Tag: obesity

Common and Uncommon Threats to Men’s Sexual Health

3 Common—and 4 Uncommon—Risks to Men’s Sexual Health

You might know some of these threats to your sexual well-being. Others might surprise you.

Author: Kurtis Bright
Published: March 22, 2023

This article is a repost which originally appeared on Giddy

Edited for content. The opinions expressed in this article may not reflect the opinions of this site’s editors, staff or members.

Key Points

‧ Sexual health information is more abundant and easier to access than ever.

‧ Ironically, men are at a greater risk of diseases caused by excess and poor lifestyle choices than ever.

‧ ED is a notorious side effect of common ailments like diabetes and poor cardiovascular health.

Sexual health information is everywhere these days, both quality info and the not-so-high-quality kind that’s widespread on social media platforms. Even with all this access to so much information, though, certain lesser-known threats to our sexual health and fertility may slip under the radar.

At the same time, the seriousness of certain sexual health risks that “everyone knows about” may go ignored.

Here are three of the more common risks to men’s sexual health and fertility, as well as a handful of risks that aren’t always recognized as threats.

What are the biggest risks to men’s sexual health?

When we talk about threats to sexual health, we’re often talking about systemic problems. That is to say, if you’re having a problem with how your penis works, it’s not necessarily about your penis.

In modern society, we tend to view medicine as slapping on a bandage or taking a pill to alleviate the most obvious symptom we can see. In reality, lots of problems you might have in other parts of your body can affect how your penis functions.

“Sexual health is health,” said Justin Dubin, M.D., a urologist and men’s health specialist with Memorial Healthcare System in South Florida. “So sexual health problems, in general, can be a warning sign or a result of other health issues: diabetes, heart issues, infections, depression, anxiety, testosterone issues, obesity, other lifestyle issues—you name it. Having ED is the canary in the coal mine.”

Common sexual health issues

Three of the most common issues that can affect sexual health are cardiovascular disease, obesity and diabetes. They work against us in different ways.

Cardiovascular disease

Heart disease and vascular problems are strongly associated with erectile dysfunction (ED). A vital component of getting an erection is good blood flow to the penis, and issues such as atherosclerosis and high blood pressure hamper it.

Obesity

Obesity is a big risk factor for ED. One study indicated 79 percent of men who presented with ED were clinically obese, and obesity hampers your heart’s ability to pump blood. Plus, it’s a comorbidity for another risk factor, diabetes.

Diabetes

Diabetes causes a condition called diabetic neuropathy, which affects nerve endings and can result in numbness, tingling and loss of sensation. Along with blood flow, nerves are crucial for the penis to receive the signals from the brain and nervous system to get erect.

“You need to have good nerves in your penis,” Dubin said. “People [with diabetes] who have bad sensation in their feet or fingers or their eyesight, well, the nerves in the penis are very small as well, and poorly controlled diabetes can cause ED.”
Less common risks to sexual health

Four of the less obvious issues that can affect your sexual health include smoking, sexually transmitted infections (STIs), Peyronie’s disease and mental health.

Smoking

The dangers associated with smoking often focus on the lungs and heart, and rightly so. However, a lesser-known effect of smoking is that it’s associated with ED.

“Smoking and ED are linked to overall cardiovascular health,” said Neel Parekh, M.D., a men’s fertility and sexual health specialist with Cleveland Clinic. “It’s associated with cardiovascular disease, so that’s another reason why it can make it more difficult to achieve an erection. It can even affect fertility; smoking has a negative effect on how well the sperm swim.”

Indeed, according to some studies, smoking has a negative impact on semen parameters. Luckily, other studies show that quitting can greatly improve them in a short amount of time.

STIs

When it comes to fertility, another little-known issue some guys may encounter is that sexually transmitted infections can affect your sperm. An STI can travel up the urinary tract and cause problems in the rest of your reproductive system in ways that may affect you long after you’ve taken your antibiotics and the symptoms have gone away.

“Chlamydia and different bacterial infections can lead to epididymitis—the inflammation of the epididymis—which is where sperm is stored,” Parekh said. “These STDs can cause scarring of the epididymis or vas deferens and cause blockages for guys, preventing sperm from traveling through.”

Peyronie’s disease

Another issue that can fly under the radar is Peyronie’s disease. It’s a buildup of fibrous plaque or scarring in the penis that may result in a lump or new curvature that wasn’t there before. It’s thought to affect 1 in 10 men and may come on suddenly due to overenthusiastic sexual activity or over time through buildup. It can also cause erections to be painful during the acute phase.

“Peyronie’s disease is another uncommon disease that some guys will let go unchecked,” Parekh said. “A painful lump in the penis can lead to worsening curvature to the point where they can’t penetrate. Some guys will kind of ignore it for a while; maybe they’re embarrassed by it and they don’t want to tell anybody.”

Mental health

It’s an old trope: The biggest sex organ in the body is the brain. If your emotional state isn’t good, it can have a profound impact on sexual function.

Don’t forget that some antidepressants have a negative effect on sexual function, too, so it’s important to talk with your healthcare provider and make sure you address both mental health and sexual health.

“Mental health is health, too, just like sexual health,” Dubin said. “Depression, anxiety and medications that treat depression and anxiety can cause ED. I always quote the great Robin Williams: ‘God gave man a brain and a penis, and only enough blood to control one at a time.’ So if you’re up in your head, your penis is just not going to work. It’s just not.”

Conclusions

A wide variety of health issues can affect your sexual health and fertility. But perhaps the main takeaway should be that instead of trying to list all the possible factors that could specifically affect your penis, try to remember that the penis is just one part of the intricate and complex machine that is your body. Mess with one part of the network and it’s likely to have downstream effects. Take care of your body, and it’ll take care of you.

If your overall health is solid but erectile dysfunction is an issue, even intermittently, a wearable device free of the side effects of popular medications can restore sexual function. Eddie® is an FDA-registered Class II medical device designed to treat erectile dysfunction and improve male sexual performance. Its urologist-designed shape and fast-acting results allow you to treat your ED with more control. With Eddie, you don’t need to wait for a pill to kick in, use an awkward pump or subject yourself to painful injections.

In 2021 clinical trials, 95 percent of men who used Eddie reported a positive effect on their sex life.

anti-depressants chlamydia diabetes ED Eddie FDA-registered Class II medical device mental health neuropathy obesity peyronie's disease smoking STDs stis

Unhealthy habits that affect men’s sexual health; ways to bid them goodbye

Men’s fertility health is as important as women’s reproductive health. Apart from contributing towards a healthy pregnancy, it also keeps men’s overall health fine and free of diseases. Read on to know what unhealthy hay habits which lead to sexual disorders in men and how you can treat them.

Authored by: Ashima Sharda Mahindra

Updated Dec 11, 2022 | 01:32 PM IST

This article is a repost which originally appeared on TIMES NOW.

Edited for content. The opinions expressed in this article may not reflect the opinions of this site’s editors, staff or members.

Key Points

‧ There are many things one can do to improve sexual performance.

‧ A leaner body composition will usually result in better performance.

‧ Engaging in better habits- like more foreplay; and decreasing negative habits- like alcohol consumption- will improve potency.

New Delhi: Many times, sexual disorders in men are equated with their masculinity. Time and again the myth has been debunked by doctors since the stigma does not let men openly talk about and seek help regarding sexual issues they face.

Across the world, men suffer from various sexual and fertility disorders that make them prone to stress, depression, and other mental as well as physical health issues, including infections, kidney failures, and even fatal diseases like cancers.

What are male sexual disorders?

According to Cleveland Clinic, sexual dysfunctions can affect men of all ages but is especially common in older men. The most common problems related to sexual dysfunction include

‧ Ejaculation disorders
‧ Erectile dysfunction
‧ Inhibited sexual desire

These issues can often be corrected by treating the underlying causes. According to statistics, infertility affects about one in every 6-to 7 couples and is treatable only in a few cases but only up to a few extents.

Unhealthy habits that affect men’s sexual health

Here is a list of a few unhealthy habits that affect sexual health in men:

‧ Eating too much salt: According to WebMD, amounts of salty foods are likely to increase blood pressure levels, leading to lower libido. Health experts call for steering clear and away from pre-packaged and processed foods which are high in sodium levels, preservatives, and unsaturated fats.
‧ Stress: Stress is one of the biggest underlying factors which cause most health issues. Constant strain and high levels of anxiety wear you out and decrease sexual desires. Try working towards decreasing stress levels, which are also detrimental to overall health.
‧ You do not indulge in foreplay: According to sexual health experts, it is very important to indulge in foreplay before sex to enjoy and make it last. However, due to various reasons, men do not include more types of stimulation beforehand.
‧ Alcohol dependence: Increased dependence on alcohol and addiction might be a good thing for a short while as they can help you relax but binging on booze can cause you to crash and burn in the bedroom. Doctors say that men struggle with sexual performance issues when they are drunk.
‧ Obesity and being overweight: Obesity and weight issues are one of the main reasons for bad performance in bed. Studies have said that men who are obese are more likely to have erectile dysfunction than those who are not.
‧ Smoking: Smoking, like a lot of other health issues, harms your sexual health as well. Chemicals in tobacco can mess with blood flow, which can cause sexual problems, especially for men.

Ways to boost sexual health

Try some of the following methods to reduce erectile dysfunction, increase stamina, and improve the overall quality of sex:

Manage your stress and anxiety

Since both anxiety and stress can make it hard to get or maintain an erection and distract people from sexual intimacy, you need to formulate some strategies to manage them. A few of them include:

‧ Focusing physical sensations
‧ Regular workouts
‧ Regulating sleep patterns
‧ Working on emotional aspects of your relationship
‧ Seeking therapy

Communicate and address relationship issues

Sexual health is deeply linked with mental health, as emotional bonds can improve sexual experiences. Resolving the situation together with your partner can make you feel less isolated and address any concerns or guilt.

Exercise regularly

Studies have shown that being physically active can drastically reduce a lot of health problems, including sexual ones. Conditions like high blood pressure, heart disease, and diabetes damage nerves and change the amount of blood that flows to the penis. This can make it more difficult to get or maintain erections. Exercise would help proper blood circulation across the body. Also, exercising improves mental health and reduces anxiety.

According to Medical News Today, men can also benefit from exercising the muscles involved in arousal and ejaculation. The following exercise may help:

‧ While urinating, stop the flow of urine. Repeat several times and learn to identify the muscles involved.
‧ When not urinating, try to contract these muscles for 10 seconds. Relax them for 10 seconds, then contract them for another 10 seconds.

Practice meditation

Health experts suggest that the practice of mindful meditation greatly improves sexual functions, and helps you manage stress, depression, and other mental health issues as well.

Disclaimer: Tips and suggestions mentioned in the article are for general information purposes only and should not be construed as professional medical advice. Always consult your doctor or a dietician before starting any fitness programme or making any changes to your diet.

alcohol exercise foreplay obesity potency sexual performance stress

Men Should Check Their Testosterone Levels by Age 30, Urologist Says

Men should know their testosterone levels by age 30 to prevent health issues like weight gain and muscle loss, says top urologist

Gabby Landsverk
Oct 11, 2022, 12:31 PM

This article is a repost which originally appeared on INSIDER.

Edited for content. The opinions expressed in this article may not reflect the opinions of this site’s editors, staff or members.

Early testing can help identify low testosterone.

‧ Low testosterone levels can cause side effects ranging from low libido and mood to muscle loss.

‧ A urologist said more men should get tested so their doctors can see how their hormone levels change over time.

‧ There is some evidence that higher testosterone levels may prevent illness like prostate cancer, not increase the risk.

Testosterone is a crucial hormone for men’s health, and a top urologist says more men should know their levels earlier in life.

Low testosterone can cause loss of energy, muscle, and libido, and can contribute to chronic illnesses such as heart disease, diabetes, and obesity, according to research.

But diagnosing low testosterone can be tricky, because natural testosterone levels can vary.

If you don’t already know your baseline, and you start experiencing these symptoms, you may not be able to trust the results of a testosterone test, said Dr. Ananias C. Diokno, former chief medical officer and chair of urology at Beaumont Hospital, Royal Oak.

“If you ask men what their testosterone levels are, they’ll scratch their heads. They don’t know and doctors aren’t testing for this. You should know what your level is by the time you hit 30 to 35,” Diokno told Insider.

What we think of as ‘normal’ testosterone, and why it’s not a perfect barometer

Testing for low testosterone is simple, using a blood test.

In healthy men, testosterone levels can range between 260 nanograms per deciliter (ng/dL) and more than 900 ng/dL, depending on age.

Low testosterone is typically defined as less than 250-300 ng/dL, according to the Cleveland Clinic.

However, since natural testosterone levels can vary widely, Diokno said many men can be misdiagnosed for hormone deficiencies.

For example, a person with testosterone levels of 400 or 500 ng/dL won’t be diagnosed with low testosterone because it’s higher than the defined standard, but if his initial levels were 700 or higher, the drop is significant and may warrant treatment.

“Many practitioners close their minds. Someone may be having symptoms but according to the guidelines, does not have low testosterone. It’s frustrating among men and among doctors who can’t help them,” Diokno said.

One solution is more routine hormone testing so men can establish what a healthy baseline looks like for them, similar to other markers of health like cholesterol, blood pressure, and blood sugar, Diokno said.

Low testosterone can cause low energy, low libido, and loss of muscle

Over time, men’s testosterone levels dwindle as a common side effect of aging. However, younger men can also have low testosterone, causing them to experience similar symptoms to much older men.

Telltale symptoms of low testosterone can be mental, physical, and emotional, including:

‧ Decreased sex drive

‧ Brain fog

‧ Depression and mood changes

‧ Fatigue

‧ Difficulty building or maintaining muscle

“The lower the testosterone, the more symptoms,” Diokno said.

Testosterone therapy may not be as risky as previously believed

For men who have had sudden dips in hormone levels, testosterone therapy can help restore quality of life, energy, and libido, Diokno said.

Previously, testosterone therapy has been carefully regulated, in part because high testosterone has been linked to a higher risk of prostate cancer in some studies.

Diokno said the opposite may be true, according to some observational studies, and healthy testosterone levels may protect prostate health.

Loss of muscle linked to low testosterone can cause other problems, too, including a decreased metabolism that can lead to weight gain and associated health issues.

Available evidence suggests that testosterone therapy, done correctly and with medical supervision, is a safe and effective way to raise hormone levels, and more research is needed to see who could benefit, Diokno said.

“It’s a Pandora’s Box, I think there are many questions that are still unanswered,” he said.

libido muscle ng/dL obesity proatate sex drive Testosterone testosterone levels testosterone replacement therapy testosterone therapy

Sugar and Aging: What You Need to Know

People looking to extend their lives have a particular interest in sugar and aging, but what does the science actually say?

This article is a repost which originally appeared on Longevity Advice
Rachel Burger - September 13, 2021
Edited for content and readability Images sourced from Pexels

In a lot of diets, from the Mediterranean diet to the low-carb diet, all uniformly advocated for removing processed foods and refined sugar.

But mechanistically, why is sugar a problem? Does sugar contribute to aging? Are there nuances to the sugar-is-always-bad narrative?

In this article, I aim to answer all these questions. But first, I want to address a larger question: why is sugar talked so much in relation to health, nutrition, and aging?

Why is sugar a focus?

Humans are hardwired to love sweet foods.

You might meet the occasional adult who claims to hate sugar, but you’ve likely never met a kid who turned their nose up at a sweet. In fact, there’s a general consensus that sugar preferences in children are not a byproduct of advertising or food manufacturing, but of biological desires. A review published in the journal Clinical Nutrition and Metabolic Care explains, “Heightened preference for sweet-tasting foods and beverages during childhood is universal and evident among infants and children around the world.”

While “too sweet” is a concept adults are familiar with (they tend to max out at about what you’d get in a 20 oz Gatorade), there is no known upper limit to how much sweetness—sugar, by extension—kids like.

“Sugar” is shorthand for “simple carbohydrates.” There are two natural categories of sugars:

Monosaccharides: Simple carbs with a single sugar molecule. Glucose, fructose, and galactose are monosaccharides.
Disaccharides: Simple carbs with two sugar molecules joined together.

There are only three disaccharides that are naturally occurring. Sucrose, which you can find in table sugar, honey, and dates, is a combination of glucose and fructose. Lactose, or the combination of glucose and galactose, is natural milk-derived sugar, found in cream, butter, and human breast milk. Finally, there’s maltose, which has two bonded glucose molecules, which is found in germinating grains. Foods with maltose include beer and bread.

(Other sweeteners, like high fructose corn syrup, are man-made disaccharides [any of a class of sugars whose molecules contain two monosaccharide residues].)

Carbohydrates, regardless of if they’re simple or complex carbs, are used for four functions in the human body. As this is an incredibly dense topic, please use the links provided for further reading if you’re interested.

Producing energy: Most human cells prefer or require carbohydrates to produce energy and work as they’re supposed to.
Energy storage: Carbohydrates that aren’t immediately used are stored as glycogen.
Building macromolecules: Carbohydrates are used to make ribose and deoxyribose, the foundations of macromolecules like DNA and RNA.
Preserving fat and protein: Blood glucose spares the body from having to use fat and protein as the body’s main source of energy.

In other words, carbohydrates are an essential part of a functioning human body. Because simple carbs have a shorter chain of molecules, they’re easier to digest in the body. Over email, Julie Olson, BSc., CN, BCHN, CGP, of Fortitude Functional Nutrition, elaborates: “Carbohydrates are a main source of energy, converted by the body to power our cells. We need some sugar for some brain cells, some kidney cells, red blood cells, and testes cells” to function properly.

Simple carbs are a subject of conversation in nutritional circles because humans generally rely on carbohydrates to function, and humans particularly like sugar and its sweetness.

Unfortunately, our preference for sweets has led to an excess of added sugar in the Western diet.

Added sugar versus natural sugars

When I say “added sugar,” I mean simple carbs that have been mixed into foods during food processing. Natural sugars, by contrast, are simple sugars found in whole foods, like sugars found in fruits and vegetables.

Some sugars found in nature, like honey and maple syrup, are also considered added sugar.

The American Heart Association recommends consuming no more than 100 calories, or six teaspoons, of daily added sugars for females and children. Males can consume up to nine teaspoons, or 150 calories, of added sugars daily.

Unfortunately, the average American consumes 17 teaspoons of added sugar every day—that’s a 183% increase and an 89% increase from recommended daily intake for females and males, respectively.

And that excess sugar consumption has huge health consequences.

Sugar and aging

Added sugar increases the rate of biological aging. It does so in several ways. In 2018, the Annual Review of Nutrition published a systematic review of longitudinal studies on the correlation between high sugar consumption and cancer. They produced an infographic that aptly demonstrates just how much of the body added sugar ages and points to mechanisms as to why it does so:

This next section will drill down into three documented ways sugar and aging are intertwined: AGEs, inflammation, and diabetes. I’ll also cover a quick study on sugar’s effect on telomeres at the end.

Sugar and aging: a close look at AGEs

*Source: “Role of Advanced Glycation End Products in Cellular Signaling*”

Let’s talk a bit about “advanced glycation end products,” or AGEs. AGEs are a diverse group of molecules that build up in human cells, particularly in muscle tissue and plasma. They’re created as a reaction between glucose and the amino acid glycine—when sugar meets fat or protein in the body. AGEs have a particularly resistant structure to degradation.

Emerging research suggests that AGEs form endogenously at an even higher rate with fructose than glucose—sweeteners like high fructose corn syrup, apple juice, honey, molasses, caramel, and agave syrup all contain fructose.

In other words, AGEs make your skin appear dry, saggy, and wrinkled—old. While AGEs age your insides, they also quickly age your exterior as well.

Diet is a major source of AGEs—barbecued meats, in particular, are full of them. They can also form while humans metabolize their food. AGEs formed in vivo tend to particularly affect “long-lived proteins, such as hemoglobin, alkaline phosphatase, lysozyme, collagen [and] elastin.”

There’s a general consensus in the scientific community that accumulated AGEs “are an inevitable component of the aging process in all eukaryotic organisms, including humans.” The more you have, the quicker you age.

Here’s why AGEs are a problem in large quantities: they’re linked to diabetes, cardiovascular disease, and renal disease. They’re also connected to Alzheimer’s disease and kidney disease. A whole host of studies demonstrate that AGEs trigger oxidative stress and excessive reactive oxygen species (which also cause oxidative stress).

Sugar and aging: chronic inflammation

*Source: “Epigenetic signatures underlying inflammation: an interplay of nutrition, physical activity, metabolic diseases, and environmental factors for personalized nutrition*”

Inflammation is a biological defensive response to an irritant, like bacteria or viruses. If you skin your knee, the area around the cut will inflame, as a part of your immune system, to combat infection and to promote healing. Concentrations of white blood cells cause inflammation.

Inflammation can be short-term, or “acute.” If you’re like me and allergic to hay, your body will have an acute inflammatory response—an itchy, watery nose, a puffy face—until the irritant goes away. Inflammation can also be long-term, or “chronic,” and you can stay inflamed regardless if the trigger is still present.

There are a lot of age-related diseases connected to chronic inflammation. To name just a handful, they include:

Diabetes
Cardiovascular diseases
Arthritis and joint diseases
Chronic Obstructive Pulmonary Disease (COPD)
Certain kinds of cancer

Chronic inflammation can also help form AGEs.

Several studies have established that sugar, in all its forms, correlates with inflammation. Some studies have found that fructose appears to cause the most inflammation out of all of sugar’s forms, but that hasn’t been a consistent finding across all studies.

While it’s a mystery why some inflammation remains acute and other inflammation becomes chronic in some people and not others, sugar consumption is a significant precursor to chronic inflammation in many people.

Sugar and aging: diabetes

If you want to see a complicated cocktail of fact and misinformation, look closely at the relationship between sugar, obesity, and diabetes.

There is no known cure for diabetes, though diabetics can go into remission. Diabetes is the seventh-leading cause of death in the United States as of 2019.

Obesity is also a chronic disease. Obesity is defined as having a BMI, or a person’s weight in kilograms divided by the square of height in meters, of 30.0 or higher. According to Harvard Medical School, there are “genetic, developmental, hormonal, environmental, and behavioral factors” that contribute to who does and doesn’t have obesity.

Like diabetes, there are many treatments for obesity, but no known cure. One study suggests that if trends continue, all American adults will be either overweight or obese by 2048.

I choose to mention obesity and diabetes together because they have a significant causal relationship—obesity is an independent risk factor that can lay the groundwork for diabetes to develop. Almost all (89%) of people with diabetes are obese or overweight. I found a massive range of estimates of how many obese individuals develop diabetes, from 2.9% to 30%. Many of the studies cited here look at both obesity and diabetes together as comorbid conditions. For example, hypertrophic obesity—what happens when fat cells enlarge more than normal—directly leads to insulin resistance.

Researchers have formally tied added sugar consumption to obesity and diabetes several times over. Though the relationship is complex and researchers don’t fully understand all mechanisms involved, it’s clear that added sugar consumption, particularly fructose, raises the risk of developing obesity and diabetes.

For example, foods high in fructose stimulate ghrelin while suppressing leptin—hormones responsible for hunger and satiety. Sugar can promote chronic hyperglycemia, which can both lead to weight gain and is another risk for diabetes. And sugary drinks, especially, are tied directly to obesity.

Sugar and aging: a bad combination (so what should we do?)

People looking to stay young for a long time should limit their sugar consumption. While how added sugar works in the body isn’t simple or predictable, there are literally thousands of studies tying added sugar to diseases of aging.

With all that said, it’s natural for humans to crave and eat limited amounts of sugar.

Sugar and aging is a massive topic with a lot of nuance—so much so that I didn’t even get a chance to cover alternative sweeteners.

What are your takes on sugar? What do you do to avoid them or to add them mindfully to your diet?

advanced glycation end products AGE AGEs aging biohacker biohacking diabetes longevity nutrition obesity simple carbohydrates sugar sweets

Living With ED: How To Take Back Your Life

Dealing with erectile dysfunction (ED) can be incredibly difficult for men at any age. Men often feel ashamed of their condition and convince themselves that they’re “less of a man” because of it. When left untreated, the effects can spiral into other areas of their life. Self confidence, intimate relationships, and overall health can decline quickly. If you are struggling with ED, it’s important to realize that it doesn’t have to control your life. With these few tips you can get back to being your best self!

Talk To A Doctor

The first step to taking back control of your life is to talk to a doctor. With the shame or embarrassment that a lot of men feel about ED, it’s normal to even be embarrassed to tell your doctor. Remember that your physician will simply want to help you. Don’t let a mental block stop you from reaching out for help. They might help you explore options for ED medications to give you some short term relief or suggest other lifestyle changes. They also might want to make sure you don’t have any other undiagnosed illnesses. ED can be a symptom of another illness like heart disease, diabetes, or metabolic syndrome to name a few.

Exercise

Being proactive about your overall health will help you feel more in control of your ED symptoms. Working out can help tackle ED symptoms from many angles as your overall health generally improves. Since obesity increases the risk of ED, working out can get you on track to being a healthier weight and potentially reducing your symptoms. Another way that exercise can impact ED is through body positivity. Perhaps you’re not confident in your body and it’s causing some performance anxiety. If that’s the case, working out can improve your self esteem over time and potentially relieve your ED symptoms.

Diet

Incorporating a healthy diet into your routine is another great way to help alleviate ED symptoms. Being selective about what you eat and noticing the effects on your mood and mental state and your body will help you feel in control of your body. Aside from your basic “healthy balanced diet” there are some specific nutrients to help fight ED that you’ll want to be sure to incorporate. Many of these nutrients are linked to improving circulation, which is necessary for improving ED symptoms.

Remember, having erectile dysfunction does NOT diminish you as a man, or as a person. You may feel alone, defeated, betrayed by your body and unable to do the things you want when you want to. You can’t control what happens to you, but you can control how you react. Find solace in controlling other aspects of your life that you are able to control. Your mental and physical health will improve and you’ll be well on your way to getting your confidence back.

# # #

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Vaseline in Place of Viagra: Is It Safe and Effective?

Can You Use Vaseline in Place of Viagra?

Medically reviewed by Matt Coward, MD, FACS — Written by James Roland on March 17, 2021

This article is a repost which originally appeared on Healthline

Edited for content.

If you experience erectile dysfunction (ED), you may be willing to try just about anything to restore healthy sexual function.

However, there are plenty of potentially dangerous options that people have tried, including the injection of Vaseline or other petroleum jelly products into the penis.

For many years and in many cultures, the practice of injecting or inserting something into the penis to make it larger or to improve sexual stamina has been done, often without the guidance of medical experts.

If you’re tempted to use Vaseline in place of Viagra or any other approved treatment for ED, don’t waste your time or take the risk. There are plenty of safer and more effective options available.

You may also have heard of topical gels or essential oils for ED, but there has yet to be any evidence to suggest that applying Vaseline as a topical treatment to your penis will have any effect on sexual function.

The science

Numerous studies have shown that injecting Vaseline into your penis is a danger, rather than a cure. The practice can lead to:

infections
serious skin and tissue injury
other medical complications

In a small 2008 study of 16 people who were treated for Vaseline injections, researchers found that “urgent surgery” was necessary to prevent further injury.

A 2012 case report concluded that Vaseline injections are usually done without medical supervision and can lead to severe complications if the petroleum jelly or other foreign objects aren’t removed promptly.

Clinical treatments

Instead of trying risky self-help solutions for ED, consider proven medications and other treatments that have a track record of success.

Oral medications

While Viagra, known clinically as sildenafil, may be the best known ED pills, there are other FDA-approved medications. They all vary somewhat in their:

potency
how quickly they take effect
duration of effectiveness
side effects

Other ED medications on the market include:

Tadalafil (Cialis). It’s available in a generic form and can be taken daily at low doses or as needed in higher doses.
Vardenafil (Levitra). It’s available in brand-name and generic versions. it tends to remain effective a little longer than sildenafil.
Avanafil (Stendra). It’s not yet available in generic form, Stendra is unique among ED medications in that it can become effective in about 15 minutes, while others take between 30 and 60 minutes to take effect.

Your lifestyle may help determine the best ED medication for you.

Vacuum pumps

This treatment involves the use of a tube that fits over your penis and attaches to a pump that withdraws air from the tube to create a vacuum.

The vacuum created around your penis helps draw blood to fill the blood vessels within and produce an erection. An elastic ring is also placed around the base of your penis to help maintain the erection.

A 2013 research review noted that the use of vacuum devices to treat ED is usually safe and effective, particularly when combined with ED drugs known as PDE-5 inhibitors, which include:

tadalafil
sildenafil
other standard medications

Penile injections

Certain medications can be injected into your penis to increase blood flow and create a firmer erection for intercourse. Those include:

papaverine
phentolamine
prostaglandin E1 (PGE1) or alprostadil (Caverject, Edex)

There are also combinations of the above medications available.

Penile implants

Some people choose to treat ED with surgically-implanted, flexible, or inflatable rods that you can activate on demand.

Penile implants are generally reserved for individuals who have not had success with other traditional ED treatments.

Alternative treatments

Many safer and more effective alternatives to Viagra are available, including several prescription medications and over-the-counter (OTC) supplements, as well as complementary therapies, such as acupuncture, according to a 2016 research review.

Some people have had success using herbal supplements to treat ED. Some OTC products that have been supported by research include:

Korean red ginseng. It’s a plant that grows in Asia and may help both ED and alertness with relatively few side effects.
L-arginine. It’s an amino acid that serves as a building block for certain proteins. A small 2019 research review of 10 studies found that L-arginine used in doses of 1,000 to 1,500 milligrams significantly improved ED symptoms compared with placebo.
Yohimbe. It’s an herbal supplement commonly used in West African cultures, proved to be at least partially effective in treating ED in about one-third of people who participated in an old 1989 study.

Lifestyle changes

In addition, improving your health may improve ED symptoms and provide other benefits, including:

more energy
better sleep
greater cardiovascular fitness

The following lifestyle changes may pay dividends in terms of sexual health:

regular aerobic exercise, at least 150 minutes per week
maintaining a manageable weight
no smoking
consuming little or no alcohol
maintaining a healthy blood pressure
getting 7 to 8 hours of sleep each night
managing stress through meditation, yoga, or other strategies

When to talk with a doctor

The first step in finding the solution that’s right for you is to talk with your primary care physician or a urologist.

And while ED can be an embarrassing and frustrating topic to discuss with anyone, understand that ED is a common condition, affecting an estimated 1 in 3 adults with penises.

In other words, you won’t be the first person to ask your doctor for advice or treatment in this department.

Occasional concern

If ED occurs occasionally, then you may not need any treatment at all. In this case, it may usually be chalked up to:

stress
fatigue
relationship concerns
a side effect of misusing alcohol

Keep in mind that ED can be a symptom of many physical and emotional health conditions, including:

cardiovascular disease
obesity
hypertension
diabetes
depression
anxiety

Sometimes treating an underlying condition can lead to improved sexual function.

Persistent concern

If ED is a persistent concern, then a conversation with your doctor is recommended. Your concerns may be an inability to:

achieve an erection at all
achieve an erection that is firm enough for satisfactory intercourse for you and your partner
maintain an erection for the duration necessary for satisfactory intercourse
become erect at certain times or with certain partners

Regardless of the nature of your ED, there is a range of treatments that may be helpful. Psychotherapy and relationship counseling may be very helpful too, so you may want to talk with your doctor about referrals for therapy.

But because medications are generally tolerated, the first approach may be a prescription for Viagra or any of the other approved ED medications.

The bottom line

ED can affect several aspects of your life, including self-esteem and relationships, so it’s not something to ignore — especially when viable treatments are available.

And rather than rely on unproven and potentially very harmful treatments on your own — such as injecting Vaseline or any foreign substance into your penis — address this common medical condition with your healthcare professional.

Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. We avoid using tertiary references. You can learn more about how we ensure our content is accurate and current by reading our editorial policy.

Cui X, et al. (2016). Acupuncture for erectile dysfunction: A systematic review.
hindawi.com/journals/bmri/2016/2171923/
Erectile dysfunction: AUA guideline 2018. (2018).
auanet.org/guidelines/erectile-dysfunction-(ed)-guideline
Hoyland K, et al. (2013). The use of vacuum erection devices in erectile dysfunction after radical prostatectomy.
ncbi.nlm.nih.gov/pmc/articles/PMC3784970/
Karakan T, et al. (2012). Injection of Vaseline under penis skin for the purpose of penis augmentation.
ncbi.nlm.nih.gov/pmc/articles/PMC3507042/
Nyirády P, et al. (2008). Treatment and outcome of Vaseline-induced sclerosing lipogranuloma of the penis.
goldjournal.net/article/S0090-4295(07)02675-1/pdf
Rhim HC, et al. (2019). The potential role of arginine supplements on erectile dysfunction: A systemic review and meta-analysis.
jsm.jsexmed.org/article/S1743-6095(18)31362-6/fulltext
Susset JG, et al. (1989). Effect of Yohimbine Hydrochloride on erectile impotence: A double-blind study.
auajournals.org/doi/10.1016/S0022-5347%2817%2941308-5

alprostadil avanafil caverject cialis diabetes ED edex erectile dysfunction l-arginine levitra obesity papaverine PDE-5 Inhibitors penile implant penile injection petroleum jelly PGE1 phentolamine prostaglandin E1 red ginseng sildenafil stendra tadalafil vacuum pumps vardenafil vaseline viagra yohimbe

Penis health: Conditions, safety, lifestyle, and care

What to know about penis health

Medically reviewed by Kevin Martinez, M.D. — Written by Jenna Fletcher on April 2, 2020

This article is a repost which originally appeared on MEDICAL NEWS TODAY

Edited for content

A healthy penis should be free of lesions, warts, and abnormal discharge. In general, the penis should be roughly the same color as the surrounding skin, though it may be a shade darker or lighter.

Also, a person should not experience any pain in their penis when urinating or engaging in sexual activity.

A sudden change in the appearance, sensation, or function of the penis may signal an underlying issue that requires medical attention.

This article describes certain lifestyle factors and health conditions that can affect penis health. It also outlines some possible symptoms of poor penis health and provides tips on penis care.

Lifestyle factors that affect penis health

Lifestyle factors that can affect penis health include sexual relationships, weight management, and alcohol use.

The sections below outline some common lifestyle factors that can affect penis health.

Sexual relationships

Sexually transmitted infections (STIs) can negatively affect penis health. Some of the most common STIs include:

human papillomavirus (HPV)
chlamydia
gonorrhea
herpes

The Centers for Disease Control and Prevention (CDC) recommend that people practice safe sex in order to reduce their risk of contracting an STI. This involves using barrier methods during sexual activity and getting vaccinated against hepatitis B and HPV.

The following can also help reduce the risk of spreading and contracting STIs:

limiting the number of sexual partners
maintaining a monogamous sexual relationship
abstaining from sexual activity

Often, people who contract an STI do not experience any symptoms. This is why it is important for people who are sexually active to attend regular sexual health screenings.

Weight management

Obesity can negatively affect many aspects of a person’s health, including penis function.

People with obesity may be more likely to experience erectile dysfunction, or impotence. This occurs when a person is unable to develop or maintain an erection during sexual activity.

According to the Obesity Action Coalition, obesity can contribute to erectile dysfunction by:

decreasing testosterone levels
causing inflammation throughout the body
damaging the blood vessels, including those that supply blood to the penis

However, one 2018 study suggests that the relationship between obesity and sexual health is not completely clear. Although obesity may contribute to erectile dysfunction, other factors may also give rise to poor sexual health. These include:

anxiety
stress
self-esteem issues

Diet

Eating a healthful, balanced diet can help prevent obesity and related sexual health problems.

A 2017 animal study investigated the potential link between diet, obesity, and erectile function. In this study, one group of rats consumed a calorie-rich diet, while a second group consumed a standard diet.

The rats that consumed the calorie-rich diet were more likely to develop obesity, and they also showed significantly poorer erectile function.

The types of food a person eats could also affect their penis health. For example, one 2016 study found that a diet rich in flavonoids was associated with a reduced risk of erectile dysfunction in men below the age of 70.

Flavonoids are chemicals that occur naturally in a range of vegetables, fruits, and grains. Some examples of flavonoid-rich foods include:

root vegetables
legumes
berries
grapes
citrus fruits
teas
chocolate

Exercise

Exercise is important in helping a person maintain a moderate weight. This means that it also helps reduce the risk of obesity-related sexual health concerns.

Exercise may also benefit sexual health more directly. For example, one 2015 study investigated whether or not regular walking exercise could help improve erectile dysfunction in men who had recently had a heart attack.

Those who took part in the regular walking program reported a 71% decrease in erectile dysfunction symptoms. Those who did not take part in the program reported a 9% increase in erectile dysfunction symptoms.

The researchers conclude that regular exercise may help reduce symptoms of erectile dysfunction.

A 2011 meta-analysis investigated the effects of aerobic exercise on erectile dysfunction. The researchers analyzed five studies involving a total of 385 participants.

All the studies showed improvements in erectile dysfunction following aerobic activity. The researchers conclude that men with erectile dysfunction may benefit from aerobic training, though further studies are necessary to confirm this.

Alcohol and tobacco use

Drinking a lot of alcohol can negatively impact many aspects of a person’s health.

According to the CDC, excessive drinking can interfere with male hormone production, potentially contributing to impotence and infertility.

Alcohol also increases the likelihood that a person will engage in risky sexual behavior. Such behavior puts a person at increased risk of contracting or transmitting an STI.

Tobacco smoking can also have a negative effect on penis health. According to the Truth Initiative, smoking may play a role in the following sexual health issues:

erectile dysfunction
infertility
decreased libido

Health conditions that may affect penis health

There are several health conditions that can directly affect penis health. Some of the more common ones include:

STIs, such as chlamydia, herpes, or genital warts
phimosis, which occurs when the foreskin cannot extend over the head of the penis
balanitis, which is inflammation of the head or foreskin of the penis

Other conditions not directly related to the penis can also affect its health. Many of these conditions may cause erectile dysfunction or issues with fertility. These include:

obesity
diabetes
high blood pressure
stress
certain heart conditions

When to see a doctor

Anyone who is sexually active should check for symptoms of STIs regularly. They should look for:

rashes, sores, or blisters on the penis
burning or itching sensations in the penis
abnormal discharge from the penis
a foul odor coming from the penis or groin area
pelvic pain
pain when urinating or passing stools

Anyone who thinks that they may have an STI should visit their doctor for a diagnosis and appropriate treatment.

Importantly, many people who contract an STI will not experience any symptoms. Regular sexual health screenings will help detect STIs that a person may not have noticed otherwise.

Anyone who thinks that they may have erectile dysfunction should also see their doctor, who will work to diagnose the cause.

How to care for the penis

A person should clean their penis at least once per day using a mild soap. Using abrasive or heavily scented soaps could irritate the skin of the penis.

A person should wash all parts of the penis, including:

the pubic hair
the scrotum
the area between the legs and scrotum
the penis shaft
the area underneath the foreskin, if uncircumcised

Tips for a healthy penis

The tips below can help a person keep their penis healthy:

using a barrier method during sex
limiting the number of sexual partners they have
undergoing a sexual health screening at least once per year if in a monogamous relationship
undergoing a sexual health screening as often as every 3–6 months if having sex with multiple partners
keeping the penis and genital area clean
limiting alcohol consumption
avoiding the use of tobacco products
exercising regularly
eating a healthful, balanced diet

Summary

A person can take several steps to maintain the health of their penis. This includes exercising regularly and eating a healthful diet. A person may also wish to avoid having unprotected sex, drinking a lot of alcohol, and using tobacco products.

To maintain a healthy penis, a person should thoroughly wash the penis at least once per day. Those who are sexually active should also go for sexual health screenings at least once per year and perform regular self-checks at home.

If a person has any concerns about their penis, they should talk to a doctor as soon as possible. The doctor will work to diagnose the cause of the issue and provide appropriate treatments.

Medical News Today has strict sourcing guidelines and draws only from peer-reviewed studies, academic research institutions, and medical journals and associations. We avoid using tertiary references. We link primary sources — including studies, scientific references, and statistics — within each article and also list them in the resources section at the bottom of our articles. You can learn more about how we ensure our content is accurate and current by reading our editorial policy.

3 ways tobacco use impacts your sex life. (2018).
https://truthinitiative.org/research-resources/harmful-effects-tobacco/3-ways-tobacco-use-impacts-your-sex-life
Begot, I., et al. (2015). A home-based walking program improves erectile dysfunction in men with an acute myocardial infarction. [Abstract].
https://www.ajconline.org/article/S0002-9149(14)02270-X/fulltext
Boyce, S. (2014). Men: Is obesity affecting your sex life?
https://www.obesityaction.org/community/article-library/men-is-obesity-affecting-your-sex-life/
Cassidy, A., et al. (2016). Dietary flavonoid intake and incidence of erectile dysfunction.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4733263/
de Souza, I. L. L., et al. (2017). Hypercaloric diet establishes erectile dysfunction in rat: Mechanisms underlying the endothelial damage.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5649200/
Esfahani, S. B., & Pal, S. (2018). Obesity, mental health, and sexual dysfunction: A critical review.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6047250/
Excessive alcohol use and risks to men’s health. (2019).
https://www.cdc.gov/alcohol/fact-sheets/mens-health.htm
How you can prevent sexually transmitted diseases. (2020).
https://www.cdc.gov/std/prevention/default.htm?s_cid=tw_SR_17004
Lamina, S., et al. (2011). Effects of aerobic exercise in the management of erectile dysfunction: A meta analysis study on randomized controlled trials.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275865/
Sexually transmitted diseases (STDs). (2020).
https://www.cdc.gov/std/default.htm
Sexually transmitted diseases (STDs): Diseases & related conditions. (2016).
https://www.cdc.gov/std/general/default.htm
What are sexually transmitted infections (STIs) or diseases (STDs)? (n.d.).
https://www.urologyhealth.org/urologic-conditions/sexually-transmitted-infections
What is erectile dysfunction? (2018).
https://www.urologyhealth.org/urologic-conditions/erectile-dysfunction(ed)
Which STD tests should I get? (2014).
https://www.cdc.gov/std/prevention/screeningreccs.htm

abnormal discharge anxiety balanitis CDC chlamydia chocolate decreased libido diabetes erectile dysfunction flavonoids gonorrhea herpes HPV human papillomavirus infertility lesions obesity penis health phimosis scrotum self-esteem sti stress warts

How to Boost Your Relationship and Sex Life with Healthy Eating

Medically reviewed by Natalie Butler, RD, LD on May 11, 2016 — Written by Tara Gidus, MS, RD, CSSD, LD/N

This article is a repost which originally appeared on HealthLine

Food and sex

Much of the lore surrounding the desire- and performance-enhancing effects of certain foods is anecdotal. But a good diet can help boost your libido and ensure your body is working well. A poor diet can lead to a host of health issues, which may negatively effect your sex life. For example, erectile dysfunction is often linked to obesity and diabetes, which can be caused by a poor diet.

Food is an important part of your everyday life and overall health. So it may not surprise you that your diet can affect your sex life. Changing your eating habits and behaviors may not be a cure-all for sexual issues, but it’s a good place to start.

Diet and supplements

Eating a well-balanced diet and taking certain supplements may help improve your overall health and sex life. It’s also important to avoid drinking too much alcohol.

Healthy diet

Fueling your body with the right kinds of food can help boost your mood and energy levels to support a healthy relationship and sex life. For optimum health, eat a nutrient-rich diet that’s low in trans fats, saturated fats, added sugars, and sodium. Eat a wide variety of fruits, vegetables, whole grains, legumes, nuts, and lean proteins. To avoid gaining weight, don’t eat more calories than you burn in a day.

Arginine and L-citrulline

Arginine, also known as L-arginine, is an amino acid used by your body to make nitric oxide. This important chemical helps your blood vessels relax, which promotes good blood flow. If you’re a man, good blood flow to the erectile tissues in your penis is important for sustaining an erection.

When you take supplemental arginine, your intestines break most of it down before it reaches your bloodstream. It may be more helpful to take L-citrulline supplements. L-citrulline is another amino acid that’s converted to arginine in your body. A small study published in Urology found that L-citrulline supplements were more effective than a placebo for treating mild erectile dysfunction.

Both amino acids are also found in foods. L-citrulline is found in foods such as watermelon. Arginine is found in many foods, including:

walnuts
almonds
fish
whey
fruits
leafy vegetables

Zinc

The link between zinc and sexual health isn’t completely understood, but zinc appears to affect your body’s production of testosterone. It’s also necessary for the development of sperm and semen in men. Adequate zinc levels may boost male fertility. Zinc and other nutrients, such as folate, may also impact female fertility.

Zinc is available in supplement form. It’s also found in some foods. Oysters are nature’s richest source of this essential element. Not surprisingly, they have traditionally been viewed as aphrodisiacs, capable of kindling sexual desire.

Alcohol

Drinking alcohol may lower your inhibitions and increase the likelihood that you’ll engage in sexual activity. However, it can also cause acute or chronic erectile dysfunction. It can lead to unsafe behavior too. When you mix sex with alcohol, you’re less likely to use proper precautions to prevent unwanted pregnancy and sexually transmitted infections. Out of control drinking can also negatively affect your behavior and relationships with other people. Don’t rely on alcohol to improve your sex life.

Food-related habits and conflicts

Sometimes, food can be a source of stress and conflict in relationships. On the other hand, you and your partner may bond over shared meals together.

Eating together

In some sense, your brain is the most important sex organ. Sex begins with affection, intimacy, and desire. Mealtime is a great time to unwind with your partner and build intimacy in a relaxed and pleasurable setting.

Food conflicts

Sometimes, different food preferences and habits can be a source of stress in a relationship. To help build intimacy and trust, talk to your partner about issues surrounding your relationship with food. Sources of potential conflicts include:

cultural differences
religious dietary restrictions
tension between a vegetarian and omnivore
tension between a picky and adventurous eater

If either of you have a history of eating disorders or chronic dieting, that can also influence your relationships with food and each other.

Support

Body weight is tied to self-esteem and body image for many people. If your partner is trying to lose weight, help them along the way. If you know they’re an emotional eater, offer them support when they seem upset. Criticizing their food choices or looking over their shoulder while they’re eating won’t foster good feelings. Be supportive, not destructive.

Diet-related conditions

Many diet-related health conditions can negatively impact your sex life, as well as your overall health and quality of life. Take steps to prevent and treat diet-related conditions, such as obesity, high blood pressure, and high cholesterol.

Excess weight

Obesity has been linked to lower fertility. Being overweight or obese may also damage your self-esteem, which can affect your libido and desire to be intimate.

To lose excess weight, burn more calories than you consume. Eat healthy portion sizes and limit foods that are high in fat and added sugars. Getting regular exercise is also important.

High blood pressure

Eating too much sodium can increase your blood pressure and limit your blood flow. This can lead to erectile dysfunction in men and reduce blood flow to the vagina in women. Certain blood pressure medications can also cause undesired sexual side effects.

To help maintain healthy blood pressure, follow a well-balanced diet, don’t eat too much sodium, and include potassium-rich foods daily. If you think you’re experiencing negative side effects from blood pressure medication, talk to your doctor. An alternative medication may be available.

High cholesterol

A diet high in saturated or trans fats can increase your “bad” LDL cholesterol. Too much LDL cholesterol can lead to a buildup of plaque in your arteries, which can limit blood flow and contribute to atherosclerosis. Atherosclerosis is the underlying cause of most heart disease. It can also contribute to erectile dysfunction.

To help maintain healthy blood cholesterol levels, eat a well-balanced diet that’s rich in fiber and low in saturated and trans fats. Include foods that are rich in omega-3 fatty acids.

Tips for a healthy sex life

Chang, C. S., Choi, J. B., Kim, H. J., & Park, S. B. (2011, December). Correlation between serum testosterone level and concentrations of copper and zinc in hair tissue. Biological Trace Element Research, 144(1-3), 264-271. Retrieved from
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Cormio, L., De Siati ,M., Lorusso, F., Selvaggio, O., Mirabella, L., Sanguedolce, F., … Carrieri, G. (2011, January). Oral L-citrulline supplementation improves erection hardness in men with mild erectile dysfunction. Urology, 77(1), 119-122
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Ebisch, I. M., Thomas, C. M., Peters, W. H., Braat, D. D., & Steegers-Theunissen, R. P. (2007, March-April). The importance of folate, zinc and antioxidants in the pathogenesis and prevention of subfertility. Human Reproduction Update, 13(2), 163-174
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Miner, M., Esposito, K., Guay, A., Montorsi, P., & Goldstein, I. (2012, March). Cardiometabolic risk and female sexual health: The Princeton III summary. Journal of Sexual Medicine, 9(3), 641-651
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Raj, A., Reed, E., Santana, M. C., Walley, A. Y., Welles, S. L., Horsburgh, C. R., … Silverman, J. G. (2009, April). The associations of binge alcohol use with HIV/STI risk and diagnosis among heterosexual African American men. Drug and Alcohol Dependence, 101(1-2), 101-106
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Rubio, C., González Weller, D., Martín-Izquierdo, R. E., Revert, C., Rodríguez, I., & Hardisson, A. (2007, January-February). Zinc: An essential oligoelement. Nutricion Hospitalaria, 22(1), 101-107
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Wong, W. Y., Thomas, C. M., Merkus, J. M., Zielhuis, G. A., & Steegers-Theunissen, R. P. (2000, March). Male factor subfertility: Possible causes and the impact of nutritional factors. Fertility and Sterility, 73(3), 435-442
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amino acids arginine atherosclerosis cholesterol diet and supplements folates food and sex hdl healthline healthy eating high blood pressure l-arginine l-citrulline ldl nitric oxide obesity omega-3 fatty acids oysters potassium sodium Testosterone trans fats vegetarian watermelon zinc

Reference Ranges for Testosterone in Men Generated Using Liquid Chromatography Tandem Mass Spectrometry in a Community-Based Sample of Healthy Nonobese Young Men in the Framingham Heart Study and Applied to Three Geographically Distinct Cohorts

Reference Ranges for Testosterone in Men Generated Using Liquid Chromatography Tandem Mass Spectrometry in a Community-Based Sample of Healthy Nonobese Young Men in the Framingham Heart Study and Applied to Three Geographically Distinct Cohorts

Shalender Bhasin, Michael Pencina, Guneet Kaur Jasuja, Thomas G. Travison, Andrea Coviello, Eric Orwoll,* Patty Y. Wang,* Carrie Nielson,* Frederick Wu,* Abdelouahid Tajar,* Fernand Labrie, Hubert Vesper, Anqi Zhang, Jagadish Ulloor, Ravinder Singh, Ralph D’Agostino, and Ramachandran S. Vasan

Recommended by Pegasus

This article is a repost which originally appeared on PUBMED

Context:

Reference ranges are essential for partitioning testosterone levels into low or normal and making the diagnosis of androgen deficiency. We established reference ranges for total testosterone (TT) and free testosterone (FT) in a community-based sample of men.

Methods:

TT was measured using liquid chromatography tandem mass spectrometry in nonobese healthy men, 19–40 yr old, in the Framingham Heart Study Generation 3; FT was calculated. Values below the 2.5th percentile of reference sample were deemed low. We determined the association of low TT and FT with physical dysfunction, sexual symptoms [European Male Aging Study (EMAS) only], and diabetes mellitus in three cohorts: Framingham Heart Study generations 2 and 3, EMAS, and the Osteoporotic Fractures in Men Study.

Results:

In a reference sample of 456 men, mean (sd), median (quartile), and 2.5th percentile values were 723.8 (221.1), 698.7 (296.5), and 348.3 ng/dl for TT and 141. 8 (45.0), 134.0 (60.0), and 70.0 pg/ml for FT, respectively. In all three samples, men with low TT and FT were more likely to have slow walking speed, difficulty climbing stairs, or frailty and diabetes than those with normal levels. In EMAS, men with low TT and FT were more likely to report sexual symptoms than men with normal levels. Men with low TT and FT were more likely to have at least one of the following: sexual symptoms (EMAS only), physical dysfunction, or diabetes.

Conclusion:

Reference ranges generated in a community-based sample of men provide a rational basis for categorizing testosterone levels as low or normal. Men with low TT or FT by these criteria had higher prevalence of physical dysfunction, sexual dysfunction, and diabetes. These reference limits should be validated prospectively in relation to incident outcomes and in randomized trials.

Androgen deficiency in men is a syndrome characterized by a constellation of symptoms and signs and low circulating testosterone levels (1). Thus, the diagnosis of androgen deficiency is predicated upon the determination of whether the circulating testosterone level is low or normal (1–3). Rigorously established reference ranges constitute the essential basis for identifying whether the circulating levels of an analyte, such as testosterone, are normal or low. The reference ranges for testosterone have been derived previously mostly from small convenience samples (2–9) or from hospital or clinic-based patients; these approaches are limited by their inherent selection bias, because patients seeking medical care are more likely to have a disease than individuals in the general population. Some recent efforts to generate reference ranges in community-dwelling men are notable; these studies included middle-aged and older men and used direct RIA (10), whose accuracy, particularly in the low range, has been questioned (3, 11, 12). In the absence of rigorously determined reference limits generated using reliable assays in community-based samples, the partitioning of total and free testosterone levels into normal or low values has been fraught with substantial risk of misclassification (2, 3, 13), relegating many healthy men to unnecessary risks of testosterone therapy and preventing others from receiving appropriate testosterone therapy because of a missed diagnosis.

We generated reference limits for total and free testosterone concentrations in a community-based sample of healthy young men in the Framingham Heart Study (FHS) third generation (Gen 3) cohort (14). Total testosterone was measured using liquid chromatography tandem mass spectrometry (LC-MS/MS), a method with high specificity, sensitivity, and accuracy (2, 3, 11–13). We applied these reference limits to three geographically distinct cohorts of community-dwelling men: FHS Gen 2 and 3 (14), the European Male Aging Study (EMAS) (15, 16), and the Osteoporotic Fractures in Men Study (MrOS) (17). We determined whether men in these three cohorts, deemed to have low total and free testosterone levels by the proposed reference limits, had a higher prevalence of physical dysfunction, sexual symptoms, and diabetes mellitus (DM), the three categories of conditions that have been associated most consistently with low testosterone levels (18–27). We used thresholds based on a healthy young reference sample (T-score approach) because in exploratory analyses, the T-score approach and age-adjusted thresholds (Z-score approach) yielded concordant results for most outcomes. Also, the spline plots of testosterone levels against outcomes in the FHS sample did not reveal clear inflection points at which the relationship between testosterone levels and outcomes changed abruptly. The T-score approach based on limits derived in a healthy young population has been favored historically for analytes that exhibit clinically meaningful age-related trends, such as estradiol and bone mineral density.

Materials and Methods

Study sample

In 1948, to identify risk factors for cardiovascular disease (CVD), the FHS recruited 5209 men and women between the ages of 30 and 62 from Framingham, MA, that constituted the original cohort. In 1971, the study enrolled a second-generation cohort (Gen 2), 5124 of the original participants’ adult children and their spouses. A third generation (4095 children of Gen 2, referred to as Gen 3) was recruited in 2002–2005 (14) to further understand how genetic factors relate to cardiovascular disease risk. The FHS design and methods have been described. The recruitment methods and the selection criteria for Gen 3 participants have been published (14) and are described briefly in the Supplemental Methods (published on The Endocrine Society’s Journals Online web site at http://jcem.endojournals.org). Of the 1912 men who attended the first Gen 3 examination (2002–2005), 1893 had total testosterone measurements, 962 were 40 yr of age or younger among whom 456 men were free of cancer (self-report of physician diagnosis supported by medical records when available), CVD (occurrence of any of the following: myocardial infarction, sudden death, stroke, congestive heart failure, coronary angioplasty or coronary artery bypass surgery, claudication, or peripheral angioplasty), DM, hypertension, hypercholesterolemia, obesity, and smoking, and constituted the reference sample (Fig. 1). Cardiometabolic disorders have been associated with low testosterone levels; therefore, men with cardiometabolic disorders were excluded from the reference sample. The men who were receiving androgen deprivation therapy or had undergone orchiectomy for prostate cancer or were taking testosterone for hypogonadism were excluded.

Fig. 1.

The STROBE diagram: selection of the FHS reference sample. Of the 1912 men who attended the first Gen 3 examination (2002–2005), 1893 had total testosterone measurements, 962 were 40 yr of age or younger, and 456 men were free of cancer, CVD, DM, hypertension, hypercholesterolemia, obesity, and smoking.

Application to EMAS, MrOS, and FHS broad samples

We assessed whether low total and free testosterone levels, defined as values below the 2.5th percentile of the reference sample, were associated with three categories of conditions that have been associated with low testosterone levels (18–27): physical dysfunction, sexual symptoms, and DM in the FHS broad sample (see below), the EMAS, and MrOS. The FHS broad sample was created by combining Gen 2 and Gen 3 samples (Supplemental Fig. 1A). The Gen 2 examination 7 (1998–2002) was attended by 1625 men. Exclusion of men with prostate cancer undergoing androgen deprivation therapy (n = 8) or testosterone therapy and those with missing testosterone data (n = 158) resulted in a sample of 1459 for Gen 2. This combined sample of 3352 men (1459 men in Gen 2 plus 1893 men in Gen 3) constituted the FHS broad sample. The walking speed data were available in 797 Gen 2 men who attended exam 7 and had nonmissing testosterone data.

The EMAS recruited 3369 men, aged 40–79 yr, at eight European centers (15, 16): Manchester (UK), Leuven (Belgium), Malmö (Sweden), Tartu (Estonia), Lodz (Poland), Szeged (Hungary), Florence (Italy), and Santiago de Compostela (Spain). The men, randomly selected from the general population, were invited for study-related assessments, including an interviewer-assisted questionnaire, several performance measures, and a fasting blood test before 1000 h. One hundred fifty men were excluded because of known pituitary, testicular, or adrenal disease or use of medications that affect sex-steroid production or action yielding an analytic sample of 3219 men (Supplemental Fig. 1B).

MrOS, an observational study of the determinants of fracture in older men, recruited 5995 community-dwelling men at least 65 yr old at six U.S. centers (17). Of 5995 men who were recruited, total testosterone was measured on fasting, morning serum specimens in 1488 randomly selected men. Among these, 19 men were excluded for missing total testosterone data, and 95 were excluded because of the use of androgens or antiandrogens or reported orchiectomy as a treatment for prostate cancer, resulting in a final analytical sample of 1488 participants (Supplemental Fig. 1C).

Physical function measures (walking speed and self-reported mobility limitation in subsets of FHS, walking speed and frailty in MrOS, and walking speed and self-reported difficulty walking or climbing stairs in EMAS) and diabetes were available in all three cohorts; data on sexual symptoms were available only in EMAS.

Ascertainment of outcomes in the FHS

The self-reported mobility limitation in FHS was determined using a modified Rosow-Breslau questionnaire (28), which has been shown to have high test-retest reliability in other large population-based studies (19, 29, 30). Participants were asked whether they were able to 1) do heavy work around the house, like shovel snow or wash windows, walls, or floors without help; 2) walk half a mile without help (about four to six blocks); and 3) walk up and down one flight of stairs. At this exam, the last item was asked as part of the Katz Activities of Daily Living scale with the following directive: during the course of a normal day, can you walk up and down one flight of stairs independently or do you need human assistance or the use of a device? Response choices included 1) no help needed, independent; 2) uses device, independent; 3) human assistance needed, minimally dependent; 4) dependent; and 5) do not do during a normal day. If the participant reported independence, he was considered able to perform the mobility task (19). A participant was considered to have a mobility limitation if he reported an inability to do one or more of the three items on the scale (19, 28).

Usual walking speed was assessed by asking the participants to walk at their usual pace over a 4-m course at an ancillary study to examination 7 in Gen 2 (19). Participants were allowed to use walking aids if necessary, but not the assistance of another person. For individuals who did not attempt or complete the walk, the value was set to the maximum value obtained by any individual.

DM was defined as a fasting blood glucose of at least 126 mg/dl and/or the use of diabetes medication. Hypertension was defined as systolic blood pressure of at least 140 or diastolic blood pressure at least 90 mm Hg and/or the use of hypertension treatment. Hypercholesterolemia was defined by total cholesterol of at least 240 mg/dl or use of cholesterol-lowering medication. Obesity was defined as body mass index of at least 30 kg/m².

Ascertainment of outcomes in the MrOS

For the measurement of walking speed, the participants were instructed to walk at a comfortable pace over a path of 6 m and completed two consecutively trials without a rest (31). Walking speed was calculated in meters per second using the time to complete two trials. The walking attempts were completed consecutively without a rest between attempts. Slow walking speed was defined if a participant was unable to complete the walk or scored in the slowest 20th percentile based on height-specific thresholds (0.99 m/sec for height ≤174.35 cm, 1.06 m/sec for height >174.35 cm).

Frailty was defined using modified criteria from the Cardiovascular Health Study and previous analyses in MrOS (32, 33). The Cardiovascular Health Study definition uses five components to define the presence of frailty: shrinking/sarcopenia, weakness, slowness, low activity level, and exhaustion (33). Participants with at least three components were defined as frail.

Diabetes was defined by fasting glucose above 126 mg/dl, use of oral hypoglycemic medications or insulin, or self-report of a physician’s diagnosis.

Ascertainment of outcomes in EMAS

The operational definitions of conditions and symptoms in the EMAS are shown in Supplemental Table 1.

Hormone measurements

FHS samples were obtained in the morning, after an overnight fast of approximately 10 h, typically between 0730 and 0830 h. The samples were aliquoted, frozen immediately, and stored at −80 C until the time of assay. The stability of FHS samples in storage has been evaluated previously by measuring the concentrations of cholesterol, high-density lipoprotein cholesterol and triglycerides in samples in the low, mid, and high range before freezing and storage at examination cycle 5 in 1991–1995 with repeated measurement in 2007, after storage at −80 C (34). The concentrations of these analytes were unchanged over a 15-yr period of storage at −80 C in the FHS repository using processes that are similar to those used for the collection and storage of samples included in the analyses reported here with correlation coefficients of measurements in 1991–1995 with repeated measurement in 2007 of 0.985, 0.997, and 0.948, respectively.

We measured total testosterone in the FHS Gen 2 and 3 samples using the same LC-MS/MS assay (19, 35). The functional limit of detection, defined as the lowest concentration, detected with less than 20% coefficient of variation (CV), was 2 ng/dl; no sample was outside the linear range of 2–2000 ng/dl. The recovery was calculated by adding known amounts of testosterone to charcoal-stripped serum and analyzing them by LC-MS/MS. The correlation between the amount added and the amount measured by LC-MS/MS was 0.998. The average recovery was 102 ± 3%. The cross-reactivity of dehydroepiandrosterone, dehydroepiandrosterone sulfate, and dihydrotestosterone, androstenedione, and estradiol in the testosterone assay was negligible at 10 times the circulating concentrations of these hormones. The interassay CV was 15.8% at 12.0 ng/dl, 10.6% at 23.5 ng/dl, 7.9% at 48.6 ng/dl, 7.7% at 241 ng/dl, 4.4% at 532 ng/dl, and 3.3% at 1016 ng/dl. As part of the Centers for Disease Control’s (CDC) Testosterone Assay Harmonization Initiative, quality control samples provided by the CDC were run every 3 months; the CV in quality control samples with testosterone concentrations in the 100- to 1000-ng/dl range was consistently less than 6%. In addition, 28 serum samples from men and women with testosterone concentrations across the male and female range were measured in a blinded manner in the Boston University and Mayo laboratories. The Pearson correlation between values obtained in the two laboratories was higher than 0.99, and Bland-Altman plots revealed no significant differences between values obtained in the two laboratories.

Total testosterone levels in the EMAS (36) and MrOS (37) samples were measured using gas chromatography-MS/MS with sensitivities of 5 and 2.5 ng/dl, respectively. The assays used for measurement of testosterone in MrOS and EMAS have not been cross-calibrated by exchange of samples. In all cohorts, free testosterone was calculated using a published law-of-mass-action equation that uses an association constant estimated from a systematic review of published binding studies and an iterative numerical method (38). The intra- and interassay CV in the low, medium, and high pools were 4.3, 5.5, and 4.9% and 2.4, 8.1, and 2.5%, respectively.

SHBG levels were measured using a two-site immunofluorometric assay (DELFIA-Wallac, Inc., Turku, Finland) (19, 39). The interassay CV were 8.3, 7.9, and 10.9%, and intraassay CV were 7.3, 7.1, and 8.7%, respectively, in the low, medium, and high pools. The analytical sensitivity of the assays was 0.5 nmol/liter.

Statistical methods

By convention, the 2.5th percentile of the FHS reference sample defines the lower limit of the reference range (40–42); total or free testosterone concentrations below the 2.5th percentile value (total testosterone <348.3 ng/dl; free testosterone <70.0 pg/ml) were deemed low.

We determined the relationship of total and free testosterone with outcomes in three community-based samples. For these cross-sectional analyses, we related total and free testosterone levels (separate models for each) to prevalence of physical dysfunction, sexual symptoms, and diabetes (fasting glucose ≥126 mg/dl or on treatment) using multivariable logistic regression models adjusting for age and smoking. Furthermore, In the EMAS and MrOS, which were multicenter studies, the analyses were also adjusted for the study site. We did not adjust for comorbid conditions because some of the comorbid conditions (e.g. diabetes) were the dependent variables in these analyses. Testosterone was modeled as a binary variable (low vs. normal).

In exploratory analyses, we evaluated the Z-score approach, in which hormone levels were regressed on age and standardized residuals were used for continuous analysis. Low testosterone levels were established by ranking the residuals and taking the lowest 10% (or 5%) as the threshold. The T-score and Z-score approaches yielded directionally concordant results (Supplemental Table 2). Also, analyses of spline plots of testosterone levels against outcomes did not yield clear thresholds at which the relationship of testosterone and outcomes changed abruptly.

All analyses were performed using SAS version 9.1 (SAS Institute, Cary, NC), and statistical significance was based on type I error probability of 0.05. The statistical analyses in the EMAS data were conducted using Intercooled STATA version 9.2 (StataCorp, College Station, TX).

Results

Subject characteristics

The STROBE (strengthening the reporting of observational studies in epidemiology) diagram (Fig. 1) illustrates the selection of reference sample of healthy men, 40 yr of age or younger, who were free of cancer, CVD, DM, obesity, hypertension, hypercholesterolemia, and smoking. The baseline characteristics of the samples are summarized in Tables 1 and and2.2. The men in the FHS broad sample were on average younger and had lower prevalence of CVD, diabetes, and cancer than those in the EMAS and MrOS samples (Table 2).

Table 1.

Characteristics of the FHS Gen 3 reference sample

	All subjects (n = 1893)	All subjects ≤40 yr (n = 962)	Reference sample ≤40 yr^a (n = 456)
Age (yr)	40.3 (8.8)	33.3 (5.5)	32.7 (5.7)
<30	224 (11.8%)	224 (23%)	125 (27.4%)
30–39	650 (34.3%)	650 (67.6%)	297 (65.1%)
40–49	726 (38.4%)	88^b (9.2%)	34^b (7.5%)
50–59	274 (14.5%)	NA	NA
≥60	19 (1%)	NA	NA
Caucasian or White	1880 (99.3%)	956 (99.4%)	454 (99.6%)
Family income
<$12,000	33 (1.8%)	17 (1.9%)	11 (2.6%)
$12,000–$24,000	60 (3.3%)	39 (4.3%)	18 (4.3%)
$25,000–$49,999	323 (18%)	192 (21.3%)	73 (17.3%)
$50,000–$74,999	448 (24.9%)	220 (24.4%)	105 (24.8%)
$75,000–$100,000	369 (20.5%)	184 (20.4%)	94 (22.2%)
>$100,000	566 (31.5%)	249 (27.6%)	122 (28.8%)
Systolic BP (mm Hg)	120.8 (12.6)	118.5 (11)	115.5 (8.9)
Diastolic BP (mm Hg)	78.3 (9.3)	76.9 (9.4)	74.1 (7.6)
Hypertension treatment	194 (10.3%)	40 (4.2%)	NA
Total cholesterol (mg/dl)	193 (37.2)	188.5 (39.5)	178.5 (30.2)
LDL cholesterol (mg/dl)	119.8 (31.6)	116.9 (31.9)	110.6 (27.4)
HDL cholesterol (mg/dl)	46.8 (12.4)	46.4 (12.0)	47.6 (11.8)
Triglycerides (mg/dl)	136.1 (109.7)	128 (102.4)	103.8 (72.3)
Cholesterol treatment	208 (11%)	45 (4.7%)	NA
Glucose (mg/dl)	98.6 (17.8)	95.6 (14.1)	93.0 (6.8)
Diabetes treatment	42 (2.2%)	8 (1%)	NA
Body mass index (kg/m²)	28.0 (4.7)	27.4 (4.6)	25.5 (2.7)
Cancer	27 (1.4%)	14 (1.5%)	NA
Prevalent CVD	45 (2.4%)	7 (1%)	NA
Diabetes	48 (2.5%)	8 (1%)	NA
Obesity	493 (26%)	216 (22.5%)	NA
Hypertension	416 (22%)	127 (13.2%)	NA
Hypercholesterolemia	370 (19.6%)	119 (12.4%)	NA
Smoker	347 (18.3%)	183 (19%)	NA

Values are means (sd) or n (%); BP, Blood pressure; HDL, high-density lipoprotein; LDL, low-density lipoprotein; NA, not applicable.

^aHealthy samples from subjects free of cancers, CVD, diabetes, obesity, hypertension, and hypercholesterolemia and who were nonsmokers.

^bThese men are exactly 40 yr of age.

Table 2.

Characteristics of the participants in the three cohorts

	Broad FHS sample (Gen 2 plus Gen 3) (n = 3352)	EMAS (n = 3219)	MrOS (n = 1488)
Age (yr)	49.4 (13.8)	59.7 (11.0)	73.7 (5.8)
<30	224 (6.7%)	0 (0%)	0 (0%)
30–39	660 (19.7%)	0 (0%)	0 (0%)
40–49	872 (26.0%)	782 (24.3%)	0 (0%)
50–59	788 (23.5%)	873 (27.1%)	0 (%)
60–69	493 (14.7%)	799 (24.9%)	447 (30.0%)
70–79	289 (8.6%)	761 (23.7%)	782 (52.6%)
≥80	26 (0.78%)		259 (17.4%)
Systolic BP (mm Hg)	124.0 (15.4)	146.1 (20.9)	138.9 (18.8)
Diastolic BP (mm Hg)	77.3 (9.6)	87.3 (12.4)	NA
Hypertension treatment	736 (22.0%)		579 (38.9%)
Total cholesterol (mg/dl)	192.7 (36.4)	214.5 (48.5)	192.7 (33.2)
LDL cholesterol (mg/dl)	119.6 (31.5)	133.7 (44.1)	113.7 (29.9)
HDL cholesterol (mg/dl)	46.2 (12.7)	54.4 (14.4)	49.2 (14.6)
Triglycerides (mg/dl)	139.3 (106.1)	139.2 (103.7)	148.8 (91.9)
Cholesterol treatment	562 (16.8%)		NA
Glucose (mg/dl)	102.9 (23.2)	101.7 (25.1)	105.9 (26.9)
Diabetes treatment	166 (5.0%)		143 (9.6%)
Body mass index (kg/m²)	28.3 (4.7)	27.7 (4.1)	27.4 (3.7)
Cancer	169 (5.0%)	170 (5.3)	424 (28.5%)
Prevalent CVD	303 (9.0%)	1137 (35.4)	434 (29.2%)
Diabetes	274 (8.2%)	236 (7.5)	149 (10.0%)
Obesity	964 (28.8%)	773 (24.5)	304 (20.4%)
Hypertension	1130 (33.7%)	895 (28.3%)	NA
Hypercholesterolemia	850 (25.4%)	786 (24.60%)	109 (7.3%)
Smoker	535 (16.0%)	681 (21.4)	57 (3.8%)

BP, Blood pressure; HDL, high-density lipoprotein; LDL, low-density lipoprotein; NA, not applicable.

Distribution of testosterone levels in the reference sample

Table 3 describes the distribution of total and free testosterone levels in the reference sample. The mean and median total testosterone concentrations were 723.8 and 698.7 ng/dl, respectively. For free testosterone, the corresponding mean and median values were 141.8 and 134.0 pg/ml, respectively. Consistent with the approach used for defining reference limits for many other analytes (41, 42), total and free testosterone values below the 2.5th percentile (less than approximately 2 sd below the mean) were deemed low. The 2.5th percentile value for total testosterone was 348.3 ng/dl (12.1 nmol/liter), and for free testosterone 70.0 pg/ml (243 pmol/liter) in the reference sample.

Table 3.

Distribution of total and free testosterone in the FHS reference sample (n = 456)

	Total testosterone (ng/dl)	Free testosterone (pg/ml)
Mean	723.8	141.8
sd	221.1	45.0
Median	698.7	134.0
Quartile range (Q3–Q1)	296.5	60.0
Percentile
99th	1322.0	266.0
97.5th	1196.6	230.0
95th	1124.0	222.0
5th	405.9	77.0
2.5th	348.3	70.0
1st	282.0	55.0

To convert total testosterone from nanograms per deciliter to nanomoles per liter, multiply concentrations in nanograms per deciliter by 0.0347. To convert free testosterone from picograms per milliliter to picomoles per liter, multiply concentrations in picograms per milliliter by 3.47.

Distribution and categorization of testosterone levels in FHS broad sample and the EMAS and MrOS samples

The distribution of total and free testosterone levels by decades of age was similar in the three cohorts and revealed the expected age-related decline (Fig. 2 and Supplemental Tables 4 and 5). Because of the higher average age of the MrOS participants than that of the other two cohorts, the prevalence of low total and free testosterone was higher in MrOS than in the other two cohorts; 10.4% of men in the FHS broad sample, 23.5% of men in the EMAS, and 40.3% of men in the MrOS had low total testosterone. The prevalence of low free testosterone was 18.1, 24.0, and 61.4%, respectively, in the FHS, EMAS, and MrOS cohorts. In the FHS broad sample, serum total and free testosterone were associated inversely with age, body mass index, and comorbidity and positively with smoking (Supplemental Table 3); similar associations have been reported previously in the EMAS and MrOS.

Fig. 2.

Distribution of total and free testosterone levels by decades of age in the FHS broad sample as well as the EMAS and MrOS validation samples. Means and sd bars are shown. To convert total testosterone from nanograms per deciliter to nanomoles per liter, multiply concentrations in nanograms per deciliter by 0.0347. To convert free testosterone from picograms per milliliter to picomoles per liter, multiply concentrations in picograms per milliliter by 3.47.

Relationship of low testosterone levels with outcomes in the three cohorts

Sexual symptoms, available in the EMAS, were analyzed using multivariable logistic regression models adjusted for age, smoking, and site. Compared with men with normal testosterone levels, men with low total testosterone were more likely to report decreased morning erections (Fig. 3), and the men with low free testosterone were more likely to report decreased morning erections, erectile dysfunction, and decreased frequency of sexual thoughts.

Fig. 3.

Association of low total or free testosterone with sexual symptoms, physical dysfunction, DM, or any one of these conditions in the FHS, EMAS, and MrOS cohorts. The odds ratios along with the 95% confidence intervals for the association of total and free testosterone with various outcomes in the three validation cohorts are shown. The composite outcome indicates the following: in FHS, one or more of slow walking speed (walking speed in the lowest 20th percentile), self-reported mobility limitation, or diabetes; in EMAS, one or more of low frequency of morning erections, erectile dysfunction, low frequency of sexual thoughts, difficulty in climbing several stairs, limited in walking more than 1 km, slow walking speed (walking speed in the lowest 20th percentile), or diabetes; in MrOS, one or more of frailty, slow walking speed (walking speed in the lowest 20th percentile), or diabetes.

In general, men with low total or free testosterone were more likely to have low walking speed, frailty, or physical symptoms than those with normal levels (Fig. 3). Thus, EMAS participants with low total or free testosterone were more likely to report difficulty climbing stairs or have low walking speed (in the lowest 20th percentile). In MrOS, men with low total or free testosterone were more likely to have slow walking speed than those with normal testosterone; men with low free testosterone were also more likely to have frailty. As reported previously (20), the FHS participants with low free testosterone were at higher risk of self-reported mobility limitation.

In all three cohorts, the men with low total and free testosterone levels were nearly twice as likely to have DM as those with normal levels (Fig. 3). Similarly, in all three cohorts, men with low total and free testosterone were more likely to have at least one of the following: sexual symptoms (EMAS only), a marker of physical dysfunction, or diabetes (Fig. 3). Sensitivity analyses (not shown) considering the 1st and 5th percentiles, as opposed to the 2.5th, as the threshold value for low testosterone, yielded qualitatively concordant results.

Discussion

We generated reference limits for total and free testosterone levels in a community-based sample of healthy young men using LC-MS/MS, an accurate method with high precision and accuracy. We demonstrated that values below the proposed lower reference limits were associated with increased risk of conditions that have been associated previously with androgen deficiency (19–27) in three geographically distinct populations. Thus, men deemed to have low total or free testosterone levels had increased prevalence of sexual symptoms (15), physical dysfunction (18–21), and DM (22–27) in one or more cohorts.

Epidemiological studies such as these do not permit inferences about the causal role of testosterone in the three categories of conditions studied in this investigation; reverse causality is possible and cannot be excluded. These conditions should not necessarily be viewed as representative symptoms or conditions resulting from an androgen-deficient state.

The Endocrine Society defined androgen deficiency in men as a syndrome characterized by symptoms and signs and low testosterone levels (1). The occurrence of low testosterone level alone does not constitute androgen deficiency. The prevalence of low total or free testosterone in the three cohorts should not be viewed as indicative of a high prevalence of androgen deficiency in these cohorts or in the general population. Previous analyses of the EMAS (15) and Massachusetts Male Aging Study data (44) have shown that the prevalence of symptomatic androgen deficiency is substantially lower (2–5%) than the prevalence of low testosterone levels. In comparison with FHS and EMAS cohorts, MrOS participants were older and had a higher prevalence of comorbid conditions such as cancer and diabetes and also of low total and free testosterone levels.

This study has several strengths. The FHS reference cohort has many characteristics of an optimum sample described by the International Federation of Clinical Chemistry (40–42). This was a community-based sample of healthy men in sufficiently large numbers (40–42). Unlike some other epidemiological studies, which included only middle-aged and older individuals (10), the FHS included both young and older individuals. The FHS samples were drawn in the morning after overnight fast, as recommended by the Endocrine Society guidelines (1), and stored at −80 C and never thawed. The data have internal consistency, as indicated by the expected inverse association of testosterone with age, body mass index, and comorbid conditions and a positive association with smoking. We used LC-MS/MS, the method with high specificity and accuracy. The consistency of the associations of low testosterone with the prevalence of sexual, physical and metabolic conditions across three geographically distinct samples is noteworthy.

This study also has some limitations. These reference ranges were derived from single morning samples, which discount the pulsatile, diurnal, and circannual rhythms. Symptomatic androgen deficiency designation may not be persistent over time (45). Our analyses show that early morning testosterone levels, obtained in a manner similar to that used by physicians in practice, are associated cross-sectionally with symptoms and clinical outcomes. The mass spectrometry methods used for measuring testosterone concentrations differed across the three cohorts, and the assays from EMAS and MrOS have not been cross-calibrated. The assays were performed in samples stored at −80 C; the stability of SHBG in stored samples cannot be assumed. We determined reference ranges in men 40 yr of age or younger. This age cutoff is admittedly arbitrary because there is no evidence of an inflection point in the trend line at this age. Our approach of generating the reference range in healthy young men is similar to the use of T-scores for bone mineral density. Although for some analytes, it may be appropriate to generate age-adjusted reference ranges (40–42), for others that exhibit substantial age-related change, it may be more appropriate to derive the reference ranges in a healthy, young population. However, it is difficult to determine with certainty at this time whether age-adjusted reference ranges may be needed. Given the white ethnicity of the reference sample, investigations of multiethnic cohorts to evaluate the generalizability of the proposed reference limits is important. Some studies have reported significant geographic and racial differences in sex-steroid levels (46), whereas others have not (47, 48). We calculated free testosterone concentrations using a previously published equation (38); calculated free testosterone concentrations may differ from those measured by the equilibrium dialysis method (49–51). Furthermore, different equations may yield different results depending upon the dissociation constants and the assumptions embedded in the equation. Finally, we cannot exclude the possibility that some men with putative androgen deficiency may have been included in the reference sample.

The lower limit of total testosterone levels in the FHS reference sample is slightly higher than the threshold reported historically (∼300 ng/dl, 10.4 nmol/liter) but closer to the thresholds associated with sexual and physical symptoms in a recent investigation of older men (15). The thresholds for various sexual and metabolic outcomes in men supplemented with graded doses of testosterone after pharmacological suppression of endogenous testosterone production or in men with androgen deficiency receiving replacement doses of testosterone generally have been in the 250- to 400-ng/dl range (39, 52, 53). In contrast to our study, which generated the reference range in healthy men, 19–40 yr of age, using LC-MS/MS, previous epidemiological studies included middle-aged and older men and used immunoassays. We excluded men with comorbid conditions from the reference sample.

Despite these attempts to remove influences of comorbid conditions and other factors, however, there remain many sources of variation that cannot be controlled. Differences in study populations, subject selection, time of sample collection, and testosterone assays may contribute to the differences in normative ranges observed here and in other studies. These reference ranges, generated in a reference sample of healthy, lean young men of the FHS, cannot be applied to other assays in other laboratories without appropriate cross-calibration of assays. Historical experience with cholesterol and hemoglobin A1C assays indicates that the application of reference ranges across laboratories is a challenging process that requires mechanisms for standardizing assays (43, 54). The CDC testosterone standardization effort addresses this challenge and will facilitate the application of these reference ranges across laboratories.

It is likely that the results exhibited here may apply to other thresholds proposed for the lower limit to normative ranges. The proposed reference ranges represent the essential first step in defining androgen deficiency syndrome in men. The data here define only a potential reference interval from a general population; how well these discriminating thresholds can be applied to clinical diagnosis of androgen deficiency syndrome needs further validation using receiver operating characteristic curves in clinical populations. The association of low testosterone defined using these criteria with incident outcomes should be evaluated longitudinally to exclude reverse causality. Ultimately, placebo-controlled, randomized trials would be necessary to determine whether testosterone therapy improves outcomes in men deemed androgen deficient by the presence of testosterone levels below the thresholds reported here and symptoms and signs.

Acknowledgments

This work was supported by primarily by National Institutes of Health (NIH) Grant 1RO1AG31206 to S.B. and R.S.V. Additional support was provided by the Boston Claude D. Pepper Older Americans Independence Center Grant 5P30AG031679 from the National Institute on Aging (NIA) and by a grant from the CDC Foundation. The Framingham Heart Study is supported by the National Heart, Lung, and Blood Institute’s Framingham Heart Study contract N01-HC-25195. The EMAS is funded by the Commission of the European Communities Fifth Framework Program “Quality of Life and Management of Living Resources” Grant QLK6-CT-2001-00258. The Osteoporotic Fractures in Men (MrOS) Study is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the NIA, the National Center for Research Resources, and NIH Roadmap for Medical Research under the following grant numbers: U01 AR45580;, U01 AR45614;, U01 AR45632;, U01 AR45647;, U01 AR45654;, U01 AR45583;, U01 AG18197;, U01-AG027810;, and UL1 RR024140.

The External Advisory Board included Peter J. Snyder, M.D.; Andre Araujo, Ph.D.; and William Rosner, M.D.

Members of the EMAS Group include A. J. Silman and T. W. O’Neill (Andrology Research Unit, Manchester, UK), G. Bartfai (Albert Szent-Göorgy Medical University, Szeged, Hungary), F. Casanueva (Instituto Salud Carlos III, Santiago de Compostela, Spain), G. Forti (University of Florence, Florence, Italy), A. Giwercman (Malmö University Hospital, University of Lund, Sweden), T. S. Han and M. E. J. Lean (University of Glasgow, Glasgow, Scotland, UK), I. T. Huhtaniemi (Imperial College London, London, UK), K. Kula (Medical University of Lodz, Lodz, Poland), N. Pendleton (The University of Manchester, Hope Hospital, Salford, UK), M. Punab (United Laboratories of Tartu University Clinics, Tartu, Estonia), S. Boonen (Catholic University of Leuven, Leuven, Belgium), and D. Vanderschueren (Centers for Disease Control and Prevention, Atlanta, GA).

Disclosure Summary: The authors have no conflicts in relations to this research.

Footnotes

Abbreviations:

CVD: Cardiovascular disease
DM: diabetes mellitus
EMAS: European Male Aging Study
FHS: Framingham Heart Study
Gen 3: third generation
LC-MS/MS: liquid chromatography tandem mass spectrometry
MrOS: Osteoporotic Fractures in Men Study.

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Tag: obesity

3 Common—and 4 Uncommon—Risks to Men’s Sexual Health

Men should know their testosterone levels by age 30 to prevent health issues like weight gain and muscle loss, says top urologist

What we think of as ‘normal’ testosterone, and why it’s not a perfect barometer

Low testosterone can cause low energy, low libido, and loss of muscle

Testosterone therapy may not be as risky as previously believed

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Sugar and aging

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Sugar and aging: diabetes

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Talk To A Doctor

Exercise

Diet

Can You Use Vaseline in Place of Viagra?

The science

Clinical treatments

Oral medications

Vacuum pumps

Penile injections

Penile implants

Alternative treatments

Lifestyle changes

When to talk with a doctor

Occasional concern

Persistent concern

The bottom line

What to know about penis health

Lifestyle factors that affect penis health

Sexual relationships

Weight management

Diet

Exercise

Alcohol and tobacco use

Health conditions that may affect penis health

When to see a doctor

How to care for the penis

Tips for a healthy penis

Summary

How to Boost Your Relationship and Sex Life with Healthy Eating

Food and sex

Diet and supplements

Healthy diet

Arginine and L-citrulline

Zinc

Alcohol

Food-related habits and conflicts

Eating together

Food conflicts

Support

Diet-related conditions

Excess weight

High blood pressure

High cholesterol

Tips for a healthy sex life

Try these

Context:

Methods:

Results:

Conclusion:

Materials and Methods

Study sample

Application to EMAS, MrOS, and FHS broad samples

Ascertainment of outcomes in the FHS

Ascertainment of outcomes in the MrOS

Ascertainment of outcomes in EMAS

Hormone measurements

Statistical methods

Results

Subject characteristics

Table 1.

Table 2.

Distribution of testosterone levels in the reference sample

Table 3.

Distribution and categorization of testosterone levels in FHS broad sample and the EMAS and MrOS samples

Relationship of low testosterone levels with outcomes in the three cohorts

Discussion