Given the association between depression, erectile dysfunction (ED) and low testosterone levels, it often is worthwhile to screen men with depression for ED - and vice versa - and to supplement their testosterone if tests show it is low, according to two UCLA experts. Between the ages of 45 and 55, some men may develop what has become known as manopause - also called andropause. Their testosterone levels may begin to decline, reducing their sex drive and in some cases their sexual function. It is also a period when many men experience depression. "We know that low testosterone can cause both depression and ED," says UCLA urologist Jacob Rajfer, M.D. "Depression can also lower testosterone and sexual interest. It's not always clear what's causing what, but as urologists we approach it the same way regardless of which came first."
If a patient presents with depression and low testosterone but normal sexual function, Dr. Rajfer says he refers him first to a mental-health expert for evaluation. But for patients with depression, low testosterone and ED, he recommends three months of hormonal treatment. "I will know within those three months whether the testosterone level was the cause of the depression and ED," he says.
"Even though we don't always know which came first, the lower testosterone or the depression, I treat both," says UCLA endocrinologist Stanley Korenman, M.D. "Raising testosterone levels may improve erectile function, and it has the added benefit of enhancing mood."
Dr. Rajfer points out that as men age, many experience ED and declining testosterone. But for most, replenishing their testosterone will not solve the ED. "In many men, it appears that other things are going on when low testosterone and ED intersect," he says.
In fact, notes Dr. Korenman, low testosterone is a primary cause of erectile dysfunction in only 10-to-20 percent of cases. The most common cause of ED is vascular, usually related to coronary-artery disease. The next leading cause is psychogenic (typically depression or anxiety) followed by neurological issues, such as from multiple sclerosis, spinal-cord injuries, chronic back pain or from a procedure that affected local nerves.
Both depression and manopause syndrome, though, are characterized in part by a reduced interest in sex. "Depression tends to be expressed differently in men than in women," says Dr. Korenman. In some of his patients, he explains, ED is the most prominent depression symptom, and in many of these cases, testosterone is also low. "They may still be able to have intercourse, but they are less interested and their erections don't last as long, or are not as full," Dr. Korenman says.
In general, Dr. Korenman considers testosterone to be low if it is below 300 ng/dL on two occasions, measured in the morning when the patient is fasting. Whether testosterone replacement is indicated depends on the man's age and interest in reproduction. The vast majority of men who are treated with testosterone will become infertile; for men who want to remain fertile, an agent that stimulates testosterone production can be used.
When ED is part of the picture, Drs. Korenman and Rajfer will include a phosphodiesterase inhibitor such as sildenafil along with the testosterone and depression treatment. "As patients improve, you can begin to take things away," Dr. Korenman says, noting that many patients would prefer not to use oral medications if they are able to obtain spontaneous erections. Because the oral ED medications are most effective when testosterone levels are normal, Dr. Rajfer notes, providing the pill without treating the testosterone in a patient with a low testosterone level is less likely to achieve the desired result.
Dr. Korenman says physicians who are uncomfortable talking with their patients about sexual matters or treating them with testosterone should consider referral to a specialist with that interest or expertise.