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I get so much email on this that I wanted to make a summary page to refer people to.  I'm not a doctor but this is a summary of what I've read.

I recommend a blood test for TSH (thyroid), HDL cholesterol, prolactin, cortisol, free testosterone, glucose (for diabetes) and estrogen.  I'd also check for hypertension and maybe go with an ARB.  Some references:

Atherosclerosis (http://qualitycounts.com/fphardeningofarteries.htm):

• What about erectile dysfunction? - Dr. Murray Natural Facts, 8/24/05 - "by far the most common cause of impotence by far is atherosclerosis of the penile artery. Atherosclerosis refers to a process of hardening the artery walls due to a build up of plaque containing cholesterol, fatty material, and cellular debris"
• Major Statin Study Reveals Several Important Findings For Reducing Prostate Cancer And Disease - Science Daily, 4/26/09 - "non-statin users were three times more likely to develop prostate cancer, suggesting statin use may prevent development of prostate cancer ... Overall, statin use was not significantly associated with a decreased risk of developing ED. However, statins were associated with a decreased risk of ED among older men (>60 years). Men in this age category who used statins were less likely to develop ED, compared to older men who did not use statins. Additionally, men who took statins for a longer time were more protected against developing ED. For example, men who took statins for nearly nine years or more were 64 percent less likely to develop ED, while men who took statins for less than three years had about the same risk of developing ED. compared to men who did not take statins" - See atorvastatin at OffshoreRx1.com.
• Erectile Dysfunction, Artery Problems Linked? - WebMD, 10/11/05 - "Erectile dysfunction often stems from blood vessel problems tied to atherosclerosis, the hardening of the arteries"

Benign enlargement of the prostate gland (BPH) (http://qualitycounts.com/fpprostate.html):

• ED Drugs May Treat Urinary Problems - WebMD, 5/23/07 - "Sexual performance in men seems to decline as their prostate enlargement becomes more severe, experts have begun to notice ... A once-a-day dose of Cialis helped men with erectile dysfunction and moderate to severe urinary tract symptoms due to an enlarged prostate improve sexual functioning" - See tadalafil at OffshoreRx1.com.
• Lilly ICOS Announces Positive Results from Phase 2 Study of Tadalafil in Treating Symptoms of Benign Prostatic Hyperplasia - genengnews.com, 10/12/05 - "After stepping up to 20 mg tadalafil and continuing therapy once-a-day for another six weeks, patients experienced a mean 3.8 point improvement from baseline in the IPSS, compared to a mean 1.7 point improvement for patients on placebo ... More than half of men over age 50 have symptoms caused by BPH. More than 50 percent of men with BPH also suffer from ED" - See tadalafil at OffshoreRx1.com or SuperSaverMeds.com.

Thyroid (http://qualitycounts.com/fphypothyroidism.html):

• Erectile Dysfunction / Impotence - Prostate Health Guide - U. of Maryland Medicine - "Hormonal abnormalities such as increased prolactin (a hormone produced by the anterior pituitary gland), steroid abuse by body-builders, too much or too little thyroid hormone, and hormones administered for prostate cancer may cause impotence. Rarely is low testosterone responsible for impotence"
• Evaluation and Treatment of Male Sexual Dysfunction - aace.com - "Other endocrine disorders that may cause libido or erectile difficulties include hypothyroidism, hyperthyroidism, adrenal insufficiency, or excessive levels of adrenal corticosteroids."

HDL (http://qualitycounts.com/fphdl.html):

• Erectile Dysfunction / Impotence - Prostate Health Guide - U. of Maryland Medicine - "Direct risk factors for erectile dysfunction may include the following: ... low levels of HDL (high-density lipoprotein)"
• Laboratory Investigations of Erectile Dysfunction - WebMD - "men with erectile dysfunction frequently have low levels of high-density lipoproteins, the good form of cholesterol."

Glucose (http://qualitycounts.com/fpdiabetes.html):

• Erectile Dysfunction / Impotence - Prostate Health Guide - U. of Maryland Medicine - "There are 5 million adult men in the US with diabetes, and it is estimated that half are impotent and the other half will become impotent in time. The process involves premature and unusually severe hardening of the arteries. Peripheral neuropathy, with involvement of the nerves controlling erections, is commonly seen in persons with diabetes"
• Cause Of Diabetes-related Erectile Dysfunction Is Clarified By Johns Hopkins Researchers - Science Daily, 8/11/05 - "one particular simple sugar, present in increased levels in diabetics, interferes with the chain of events needed to achieve and maintain erection and can lead to permanent penile impairment over time"
• Glycosylated haemoglobin levels and the severity of erectile function in diabetic men - BJU Int. 2005 Mar;95(4):615-7 - "This study suggests that the severity of ED is associated with increasing HbA(1c) levels in diabetic men"
• Erectile Dysfunction May Be Warning Sign - WebMD, 1/20/04 - "erectile dysfunction affects about 52% of men between ages 40 and 70 years, and the majority of cases are caused by conditions that affect blood flow to the penis, such as atherosclerosis and diabetes"
• Relationship between obesity-related metabolic abnormalities and sexual function - J Endocrinol Invest. 2003;26(3 Suppl):62-4 - "it will be reported about the 3 possible mechanisms through which obese people may suffer from sexual dysfunction: a) insulin resistance and associated hormonal changes, b) dyslipidemia and related drugs, and c) psychological problems"
• Pathophysiology of diabetic sexual dysfunction - J Endocrinol Invest. 2003;26(3 Suppl):65-9
• The Metabolic Syndrome: a Cause of Sexual Dysfunction in Women - Medscape, 5/27/05 - "women with the metabolic syndrome reported significantly lower arousal, orgasm, and lubrication scores"

Prolactin (http://qualitycounts.com/fpprolactin.html):

• Prolactin - colostate.edu - "Excessive secretion of prolactin - hyperprolactinemia - is a relative common disorder in humans ... Men with hyperprolactinemia typically show hypogonadism, with decreased sex drive, decreased sperm production and impotence. Such men also often show breast enlargement (gynecomastia)"
• Evaluation and Treatment of Male Sexual Dysfunction - aace.com - "Libido problems may be related to hypogonadism, hyperprolactinemia, depression, fear of sexual failure, certain medications, or systemic illness ... increased prolactin levels may also result in erectile problems, even in the presence of a normal testosterone level ...  Excessive consumption of alcohol or use of other recreational drugs may cause sexual dysfunction, either by causing increased prolactin or decreased testosterone production (or both) ... Psychotropic agents may raise prolactin levels"
• 5-HTP SeroTonic™ & 5-HTP Slim™ May Help Make Spring Come Sooner - Apr. 1998 - Life Enhancement Magazine, 4/98 - "High levels of prolactin have been shown to reflect many depressive states ... 5-HTP reduces prolactin"
• Effects of pyridoxine hydrochloride (vitamin B6) on chlorpromazine-induced serum prolactin rise in male rats - J Pharm Sci. 1979 Sep;68(9):1179-81 - "Pyridoxine hydrochloride significantly suppressed the chlorpromazine-induced prolactin rise"
• Acute effects of LI 160 (extract of Hypericum perforatum, St John's wort) and two of its constituents on neuroendocrine responses in the rat - J Psychopharmacol. 2000;14(4):360-3 - "LI 160 also lowered plasma prolactin and prevented the increase in plasma prolactin following haloperidol administration"
• Aripiprazole Benefits Are Sustained Over Time - Clinical Psychiatry News, 5/03 - "Pooled data from short-term clinical studies showed a mean decline of 57% in serum prolactin among 729 patients receiving aripiprazole"
• Prolactin Excess - asrm.org - "Bromocriptine (Parlodel®) is the main drug used to treat prolactin excess.  I works by suppressing prolactin production.  The starting dosage is usually 1.25 to 2.5 mg nightly, with the dosage slowly increased until prolactin level return to the normal range"

Estrogen (http://qualitycounts.com/fparomatization.html):

• Androgel prescribing information - androgel.com - "Serum estradiol (E2) concentrations increased significantly within 30 days of starting treatment with AndroGel® 5 or 10 G/day and remained elevated throughout the treatment period but remained within the normal range for eugonadal men"
• Aromatase Inhibition Corrects Endocrinopathy In Infertile Men - Doctor's Guide, 4/9/01 - "investigators found that men with severe infertility had significantly lower testosterone (328 versus 543 ng/dl) and significantly higher oestradiol (58.4 versus 43.5 ng/l) than the fertile controls. As a result, the infertile men had much lower testosterone-to-oestradiol ratios ... These abnormalities were corrected in the 45 men who received testolactone and their testosterone-to-oestradiol ratios rose into the normal range"
• Replenish Testosterone Naturally - Life Extension Magazine, 1/00  - "Through a variety of mechanisms, aging men suffer from the dual effects of having too little testosterone and excess estrogen. The result is a testosterone/ estrogen imbalance that can severely inhibit sexual desire and performance ... Too much estrogen plays havoc with a man's sex life by binding to testosterone receptor sites and may contribute to the over-production of SHBG. SHBG binds free testosterone in a way that makes it unavailable to receptor sites in the brain, nerves and genitals."

Cortisol (http://qualitycounts.com/fpcortisol.html):

• The relationship of serum and salivary cortisol levels to male sexual dysfunction as measured by the International Index of Erectile Function - Int J Impot Res. 2009 May 7 - "testosterone (T) and cortisol (F) ... (Total-T, Free-T, Bioavailable-T, Total-F and Bioavailable-F) and salivary hormones (Saliva-T and Saliva-F) ... International Index of Erectile Function (IIEF) ... Free-T and Bioavailable-T showed significant inverse correlations with age (P<0.01). In the group not taking antidepressants, the levels of Bioavailable-F and Saliva-F showed significant inverse correlations with a portion of the IIEF score (P<0.05). However, reductions in Bioavailable-T and Saliva-T showed no association with the IIEF score. In the group taking antidepressants, these hormone levels showed no correlation with IIEF"
• Evaluation and Treatment of Male Sexual Dysfunction - American Association of Clinical Endocrinologists and The American College of Endocrinology - "Most problems revolve around dysfunction of the hypothalamic-pituitary-gonadal axis and are associated with either excess prolactin or decreased testosterone levels. Other endocrine disorders that may cause libido or erectile difficulties include hypothyroidism, hyperthyroidism, adrenal insufficiency, or excessive levels of adrenal corticosteroids."
• Physical and Psychological Effects of Stress - MedicineNet.com, 2/02 - "Under excessive stress, we tend to produce cortisol, the classic anti-stress hormone produced by our body, perhaps to conserve energy. However the side-effect here is sexual dysfunction and infertility as cortisol also inhibits production of the hormones essential for sexual"

Testosterone (http://www.qualitycounts.com/fptestosterone.html):

• Improving Erectile Function: Detection, Prevention, and Treatment of ED - PowerPak.com, exp. 4/1/05 - "ED was 82% more likely in men with depression ... Low serum testosterone levels are noted in up to 36% of patients with ED. However, the correction of sexual dysfunction with testosterone replacement therapy alone is poor, with treatment response at approximately 35%" - That may be because testosterone does two things that hinder sexual function.  It decreases HDL cholesterol and it increases estrogen.  See:
  • Testosterone administration to men increases hepatic lipase activity and decreases HDL and LDL size in 3 wk - Am J Physiol Endocrinol Metab 2003 Jun;284(6):E1112-8 - "To determine how HDL-C and LDL-C particles are affected by testosterone administration to eugonadal men, testosterone was administered as a supraphysiological dose (600 mg/wk) for 3 wk to elderly, obese, eugonadal men before elective hip or knee surgery, and lipids were measured by routine methods and by density gradient ultracentrifugation. Hepatic lipase activity increased >60% above baseline levels, and HDL-C, HDL(2), and HDL(3) significantly declined in 3 wk. In addition, the LDL-C peak particle density and the amount of LDL-C significantly increased. Testosterone is therefore a potent stimulator of hepatic lipase activity, decreasing HDL-C, HDL(2), and HDL(3) as well as increasing LDL particle density changes, all associated with increased cardiovascular risk"
  • Androgel prescribing information - androgel.com - "Serum estradiol (E2) concentrations increased significantly within 30 days of starting treatment with AndroGel® 5 or 10 G/day and remained elevated throughout the treatment period but remained within the normal range for eugonadal men"
• Erectile Dysfunction / Impotence - Prostate Health Guide - U. of Maryland Medicine - "Hormonal abnormalities such as increased prolactin (a hormone produced by the anterior pituitary gland), steroid abuse by body-builders, too much or too little thyroid hormone, and hormones administered for prostate cancer may cause impotence. Rarely is low testosterone responsible for impotence"

Hypertension (http://qualitycounts.com/fpbloodpress.html):

• Erectile Dysfunction Seen in Men With Prehypertension - Doctor's Guide, 5/19/05
• Blood Pressure Linked to Erectile Dysfunction - WebMD, 5/16/05 - "if a man's blood pressure is anything but normal, he may have a higher risk of erectile dysfunction ... Thirty-five percent had some degree of erectile dysfunction, compared with 14% of men without high blood pressure ... In men with high blood pressure, 20% of those taking no medication had erectile dysfunction, while 36% on one medication and 47% on more than one reported erectile dysfunction ... Men on older high blood pressure medications (diuretics, beta-blockers) had higher rates and more severe erectile dysfunction than men on newer medications (calcium antagonists, ACE inhibitors, angiotensin II receptor blockers)"
• More Guidelines, CCBs, ACEs, and ARBs, and Novel Predictors - Medscape, 9/14/04 - "spontaneously hypertensive rats (SHR) demonstrate detectable erectile dysfunction (ED) before the onset of hypertension This may be due to earlier manifestation of the effects of endothelial dysfunction and tissue remodeling in erectile tissue compared with vascular tissue"
• High Blood Pressure Kills Sex - WebMD, 3/21/02 - "the problem may not be with blood flow alone. New research suggests plummeting levels of the male hormone testosterone could partly be to blame"
• Valsartan Appears to Improve Sexual Function in Men and Women with Hypertension - Doctor's Guide, 5/18/03 - "Men and women being treated with the angiotensin II receptor blocker valsartan for mild-to-moderate hypertension appear to show improvements in sexual function and desire"
• Impotent Patients on Valsartan Find Increased Interest in Sex; Use Sildenafil More Often - Doctor's Guide, 5/19/02 - "Because the use of sildenafil significantly increased with the use of valsartan, it suggests that angiotensin II antagonism induces an increase in sexual desire in impotent hypertensive men ... It could be related to the reactive stimulation of angiotensin cascade due to AT1 receptors blockade"
• Blood pressure drug reverses sexual dysfunction - Life Extension Magazine, 7/01 - "the active ingredient in Cozaar and Hyaar (losartan) can significantly improve sex lives of men who suffer from sexual dysfunction"
• Newest Hypertension Drug, Losartan, May Improve Sexual Function - Doctor's Guide, 5/1/01
• Carvedilol Reduces But Valsartan May Increase Sexual Activity In Hypertensive Men - Doctor's Guide, 2/1/01 - "carvedilol induces a chronic reduction of sexual activity whereas valsartan, an angiotensin II antagonist, not only does not significantly reduce sexual activity but may even increase it."

Iron overload (http://www.qualitycounts.com/fpiron.html):

• Iron Overload - MedicineNet.com - "Iron deposits in the pituitary gland and testicles cause shrinkage of the testicles and impotence"
• Iron Disorders Institute - Disorder Overview - irondisorders.org - "Undiagnosed, untreated iron overload, regardless of its origin can lead to diabetes, arthritis, depression, impotence, liver-gall bladder disease, complete liver failure, heart attack and cancer"
• Hemochromatosis: If you don't know what it is, you should - CNN, 7/26/99

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