Impact of the association between elevated oestradiol and low testosterone levels on erectile dysfunction severity

Abstract

Our aim was to assess the impact of the association between elevated oestradiol (E 2 ) and low testosterone (T) levels on erectile dysfunction (ED) severity. A total of 614 male patients with ED and a normal or low T level in association with normal or elevated E 2 levels were enrolled. Patients underwent routine laboratory investigations in addition to measurements of total T, total E 2 , follicle-stimulating hormone (FSH), luteinizing hormone (LH) and prolactin. We compared the responses to the erectile function domain, Q3 (achieving erection) and Q4 (maintaining erection) of the International Index for Erectile Function (IIEF) score in patients with the following: normal T and E 2 levels; low T level; low T level and elevated E 2 level; and elevated E 2 level. Of the patients included, 449 (73.1%) had normal T and E 2 levels, 110 (17.9%) had a low T level, 36 (5.9%) had a low T level and an elevated E 2 level, and 19 (3.1%) had an elevated E 2 level. Increased ED severity was significantly associated with low T levels, elevated E 2 levels, and both a low T level and an elevated E 2 level. Additionally, the mean values of the EF-domain, Q3 and Q4 were significantly lower in patients with both a low T level and an elevated E 2 level compared to patients with any condition alone.In conclusion, a low T level had the primary effect on erectile function; however, a concomitantly elevated E 2 level had an additive impairment effect. Keywords: erectile dysfunction (ED); hypogonadism; testosterone; oestradiol INTRODUCTION A diminution in testicular function with a consequence of testosterone (T) depletion is a common occurrence in older men. 1,2 The multi-factorial mechanisms of this phenomenon, which involve the hypothalamic-pituitary-testicular axis, have been reported. 3 Several studies have demonstrated that T has substantial effects on cavernosal tissues and that T deficiency impairs the anatomic and physiological substrates of erectile capacity that could be partly reversed upon androgen replacement. 4,5 Oestradiol (E 2 ) possesses an opposing functional role of T; therefore, a decline in the T level will affect its physiological balance with E 2 in men. 6 As a consequence, a high E 2 level, which has a strong gonadotropin suppressive effect, may lead to secondary hypogonadism in the ageing male. 7 Despite the concomitant elevation of E 2 in hypogonadal men, the information available on the physiological role of E 2 in erectile function is insufficient to correlate the aetiology of erectile dysfunction (ED) to a high E 2 level. 8 The likelihood of E 2 affecting the T balance and the independent effect of E 2 on erectile function have not been well evaluated. 9 Furthermore, although the association between ED severity and the prospective decrease in testosterone has been investigated, 10 the impact of an elevated E 2 level on ED severity has not been well addressed. The current study was designed to assess the impact of an association between an elevated E 2 level and a low T level on ED severity.

The CATCH checklist to investigate adult‐onset hypogonadism

“…Estrogens have an important role in the regulation of gonadotropin feedback, reducing LH and FSH (Finkelstein et al ., ). An inappropriate increase in estradiol (E2) can induce a decrease in testicular volume, impaired spermatogenesis, and sexual dysfunction (El‐Sakka, ; Schulster et al ., ). Moreover, estradiol too has effects on the body fat mass and sexual function.…”

The role of estradiol in male reproductive function

“…In addition, increased severity of ED, assessed with the International Index for Erectile Function, 48 in men with low testosterone levels is worsened with high estrogen levels implying an additive effect by the two hormones. 49 However, while low testosterone increases the incidence of ED, elevated estrogen levels do as well. 40 This point, coupled with the fact that the corpus cavernosum vasculature and urothelium have extensive ERs, significantly more than other steroid receptors, and particularly around the neurovascular bundle, suggests mechanisms of ED separate from and in addition to central testosterone inhibition.…”

Psychobiological Protective Factors Modifying the Association Between Age and Sexual Health in Men: Findings From the Men’s Health 40+ Study

“…Besides vascular or neurogenic causes, hormonal factors seem to play a major role in the development and maintenance of ED ( Mola, 2015 ). Higher levels of testosterone (T) and dehydroepiandrosterone (DHEA) as well as estradiol (E2) have been reported to be associated with better overall sexual function and less ED in different age groups ( Finkelstein et al, 2013 ; Luo et al, 2015 ; Rabijewski, Papierska, Kuczerowski, & Piątkiewicz, 2015 ), although there is conflicting literature on the association between E2 and ED ( El-Sakka, 2013 ; O’Connor et al, 2011 ; Vignozzi et al, 2014 ). A recent study reported that changes in T and E2 levels in response to T treatment were associated with improvements in sexual activity and sexual desire, but not erectile function in older men ( Cunningham et al, 2016 ).…”