Men with erectile dysfunction may face higher risk of death -- study

Before you get too far into reading this article, we should just put this out there again: Erectile dysfunction is extremely common. The condition affects one in ten men. But it can also be a signal of bigger health problems, a new study has revealed.

Men with erectile dysfunction have a higher risk of death, regardless of a factor you think might contribute to it: their testosterone levels. That is because erection issues can take a toll on men’s mental and physical health, too.

Other sexual symptoms, like low libido and poor morning erections, also predict premature death. Getting these symptoms -- and the factors driving them -- under control could lead to huge sexual and physical health gains.

“Men dealing with sexual symptoms should keep in mind that sexual symptoms could be an early warning sign of a poor or worsening health status as well as increased risk for (cardiovascular) disease and mortality,” Leen Antonio, a co-author on the new study and researcher at KU Leuven-University Hospitals in Belgium, tells Inverse.

“It is important to discuss sexual symptoms with your doctor, as to identify and treat other cardiovascular risk factors or apparent cardiovascular disease.”

The research will be published in a special supplemental section of the Journal of the Endocrine Society. It was to be presented at an annual meeting but it was canceled because of the Covid-19 pandemic.

In the past, low testosterone has been associated with higher mortality rates in middle-aged and older men, but this link should be interpreted “with care” Antonio says, because studies have been inconsistent and heterogeneous. The higher risk of death may have been driven by underlying health conditions or confounding factors.

When it comes to erectile dysfunction, other literature reviews have also found the condition is associated with higher mortality rates.

To shed light on the mixed bag of research, Antonio and her team analyzed data from 1,913 men between 40 and 79 participating in the European Male Ageing Study.

At the start of the study, the researchers captured the relationship between participants' hormone measurements and sexual function. They looked at symptoms like poor morning erections, low libido, and erectile dysfunction, as well as men’s total testosterone and free testosterone levels, or testosterone that’s easily used by the body.

Then, they tracked the participants for 12.4 years, documenting who survived and who passed away. During the follow-up period, 25 percent of the cohort, or 483 men, died.

Analyzing the symptoms of the group was striking: In men with normal testosterone levels, those with sexual symptoms, particularly erectile dysfunction, were 51 percent more likely to die than those without these symptoms.

In men with erectile dysfunction, poor morning erections and low libido, the risk of dying was almost 1.8 times higher compared to men without symptoms. In men with just erectile dysfunction, the risk of dying was 1.4 times higher compared to men without erectile dysfunction.

Men with low total testosterone and sexual symptoms had a higher risk of death compared with men with normal testosterone levels and no sexual symptoms.

Levels of free testosterone were also lower in those who died. Men who had the lowest levels of free testosterone had a higher risk of death compared to men who had the highest levels.

From these results, it is impossible to draw "firm conclusions" about the underlying mechanism, Antonio says.

"A possible explanation could be that sexual symptoms are an early sign for increased cardiovascular risk," she says.

According to the Cleveland Clinic, having erectile dysfunction is as strong a risk factor for heart disease as smoking or having a family history for the disease.

Improving heart health is likely to curb sexual symptoms, too. Getting and sustaining an erection relies on adequate blood circulation, optimized nerve function, and a stimulus from the brain. Staying active, maintaining a healthy weight, not smoking, and drinking in moderation, or quitting completely, can help.

"Our study does not allows us to conclude that treating sexual symptoms in itself will add years to their life," Antonio cautions.

"However, implementing a healthy lifestyle and treatment of other cardiovascular risk factors can certainly be beneficial to improve general health and reduce mortality risk in men suffering from sexual dysfunction."

Objective: To study the interrelationships between sex steroids, gonadotrophins and sexual symptoms with all-cause mortality in a large prospective cohort of European men.

Methods: 1913 community-dwelling men, aged 40-79, participated in the European Male Ageing Study (EMAS) between 2003-2005. Sexual symptoms were assessed via a validated questionnaire (EMAS-SFQ). Sex steroids were measured by mass spectrometry. In 5 of 8 EMAS centres, survival status was available until 1 April 2018. Cox proportional hazard models were used to study the association between hormones, sexual symptoms and mortality. Because of the wide age range at study entry, age was used as time-scale, instead of years since inclusion adjusting for age. Results were expressed as hazard ratios (HR) with 95% confidence intervals, adjusted for centre, BMI and smoking.

Results: 483 (25.3%) men died during a mean follow-up of 12.4±3.3 years. Men who died had a higher BMI (p=0.002), but smoking status did not differ. TT levels were similar in both groups, but FT was lower in those who died (mean±SD: 312±86 pmol/L vs 270±84, p<0.001) and LH was higher (5.7±3.3 U/L vs 7.8±5.8, p<0.001). Men in the lowest FT quartile had higher mortality risk compared to men in the highest quartile (HR 1.43 (1.06-1.95); p=0.021). Also men in the highest FSH quartile had increased mortality risk (HR 1.38 (1.02-1.88); p=0.036). However, there was no association with TT, E2 or LH. Men with 3 sexual symptoms had a higher mortality risk compared to men with no sexual symptoms (HR 1.77 (1.28-2.41); p<0.001). In particular erectile dysfunction and poor morning erections, but not lower libido, were associated with increased mortality (HR 1.40 (1.15-1.73); p=0.001; HR 1.30 (1.06-1.60); p=0.012; HR 1.14 (0.93-1.40); p=0.203 respectively). Further adjusting for TT and FT did not influence the observed HRs. Also in men with normal TT (>12 nmol/L), the presence of sexual symptoms increased mortality risk (HR 1.51 (1.15-1.97); p=0.003). Finally, men with TT<8 nmol/L and sexual symptoms had a higher mortality risk compared to men with normal TT and no sexual symptoms (HR 1.92 (1.05-3.52); p=0.035).

Conclusions: Men with the lowest FT and highest FSH levels have an increased mortality risk. Sexual symptoms, in particular erectile dysfunction, predict all-cause mortality independently of T levels. As both vascular disease and low T can influence erectile function, sexual symptoms can be an early sign for increased cardiovascular risk and mortality, as well as a sequela of low T.