What are the next steps for a patient with low libido, erection issues, and changes in ejaculation, despite having normal free testosterone (FT) levels?

Management of Sexual Dysfunction with Normal Free Testosterone Levels

For patients with sexual dysfunction symptoms (low libido, erectile dysfunction, ejaculation changes) who have normal free testosterone levels, a comprehensive evaluation for other causes is necessary, as testosterone replacement therapy is not indicated.

Initial Assessment and Workup

When a patient presents with sexual dysfunction despite normal free testosterone levels, consider:

1. Rule out other hormonal imbalances:

   • Check luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to determine if there's a central vs. peripheral issue 1
   • Consider specialized testing as needed to guide treatment 1

2. Evaluate for underlying medical conditions:

   • Cardiovascular disease (ED is often an early marker of endothelial dysfunction) 2
   • Diabetes
   • Hypertension
   • Sleep apnea
   • Psychological factors (anxiety, depression, stress)

3. Medication review:

   • Antihypertensives (especially beta-blockers)
   • Antidepressants
   • Antiandrogens
   • Opioids
   • Recreational drugs and alcohol

Treatment Algorithm

First-Line Approaches:

1. Lifestyle modifications (high priority):

   • Regular exercise combining resistance and aerobic training (150 minutes weekly) 3
   • Mediterranean diet rich in fruits, vegetables, whole grains, and lean proteins 3
   • Weight loss if overweight/obese
   • Limit alcohol consumption to less than 21 units per week 3
   • Smoking cessation

2. PDE5 inhibitors:

   • First-line pharmacological therapy for erectile dysfunction 2
   • Options include sildenafil, tadalafil, vardenafil, avanafil
   • Adjust dosing based on response and side effects

Second-Line Approaches:

1. Consider selective estrogen receptor modulators (SERMs):

   • Clomiphene citrate can increase endogenous testosterone production while preserving fertility 4
   • May be beneficial in men with secondary hypogonadism and normal free testosterone
   • Response rates decrease with age and in men with chronic diseases 4

2. Psychological intervention:

   • Referral to a mental health professional to reduce performance anxiety and address relationship issues 1
   • Cognitive-behavioral therapy for sexual dysfunction

3. Vacuum erection devices:

   • Non-pharmacological option for erectile dysfunction
   • Particularly useful when PDE5 inhibitors are contraindicated

Third-Line Approaches:

1. Intracavernosal injections:

   • Alprostadil, papaverine, phentolamine (alone or in combination)
   • Higher efficacy than oral medications but more invasive

2. Intraurethral suppositories:

   • Alprostadil urethral suppository (MUSE)

Special Considerations

• Resumption of sexual activity itself may improve testosterone levels - studies show that lack of sexual activity can lead to reversible reductions in serum testosterone 5

• Age-related factors - older men may have more complex causes for sexual dysfunction and may respond less well to single interventions 4

• Cardiovascular risk - ED is a risk marker for underlying cardiovascular disease that may warrant evaluation 1

Monitoring and Follow-up

• Reassess symptoms using validated questionnaires (e.g., Sexual Health Inventory for Men, Erection Hardness Score) 1
• Follow-up within 1-3 months of initiating therapy to assess efficacy and side effects
• Consider referral to specialists (urologist, endocrinologist, sex therapist) if no improvement with initial management

When to Consider Testosterone Therapy

Testosterone therapy should only be considered if:

• Free testosterone levels fall below normal range on repeat testing
• Patient has symptoms consistent with hypogonadism
• Other causes of sexual dysfunction have been addressed

Remember that normal free testosterone levels indicate that sexual dysfunction is likely due to other factors, and testosterone supplementation is unlikely to provide significant benefit in these cases.