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admin | Category: Ed Treatment For Migraine | 07.10.2015
By: Giorgio Gandaglia a , Alberto Briganti a , Graham Jackson b , Robert A. Erectile dysfunction (ED) is considered a vascular impairment that shares many risk factors with cardiovascular disease (CVD). To analyze the relationship between ED and CVD, evaluating the pathophysiologic links between these conditions, and to identify which patients would benefit from cardiologic assessment when presenting with ED. A systematic literature review searching Medline, Embase, and Web of Science databases was performed. ED and CVD should be regarded as two different manifestations of the same systemic disorder. Erectile dysfunction (ED) and cardiovascular disease (CVD) should be regarded as two different manifestations of the same systemic vascular disorder.
Keywords: Erectile dysfunction, Coronary artery disease, Cardiovascular diseases, Artery-size hypothesis, Screening, Phosphodiesterase type 5 inhibitors. This review analyzes the relationship between ED and CVD by addressing the pathophysiologic links between these two conditions and by examining the role of ED as an early sign of symptomatic CVD.
A systematic literature review was performed in May 2013 using the Medline, Embase, and Web of Science databases. ED is commonly considered a vascular disease, and it is well known to share many risk factors with CVD such as aging, hypertension, smoking, diabetes, obesity, and metabolic syndrome [3] and [4]. Based on experimental data and a common pathophysiologic background, several researchers tried to prove causality between ED and CVD. An additional rational step was to investigate the predictive role of ED for CVD by indirect means. Table 1 summarizes the most relevant characteristics of the prospective trials addressing the impact of ED on the subsequent risk of CVD [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], and [28].
ED has also been confirmed as a predictor of CAD in men at high risk of CVD [20], [21], [22], and [26].
However, other studies failed to demonstrate an independent association between ED and CVD.
Two meta-analyses recently aimed at providing a robust and definitive answer to this matter. Although normal erectile function is a neurovascular event modulated by hormonal and psychological factors, endothelial integrity plays a major role in the physiology of penile erections [35], [36], and [37]. The relationship of endothelial dysfunction, low-grade chronic inflammation, and atherosclerosis in the pathogenesis of erectile dysfunction and coronary artery diseases.
The artery-size hypothesis proposed a common pathophysiologic mechanism linking ED and CAD.
However, studies investigating the association between penile artery stenotic lesions and CAD did not produce results in concordance with such clinical evidence [13] and [33]. Endothelial dysfunction plays a major role in the pathogenesis of ED and CAD [33], [43], and [44]. Low androgen levels have been shown to be associated with ED, metabolic syndrome, diabetes, and CVD [49], [50], [51], and [52]. Endothelial and smooth-muscle cells are the main targets for androgen effects in penile and CV systems, and hypogonadism is associated with an increased risk of atherosclerotic vascular remodeling [49] .
Taken together, these data support a crucial role of testosterone in the homeostasis of vascular tissues of penile and CV systems. Although ED can be considered a warning sign of a future MACE, it could also identify men at a higher risk of harboring silent CAD. In diabetic patients, the typical signs of heart disease are often hidden, leading to a delay in the diagnosis of CAD with consequent difficulties to modify the natural history of the disease itself [7] .
In 2012, the Third Princeton Consensus Conference addressed the role of CVD screening in ED patients according to CVD risk [58] . The Consensus Panel recommends the Framingham Risk Score (FRS) (or the Systematic Coronary Risk Evaluation [SCORE] for European populations) as a starting point for estimating the likelihood of future cardiac events in men with ED. After the initial evaluation, exercise ability should be considered to estimate CV risk associated with sexual activity. Patients with known CVD should be categorized according to their CV status into low, indeterminate, and high risk. Management of erectile dysfunction (ED) in all men with ED, especially those with known cardiovascular disease according to the Princeton III Consensus Recommendations.
Studies have suggested that the improvement of erectile function by lifestyle changes or pharmacologic intervention might be beneficial in terms of the prognosis in patients complaining of ED [65] . ED and CVD should be considered two different manifestations of the same systemic disorder. Author contributions: Charalambos Vlachopoulos had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Critical revision of the manuscript for important intellectual content: Briganti, Jackson, Kloner, F.
Erectile dysfunction (ED), male impotence, may be due to a vitamin D deficiency, according to a recent study.
A vitamin D deficiency was present in 35 percent of the men with erectile dysfunction, compared to 29 percent without. The researchers suggest that men with low vitamin D levels have a 32 percent higher risk of developing erectile dysfunction compared to men without the deficiency. Although the findings are observational and do not prove cause and effect, additional research is required to better understand the association and determine the exact link. It’s estimated that 40 percent of men over the age of 40 and 70 percent of those over 70 have erectile dysfunction. Aside from the observational association between low vitamin D and erectile dysfunction, there are other reasons – both physical and psychological – that can increase the risk of erectile dysfunction.
For these reasons, it’s a good idea to employ lifestyle changes in order to treat erectile dysfunction. Below is the recommended dietary intake of vitamin D, as suggested by the National Institutes of Health (NIH). Vitamin D is known as the “sunshine vitamin” because we get it from the sun; therefore, if you live in a place where the amount of sunlight is shortened or you don’t get out often to enjoy the sun, your vitamin D intake could be limited. Erectile dysfunction doesn’t solely affect sexual ability; new research suggests it can be a marker of undiagnosed diabetes in middle-aged men. On any matter relating to your health or well-being, please check with an appropriate health professional.
Belgravia BackThe Belgravia Centre is the UK's leading hair loss clinic for a reason!
A recent survey has revealed that South African men are more concerned about hair loss than erectile dysfunction. Almost 40% of men polled between the ages of 20 and 65 were experiencing signs of male hair loss.
Of the 600 men who responded, 22% showed early signs of male pattern hair loss, with a combined total of 17% experiencing serious hair loss problems or near baldness.
Almost 40% of men who participated in the survey and were experiencing thinning hair said they were seeking hair loss treatment of some kind.
It is important to seek treatment for hair loss as soon as you notice the first signs occurring, as the earlier the intervention, the greater the likelihood of success. The Belgravia Centre is the leader in hair loss treatment in the UK, with two clinics based in Central London. If you are worried about hair loss you can arrange a free consultation with a hair loss expert or complete our Online Consultation Form from anywhere in the UK or the rest of the world.
The worlds largest collection of hair loss success stories, with photos and comments from patients who are using our treatment programmes. Wherever you live, submit an online consultation to receive a diagnosis and effective treatment recommendations. Submit an instant online consultation so that one of Belgravia’s hair loss specialists can diagnose your condition and recommend an effective course of treatment, wherever you live. Did you know that after the age of 35, Testosterone levels begin dropping an average of 2% a year for men? Every man is different and every treatment plan varies, but most men report increased energy, sex drive, and muscle mass and increased bone density.
Like the benefits, the risks can vary, but the primary risks include erythropoiesis (production of red blood cells) and elevated PSA (Prostate-specific antigen) levels, which raises concern for prostate health. Always seek advice and treatment from a certified, trained provider who has experience specifically with Testosterone replacement therapy. We check a full lab panel including CBC (blood counts), CMP (liver, kidneys, etc.), Testosterone levels, and PSA. Testosterone boosters come in the form of topical applications, injectables, implanted pellets and other medications that affect hormone levels. At Vitality Health we use only injection Testosterone or surgically placed pellets, as these give the most accurate, reliable dose. This is a common occurrence and it is one of the reasons why it is so important to be treated by a trained clinician to adjust these levels. Are there situations Testosterone replacement therapy should not be performed for the health of the patient?

Yes, and this is why we perform several tests before starting any therapy to ensure it is in the best interest of the patient. In 2003 the Institute of Medicine reported that there was no association with Testosterone therapy and heart disease. To find out more information or schedule a consultation for Testosterone replacement therapy, contact us here.
A correlation between ED and CVD has been hypothesized, and ED has been proposed as an early marker of symptomatic CVD. The search strategy included the terms erectile dysfunction, cardiovascular disease, coronary artery disease, risk factors, pathophysiology, atherosclerosis, low androgen levels, inflammation, screening, and phosphodiesterase type 5 inhibitors alone or in combination.
The link between these conditions might reside in the interaction between androgens, chronic inflammation, and cardiovascular risk factors that determines endothelial dysfunction and atherosclerosis, resulting in disorders of penile and coronary circulation.
ED usually precedes CVD onset, and it might be considered an early marker of symptomatic CVD.
ED usually precedes CVD, and its diagnosis offers a window of opportunity for risk mitigation. We also focus on the clinically relevant aspects of this association, in order to identify which patients would benefit from a detailed cardiologic assessment. The search strategy included the terms erectile dysfunction, coronary artery disease, cardiovascular disease, risk factors, pathophysiology, artery-size hypothesis, atherosclerosis, low androgen levels, inflammation, screening, and phosphodiesterase type 5 inhibitors, alone or in combination. In this context, a large prospective trial evaluating the impact of CV risk factors on erectile function during a 25-yr follow-up clearly showed that age, body mass index (BMI), cholesterol, and triglycerides were significantly associated with ED [4] . Early retrospective studies investigated the prevalence of ED in CVD patients and showed an increased risk of ED in patients with CVD [10], [11], and [12].
The first large prospective study providing a significant body of evidence comes from the Prostate Cancer Prevention Trial.
A subanalysis of the ONTARGET and TRASCENDED trials evaluated whether ED was predictive of CV events in a population at high risk of CVD. Overall they demonstrated that ED significantly increases the risk of CV events, and that this increase is independent of conventional CV risk factors [29] and [30]. Erections depend on sexual stimulation, which causes the release of nitric oxide (NO) and other endothelial factors that determine the relaxation of smooth muscle in the arteries supplying erectile tissues and an increase in blood flow to the penis while occluding the venous outflow [35] . ED is considered a vascular disease in many patients, and the involvement of the NO pathway has been proposed as the common link between ED and CVD. The exposure to common risk factors might lead to endothelial dysfunction and flow-limiting stenosis.
Low-grade subclinical inflammation affects endothelial function and might lead to a prothrombotic status.
Testosterone plays a major role in the control of sexual function, acting both centrally and peripherally, and hypogonadism is frequently associated with ED. Androgens can reduce the expression of inflammatory markers in these tissues, and low testosterone levels have a proinflammatory and proapoptotic effect on endothelial cells [49] . Low androgens levels thus might represent a common link in the pathophysiology of ED and CVD, partially explaining the complex relationship between ED and CAD. An independent association between ED and asymptomatic CAD in diabetic patients has been reported [56] and [57].
Is there a rationale for cardiovascular disease screening among patients with erectile dysfunction? For organic ED patients with no known CVD, the panel recommends they be considered at increased risk for CVD until recommended checks suggest otherwise. A recent meta-analysis of 10 studies established a significant association between acute cardiac events and episodic physical and sexual activity that was attenuated among individuals with high levels of habitual physical activity [29] and [59]. Finally, coronary computed tomographic angiography or CACS might be appropriate for younger patients (<50 yr) with a family history of CVD, severe ED, diabetes, or multiple risk factors as a first test.
The low-risk group is limited to individuals for whom sexual activity does not represent a significant CV risk. A practical algorithm was recently proposed by a European group of experts for the management of ED patients with or without known CVD [60] . According to the Third Princeton Consensus Conference recommendations, testosterone levels should be measured in all men with ED, and androgen replacement should be considered for patients with symptoms of testosterone deficiency [58] .
Phosphodiesterase type 5 inhibitors (PDE5-Is) represent the first-line pharmacologic treatment to improve sexual function in men with ED. The link between these conditions resides in the interaction between CV risk factors, androgens, and chronic inflammation, which leads to atherosclerosis and flow-limiting stenosis. To achieve their findings, researchers analyzed data from over 3,400 American men over the age of 20. Even when other risk factors for erectile dysfunction were taken into account, the association still remained.
Forty percent of Americans also have a vitamin D deficiency, according to the Centers for Disease Control and Prevention (CDC). Published in the Annals of Family Medicine research shows that men suffering with erectile dysfunction should also undergo testing for diabetes.
Types and symptoms of pneumoniaSebaceous cyst, noncancerous small lump behind the ear, beneath the skinHypothyroidism vs. No statement herein is to be construed as a diagnosis, treatment, preventative, or cure for any disease, disorder or abnormal physical state.
The questionnaire should take no more than 10 minutes to complete and will provide our hair loss specialists with all the information required to recommend an effective course of home-use treatment.
The survey was carried out by an independent research firm working in conjunction with Alpecin Caffeine Shampoo, with 600 men in Durban, Cape Town and Johannesburg taking part.
For men aged 36 to 55, this figure rose to 75%, with men of this age claiming hair loss was of greater concern to them than bad breath, body odour or erectile dysfunction – only issues relating to their weight concerned them more. Almost 50% of men questioned said they would be happy to spend money on hair loss prevention, with men who were separated, divorced or single willing to spend more than those who were married. View our Hair Loss Success Stories, which are the largest collection of such success stories in the world and demonstrate the levels of success that so many of Belgravia’s patients achieve.
It almost seems as if my hair is missing from the front when I pretend to do a man bun style.
This client has two separate conditions – Chronic Telogen Effluvium and Female Pattern Hair Loss which are being treated simultaneously, thanks to a personalised treatment plan, based around a high strength minoxidil product available from Belgravia, as devised by her dedicated hair loss specialist. This can result in a slow decline of mental cognition, loss of muscle retention, depressed mood, decreased energy levels and sexual dissatisfaction. It can have a great impact on quality of workouts, ability to gain muscle, decreased fat, particularly around the mid-section, and controlled insulin levels. At Vitality Health we check these levels frequently as well as adding in an EKG (electrocardiogram) to test the electrical activity of your heart. At Vitality Health only board-certified physicians, physician assistants, or nurse practitioners see patients for men’s health. It is important, however, that whoever is seeing you or administering this medication is familiar with the various aspects of Testosterone insufficiency, the medications involved, and the clinical management.
Pills, intranasal, patches and gels are very unpredictable since you really don’t know what dose is being absorbed, which raises risks and adds in too many variables. Since we measure your labs at day 1, month 3, and quarterly, we are able to safely and effectively adjust your levels and ensure you get the proper amount of hormone. Because penile artery size is smaller compared with coronary arteries, the same level of endothelial dysfunction causes a more significant reduction of blood flow in erectile tissues compared with that in coronary circulation.
Beyond the aging process, other cardiovascular (CV) risk factors such as hypertension, diabetes, smoking, obesity, and dyslipidemia have been shown to be significantly associated with ED [3] and [4]. We limited our search to prospective trials and major preclinical and retrospective studies published between January 2005 and May 2013.
Additional CV risk factors such as smoking, BMI, hypertension, dietary intake of cholesterol, and unsaturated fat have been reported as predictors of ED [3] . The first compelling evidence of an association between ED and coronary artery disease (CAD) came from the pioneering study by Montorsi et al. When considering only men included in the placebo arm, those with baseline or incidental ED developed during the follow-up had a 1.45-fold higher probability to experience a CV event compared with individuals without ED. These events lead to a trapping of blood within the corpora cavernosa and to a significant increase of the intracavernous pressure, resulting in erections. The initial impairment in endothelial-dependent vasodilatation might lead to a number of structural vascular abnormalities, resulting in penile artery atherosclerosis and flow-limiting stenosis ( Fig. Given the systemic nature of atherosclerosis, it could be hypothesized that all vascular beds might be affected to the same extent, but the onset of symptoms might be related to the artery size [5], [12], and [13].
Several studies reported that ED onset and severity are associated with an increased expression of markers of inflammation [44], [45], [46], and [47]. Testosterone levels have been reported to be inversely related to the risk of major adverse cardiac events (MACEs) and to CAD mortality [50], [52], and [53]. Subclinical chronic inflammation might further impair endothelial function, leading to a prothrombotic status [44] .
These findings indicate that patients with ED with CV risk factors should be considered at a higher risk of silent CAD and should undergo detailed CV evaluation.

Sexual activity is equivalent to walking 1 mile on the flat in 20 min or briskly climbing two flights of stairs in 10 s.
These patients can safely perform sexual activity, and they might benefit from pharmacologic treatment of ED without further testing or evaluation. Taken together, these recommendations highlight the role of the primary physician, urologist, and cardiologist in the evaluation of CV risk factors in patients complaining of ED, to implement lifestyle modifications and to identify which patient would really benefit from further cardiologic assessment ( Table 2 ).
It is well documented that testosterone supplementation results in a significant improvement of sexual function in individuals with low androgens levels [61] . Macroscopically invisible alterations, such as endothelial dysfunction and autonomic hyperactivity, might in part explain the complex relationship between ED and CVD. Thirty percent of the men were found to have low vitamin D – below 20 nanograms per millimeter of blood. Michos added, “Checking vitamin D levels may turn out to be a useful tool to gauge ED risk. The statements herein have not been evaluated by the Foods and Drugs Administration or Health Canada.
The survey also revealed that 25% of men felt balding would affect how attractive their partners found them, whilst almost 35% believed it could negatively impact their social lives.
You can also phone 020 7730 6666 any time for our hair loss helpline or to arrange a free consultation. You may have heard about Testosterone replacement therapy, but what are the benefits versus risks, how does it work, and who should you trust to perform this type of treatment? There are countless studies that support Testosterone as a very safe, effective medication. Family physicians will often schedule patients every few weeks for testosterone replacement therapy, which causes patients testosterone levels to have lots of highs and lows.
Before beginning treatment, you’ll meet with your provider to determine what form of treatment is best for your situation and lifestyle.
We prescribe Anastrazole, which blocks the conversion of excess Testosterone to estradiol, a form of estrogen.
T has such a great affect on mood, energy, increased muscle, decreased fat in the midsection, etc. If someone already has cancerous cells, Testosterone therapy can increase the rate of growth, but it will not cause cancer to develop. For this reason, a correlation between ED and cardiovascular disease (CVD) has been hypothesized, and ED has been proposed as an early manifestation of a larger subclinical systemic disorder that might subsequently result in CVD [5] and [6]. Cited references from selected articles and from review articles retrieved in our search were also used to identify manuscripts that were not included in the previous search. However, these results were limited by the lack of validated questionnaires, the heterogeneity of CV events used as end points, and by the high rate of patients who developed ED during follow-up (65% after 7 yr) [18] . Similarly, three prospective studies confirmed the relationship between ED and CVD in patients affected by type 2 diabetes mellitus [20], [21], and [26].
Androgens when in physiologic levels contribute to the preservation of smooth-muscle homeostasis through a direct mechanism, and hypogonadism leads to an increased proliferation and migration of these cells in the vascular tissue [49] . Further evaluation using the exercise stress test (EST) is required for intermediate-risk patients. The high-risk group includes patients with cardiac conditions severe enough to lead to a significant risk related to sexual activity (ie, unstable or refractory angina, uncontrolled hypertension, congestive heart failure [New York Heart Association class IV], recent MI without intervention [within 2 wk], high-risk arrhythmia, obstructive hypertrophic cardiomyopathy, moderate to severe valve disease).
Testosterone replacement might not only improve erectile function but also exert beneficial effects on the CV system. Because they are active not only in the penile vascular tissue, but also in the systemic circulation, they might be of benefit for CAD in patients affected by ED.
Erectile dysfunction and its association with metabolic syndrome and endothelial function among patients with type 2 diabetes mellitus.
Sex, at any age, is not only beneficial for relationships but it can offer many health benefits. We do weekly injections at Vitality Health, this gives our patients the steady, healthy level of Testosterone Replacement Therapy they need to feel great.
If this is not prescribed, patients may show signs of excess estrogen such as weight gain, water retention, moodiness, and emotional liability. This is why screening labs, specifically a Prostate Specific Antigen level, are vital before you being Testosterone treatment. From a clinical standpoint, because ED may precede CVD, it can be used as an early marker to identify men at higher risk of CVD events. The articles that provided the highest level of evidence were selected with the consensus of all the authors. In this regard, the prevalence of ED among diabetic patients >60 yr of age is roughly 75% and increases proportionally to the severity of the disease [7] . Chronic inflammation is involved in the pathogenesis of metabolic syndrome, and an increased expression of proinflammatory cytokines has been reported in obese and diabetic patients [46] and [48], linking these conditions with ED. Patients who had a positive test underwent coronary angiography to document silent CAD and to evaluate the severity of the disease. These patients should defer sexual activity until the cardiac condition has been stabilized. Although testosterone is not a medication with cardiovascular indications, it might indirectly affect CVD, primarily acting on risk factors (ie, improving lipid profile, glycemic state, blood pressure, and reducing BMI) [62] . Several studies reported a reduction of infarct size in animals receiving sildenafil compared with controls [66] . Specifically developed algorithms identify those patients complaining of ED who should undergo detailed cardiologic assessment and receive intensive treatment for risk factors. Erectile dysfunction and coronary risk factors: prospective results from the Massachusetts male aging study. Heart disease risk factors predict erectile dysfunction 25 years later: the Rancho Bernardo Study.
Association between erectile dysfunction and coronary artery disease: matching the right target with the right test in the right patient. The artery size hypothesis: a macrovascular link between erectile dysfunction and coronary artery disease. ED patients at high risk of CVD should undergo detailed cardiologic assessment and receive intensive treatment of risk factors.
Endothelial dysfunction and penile atherosclerosis might represent the common denominator between ED and diabetes mellitus. They should also be referred to a cardiologist for further evaluation and receive intensive risk factors treatment. Randomized trials found that testosterone supplementation given on top of optimal medical therapy improved functional capacity and symptoms in patients with chronic heart failure and ischemic heart disease [63] . In addition, PDE5-I administration has been shown to reduce cardiac hypertrophy, to increase NO synthase, and to improve survival in a preclinical setting [66] . However, the relationship between these two clinical conditions is complex and might also involve other pathophysiologic mechanisms, such as autonomic neuropathy and hormonal alterations [8] and [9]. If this hypothesis is valid, ED should usually precede CAD, and the prevalence of ED should be higher in patients affected by chronic coronary syndrome.
Finally, indeterminate-risk patients should receive EST to reassign them to low- or high-risk groups [58] . Although testosterone administration might increase hematocrit and decrease high-density lipoprotein cholesterol, all available clinical trials except one indicated that the use of testosterone was not associated with increased CV risk [63] and [64]. In patients with severe stenosis of at least one coronary artery, sildenafil administration did not adversely affect peak coronary flow velocity, artery diameter, blood flow, or vascular resistance [67] .
Nevertheless, these neutral studies cast doubt on the association between ED and CV end points. Sildenafil did not exacerbate ischemia or worsen exercise tolerance in patients with known or highly suspected CAD who succeeded in exercises comparable or greater than sexual intercourse [68] . Hemodynamically, relevant arterial penile lesions were rare (12.9%) compared with a high prevalence in the coronary system (87%) and in the internal iliac artery area (77%) [41] . Of importance is the finding that PDE5-Is marginally reduced the incidence of MACE in a cohort of 291 diabetic patients with angiographically documented asymptomatic CAD [20] . Accordingly, although the artery-size hypothesis largely explains the complex relationship between ED and CAD, in a unifying approach incorporating all available data, vasculogenic ED does not result solely from penile artery atherosclerosis but is also related to dynamic, macroscopically invisible abnormalities related to endothelial dysfunction and autonomic hyperactivity [42] .
Overall, these pieces of evidence support a protective role of PDE5-Is in patients affected by ED at high risk for CAD. However, larger prospective randomized trials are needed to further clarify this issue ( Table 3 ).

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