April 15, 2020
Erectile dysfunction may be an early warning sign of broader health problems. That’s the suggestion from a new retrospective analysis of European men, which found that erectile dysfunction and other sexual symptoms were associated with a greater risk of death, independent of testosterone levels.
Similar studies have shown links between mortality and sexual dysfunction, or between mortality and testosterone level, but the current study is unique, Leen Antonio, MD, PhD, assistant professor of endocrinology at Katholieke Universiteit Leuven (Belgium), said in a presentation during the annual meeting of the Endocrine Society, which was presented online this year. The actual meeting, scheduled for March 28-31 in San Francisco, was canceled because of COVID-19 concerns.
“It’s the first time we have put both together in the same group of people, and we can say that it’s mostly the sexual symptoms that are predicting the mortality risk, independent of the testosterone levels of these men,” Dr. Antonio said in an interview.
“We can regard sexual symptoms as a marker for adverse health status in general. It’s like a warning signal that you’re at risk for more severe problems,” Dr. Antonio added.
Dr. Antonio advised clinicians to test blood pressure and cholesterol levels in men presenting with sexual dysfunction and to counsel lifestyle changes, such as physical activity and weight management. “These can be beneficial for sexual symptoms and for general health and the risk for cardiovascular disease in the future.”
Although the study could not identify a reason for the relationship between sexual dysfunction and mortality, Dr. Antonio hypothesized that the narrow penile artery may be more likely to suffer noticeable effects in the early stages of atherosclerosis, before clinical effects occur in the coronary artery.
Michael Blaha, MD, professor of medicine and director of clinical research at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University, Baltimore, who has studied erectile dysfunction (ED) and its association with cardiovascular disease, said that the study is further evidence that ED is an important and independent risk factor for cardiovascular disease and other health risks. He would like to see a move toward establishing men’s health clinics, where risk factors can be identified and mitigated through lifestyle changes and therapies.
“There needs to be a complete rethink of the way we approach the whole group of patients who present with erectile dysfunction to various specialists,” he said in an interview, noting that middle-aged men often present to ED specialists after years of not having any contact with the health system. In that group, ED can be an early warning sign that could trigger broader interventions.
“This points to the need for more men’s health clinics that are focused on the early detection of risk factors, and treating erectile dysfunction and other risk factors in a more comprehensive way,” said Dr. Blaha, who was not associated with the study.
Dr. Antonio and colleagues studied 1,913 community-dwelling men, who participated in the European Male Ageing Study. Baseline information on sexual function and testosterone levels was collected between 2003 and 2005. The men were aged 40-79 years at study entry, and “because of the wide age range at study entry, age was used as time scale, instead of years since inclusion adjusting for age,” the researchers explained.
Over a mean follow-up of 12.4 years, 25.3% of participants died. Body mass index was higher in men who died (P = .002), but there was no significant difference in smoking status. Both groups had similar levels of total testosterone, but free testosterone was lower in the deceased population (270 pmol/L vs. 312 pmol/L; P < .001), whereas luteinizing hormone levels were higher (7.8 units/L vs. 5.7 units/L; P < .001). The lowest quartile of free testosterone level was associated with higher mortality risk (hazard ratio, 1.43; P = .021), whereas the highest quartile of follicle-stimulating hormone was associated with greater mortality risk (HR, 1.38; P = .036). There was no association between mortality risk and total testosterone or estradiol.
Men reporting three sexual symptoms at baseline had a higher mortality risk than those reporting no symptoms (HR, 1.77; P < .001). There was an association between mortality risk and ED (HR, 1.40; P = .001) and poor morning erections (HR, 1.30; P = .012), but not low libido. The associations were not affected after adjustment for total testosterone or free testosterone. Among men with normal total testosterone (>12 nmol/L), sexual symptoms were associated with heightened mortality risk (HR, 1.51; P = .003), and the same was true in men with total testosterone levels of less than 8 nmol, compared with men with normal total testosterone who reported no sexual symptoms (HR, 1.92; P = .035).
The European Male Ageing Study received support from the European Union. Dr. Antonio has no relevant financial disclosures. Dr. Blaha has received grants from Amgen and is on advisory boards for Amgen and other pharmaceutical firms. Dr. Antonio and her team’s research will be published in a special supplemental issue of the Journal of the Endocrine Society. In addition to a series of news conferences on March 30-31, the society will host ENDO Online 2020 during June 8-22, which will present programming for clinicians and researchers.