sexual performance) to greater heights.

Even if you’re getting good results with testosterone replacement therapy and phosphodiesterase inhibitors, supporting your circulatory health and nitric oxide production may safeguard against more serious diseases later in life – and also make sex even more awesome!


*Please Note: The terms “man,” “guy,” “fellow,” and “male” as used within this article refer specifically to individuals who were born with a penis. I acknowledge and honor that not all men are born with this anatomy, and that not all penis-owners identify as male.



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