What could be causing my reduced arousal, weaker erectile function, weaker orgasm contractions, and very low semen output?

Evaluation and Management of Combined Sexual Dysfunction Symptoms

Your constellation of symptoms—reduced arousal, weaker erectile function, weaker orgasm contractions, and very low semen output—requires a systematic evaluation starting with morning testosterone level, thyroid function tests, and a thorough medication review, as these symptoms strongly suggest either hypogonadism, medication-induced sexual dysfunction, or an underlying chronic illness affecting the hypothalamic-pituitary axis. 1

Initial Diagnostic Approach

Check morning total testosterone level first—if below 300 ng/dL, this explains your entire symptom complex and testosterone replacement therapy should be considered. 1 The combination of reduced libido, erectile dysfunction, and orgasmic/ejaculatory problems is the classic triad of hypogonadism. 1

Key Laboratory Tests

• Morning total testosterone (most critical—must be drawn before 10 AM) 1
• Thyroid function tests (TSH, free T4) 1
• Hemoglobin A1c and fasting lipids (diabetes and vascular disease commonly cause this symptom pattern) 1
• Liver function tests if you have any risk factors for liver disease 1

Critical History Elements to Assess

Medication review is essential—the following drugs commonly cause your exact symptom pattern: 1

• SSRIs/SNRIs (paroxetine, sertraline, fluoxetine, venlafaxine)—these are notorious for causing all your symptoms
• Spironolactone—causes hypogonadism and sexual dysfunction
• Beta-blockers—impair erectile function and orgasm
• Antipsychotics—suppress testosterone via prolactin elevation
• Opioids—cause severe hypogonadism

Alcohol use must be quantified—excess alcohol directly suppresses the hypothalamic-pituitary axis and causes the exact symptoms you describe. 1

Underlying Medical Conditions to Consider

Chronic Liver Disease

If you have any liver disease risk factors (alcohol use, hepatitis, fatty liver), this could explain everything. In men with advanced liver disease, low testosterone results from hypogonadotropic hypogonadism with increased peripheral conversion of androgens to estrogen, contributing to erectile dysfunction, oligospermia (low semen volume), and reduced libido. 1

Diabetes and Vascular Disease

Autonomic dysfunction from diabetes causes erectile dysfunction and ejaculatory problems through both vascular and neurologic mechanisms. 1 Cardiovascular disease decreases penile blood flow, impairing both erections and orgasmic intensity. 1, 2

Age-Related Changes

Age-related penile hypoanesthesia can cause delayed ejaculation, weaker orgasms, and reduced ejaculatory volume—this is a normal aging process but can be managed. 1, 3

Treatment Algorithm Based on Findings

If Testosterone <300 ng/dL:

Testosterone replacement therapy is indicated and will likely improve all your symptoms. 1 This addresses the root cause of hypogonadotropic hypogonadism affecting libido, erectile function, and orgasmic intensity. 1

If Medication-Induced:

Suggest replacement, dose adjustment, or staged cessation of offending medications. 1 For SSRI-induced dysfunction specifically, switching to bupropion (which enhances rather than impairs sexual function) is a proven strategy. 1

If Erectile Dysfunction is Present:

Treat with PDE5 inhibitors (sildenafil, tadalafil, vardenafil) as first-line therapy—these improve erectile rigidity and can also enhance orgasmic intensity. 1 The improved erectile function often secondarily improves orgasm quality. 1

For Orgasmic/Ejaculatory Component:

Behavioral modifications should be implemented first: 1

• Modify sexual positions or practices to increase arousal
• Incorporate alternative sexual practices or enhancement devices
• Increase physical and psychological stimulation

If behavioral approaches fail, consider pharmacotherapy: 1

• Pseudoephedrine 60-120 mg taken 120-150 minutes before sex (enhances sympathetic tone for ejaculation)
• Oxytocin 24 IU intranasal during sexual activity (enhances orgasmic contractions)
• These are off-label uses with limited but physiologically rational evidence

Psychological Factors

Referral to a mental health professional with sexual health expertise is appropriate if: 1

• Psychogenic factors are suspected (performance anxiety, relationship issues)
• Depression or anxiety symptoms are present
• Behavioral interventions alone are insufficient

Common Pitfalls to Avoid

Do not assume this is "just psychological" without checking testosterone—hypogonadism is extremely common and treatable. 1

Do not overlook medication side effects—this is one of the most common and reversible causes of your symptom pattern. 1

Do not treat erectile dysfunction alone without addressing the orgasmic/ejaculatory component—these often require separate interventions. 1

Avoid surgical interventions or unproven "regenerative" therapies—these lack FDA approval and robust clinical data. 1

Specialist Referral Indications

Refer to urology or sexual medicine specialist if: 1

• First-line treatments fail
• Testosterone replacement is contraindicated or ineffective
• Complex medication interactions exist
• Penile prosthesis or advanced interventions are being considered