Evaluation and Management of Low Libido, Erectile Dysfunction, and Perceived Testicular Changes with Normal Hormone Levels
Your Symptoms Point to Non-Hormonal Causes
With normal total testosterone (40 nmol/L ≈ 1154 ng/dL), normal LH, FSH, and sperm count, your sexual dysfunction is not caused by testosterone deficiency and requires investigation of cardiovascular, psychological, and lifestyle factors. 1, 2
Your testosterone level is well above the threshold for hypogonadism (300 ng/dL or ~10 nmol/L), making hormonal causes extremely unlikely. 3
Immediate Cardiovascular Risk Assessment Required
Erectile dysfunction at any age serves as a sentinel marker for underlying cardiovascular disease and predicts future cardiac events with strength comparable to smoking or family history of myocardial infarction—you need comprehensive cardiovascular evaluation now. 1, 4
Essential screening tests:
- Fasting glucose or HbA1c to screen for diabetes 4, 2
- Complete lipid panel (total cholesterol, LDL, HDL, triglycerides) 1, 4
- Blood pressure measurement 4
- Assessment for metabolic syndrome 4
ED can precede coronary artery disease symptoms by 2–5 years, making this evaluation urgent even without cardiac symptoms. 1, 4
Psychological and Relationship Factors Assessment
Screen immediately for depression, anxiety, performance anxiety, and relationship conflicts—these are common causes of both low libido and ED when testosterone is normal. 3, 1, 2
Key clinical indicators of psychogenic causes:
- Presence of morning or nocturnal erections suggests psychogenic component 1, 2
- Preserved masturbatory erections point toward psychological rather than organic dysfunction 1
- ED occurring only with specific partners or contexts indicates psychogenic etiology 1
Depression is both a cause and consequence of erectile dysfunction, with worsening depressive symptoms often preceding ED onset. 4
Medication and Substance Use Review
Conduct thorough review of all medications and substances, as antidepressants, antihypertensives (especially β-blockers), and tobacco use are the most common pharmacologic causes of ED and decreased libido. 3, 4, 5
Common culprits include:
- SSRIs and tricyclic antidepressants 4
- β-blockers, diuretics, ACE inhibitors 4
- Tobacco (major modifiable risk factor) 1, 5
- Excessive alcohol consumption 4
Testicular Changes Explained
Your perceived testicular shrinkage and loss of cremasteric reflex (tightening during erections) are not explained by your normal testosterone, LH, FSH, and sperm count—these findings suggest either normal anatomic variation, anxiety-related hypervigilance, or unrelated scrotal pathology requiring physical examination. 3, 2
With normal hormonal parameters and sperm production, true testicular atrophy is not occurring. 3 Physical examination by a physician is warranted to rule out varicocele, hydrocele, or other structural abnormalities. 3
First-Line Treatment: Lifestyle Modifications
Initiate aggressive lifestyle interventions immediately: smoking cessation (reduces total mortality by 36% in men with coronary disease), weight loss if BMI >30 kg/m², regular physical activity, reduced alcohol consumption, and optimization of cardiovascular risk factors. 1, 4, 5
These modifications improve endothelial function and erectile capacity independent of medication. 1, 4
Pharmacologic Treatment with PDE5 Inhibitors
Prescribe a phosphodiesterase-5 inhibitor (sildenafil, tadalafil, vardenafil, or avanafil) as first-line pharmacotherapy after cardiovascular risk stratification confirms low or intermediate risk. 3, 1, 4
Critical counseling points:
- Sexual stimulation is necessary for PDE5 inhibitors to work 4
- At least 5 attempts at maximum tolerated dose should be made before declaring treatment failure 1, 4
- PDE5 inhibitors are effective in 60–65% of men with ED 4
- These agents work for both psychogenic and organic ED 1
Contraindications and warnings:
- Absolute contraindication with nitrate use (must wait 48 hours after tadalafil before nitrate administration) 6
- Caution with cardiovascular disease, recent MI, unstable angina, uncontrolled hypertension 7, 6
- Risk of visual disturbances and sudden hearing loss (rare but serious) 7, 6
Your normal testosterone level means PDE5 inhibitors should have full efficacy without need for hormonal supplementation. 1, 4
When to Consider Psychosexual Therapy
Refer for cognitive-behavioral therapy or psychosexual counseling when psychological factors are identified—this should be offered as adjunct to medical treatment, not as replacement. 1, 4
Partner involvement in treatment decisions improves outcomes. 4
Second-Line Options if PDE5 Inhibitors Fail
If two different PDE5 inhibitors at maximum dose fail after adequate trials (minimum 5 attempts each), refer to urology for second-line therapies: intraurethral alprostadil suppositories, intracavernosal injection therapy, or vacuum erection devices. 1, 4
Penile prosthesis implantation is reserved for medical therapy failures. 1, 4
Critical Pitfalls to Avoid
Do not assume normal testosterone rules out all endocrine causes—check free testosterone or sex hormone-binding globulin if symptoms persist despite normal total testosterone, as this can prevent unnecessary investigation in up to 50% of men. 2
Do not treat ED without addressing cardiovascular risk—communication of cardiovascular risk to your primary care provider is mandatory for appropriate referrals. 1, 4
Do not delay evaluation assuming symptoms are "just psychological"—even psychogenic ED responds to PDE5 inhibitors and should be treated concurrently with counseling. 1
Do not consider testosterone supplementation—with testosterone of 40 nmol/L (~1154 ng/dL), supplementation provides no benefit and carries risks including suppression of your normal sperm production. 3, 8