Testosterone Therapy & Sexual Dysfunction: What the Evidence Really Says
It’s a familiar story. A man walks into the pharmacy, frustrated that his energy is low, his libido isn’t what it used to be, and intimacy feels harder than it should. He’s heard about testosterone therapy from a friend at the gym, or maybe from an online ad promising vitality in a vial. He wants to know: “Will testosterone fix my sex life?”
As a pharmacist, I’ve had this conversation numerous times. And recently, a Cochrane systematic review pulled together some of the best data we have on this question. The results might surprise you.
The Cochrane Review: 43 Trials, 11,419 Men
Researchers analyzed 43 randomized controlled trials (RCTs) involving more than 11,000 men aged 40 and up who had sexual dysfunction, regardless of whether their testosterone levels were low.
Here’s what they found:
Erectile Function (IIEF-EF score): Testosterone therapy improved scores by only 2.37 points (95% CI: 1.67–3.08) compared to placebo. The problem? The minimum clinically important difference (MCID) is usually around 4 points. Translation: men might not even notice the difference.
Sexual Quality of Life (AMS Scale): Improvement of −2.31 points (95% CI: −3.63 to −1.00). On a scale that runs 17–85, this is statistically significant but likely not meaningful in real life.
Cardiovascular Mortality & Safety: No clear difference was found, though prostate-related adverse events were slightly higher in TRT groups.
So, after thousands of men and dozens of trials, the conclusion was blunt: TRT offers little to no benefit for sexual dysfunction in men with normal testosterone levels.
The Catch: Hypogonadism vs “Low T” Marketing
There’s an important nuance. These trials included men with and without true hypogonadism. For men with confirmed low testosterone (clinically and biochemically), TRT can restore normal hormone levels and may improve symptoms. But for the majority—the guys targeted by “Low T Centers” and flashy ads—benefits are minimal at best.
That’s why every guideline, from the Endocrine Society to the American Urological Association, emphasizes careful diagnosis. Testosterone therapy is not a quick fix for aging or for lifestyle-related fatigue.
Beyond the Numbers: Why Men Still Ask
So why does testosterone therapy feel so appealing? Partly because it’s marketed as a cure-all for midlife malaise. But there’s also a psychological element: when libido and performance dip, men want an external solution. TRT feels tangible—an injection, a gel, a patch.
The problem is, when expectations are sky-high, the evidence can’t deliver. And disappointment often follows.
Alternatives with Stronger Evidence
If TRT isn’t the magic bullet, what is? Here are evidence-based strategies that consistently show benefits:
Optimize Cardiometabolic Health
Erectile dysfunction is strongly linked with hypertension, diabetes, obesity, and cardiovascular disease. Addressing these often improves both heart and sexual health.
Lifestyle Foundations
A Mediterranean diet, rich in vegetables, whole grains, fish, and olive oil, is associated with better semen quality and sexual health markers.
Exercise (particularly aerobic and resistance training) improves endothelial function, testosterone sensitivity, and confidence in sexual activity.
Established Pharmacotherapy
PDE5 inhibitors (like sildenafil and tadalafil) remain first-line, with robust RCT data showing real improvements in erectile function.
Counseling & Relationship Factors
Sexual dysfunction isn’t just biology—it’s psychology, relationships, and stress. Addressing these often matters more than hormones.
The Pharmacist Takeaway
Confirm low T: Never start TRT without both symptoms and documented low serum testosterone.
Manage expectations: Even with low T, improvements may be modest.
Monitor closely: Hematocrit, lipids, prostate health, and cardiovascular risk.
Guide men toward lifestyle and evidence-based therapies: Diet, exercise, PDE5s, and open conversations often deliver more tangible results than hormones.
Bottom Line
The story men want to hear is that testosterone will restore their sex life overnight. The reality, according to the best available evidence, is that TRT does very little for sexual dysfunction unless testosterone is truly low.
That’s not bad news—it’s empowering. It means men have more control than they realize. By addressing health foundations, using proven treatments, and making sustainable changes, sexual health can improve—without chasing a hormone fix that doesn’t live up to the hype.
References:
Lee H, Hwang EC, Oh CK, Lee S, Yu HS, Lim JS, Kim HW, Walsh T, Kim MH, Jung JH, Dahm P. Testosterone replacement for men with sexual dysfunction. Cochrane Database Syst Rev. 2024;1:CD013071. doi: 10.1002/14651858.CD013071.pub2
Agarwal R, Salas-Salvadó J, Davila-Cordova E, et al. Mediterranean diet, semen quality and medically assisted reproductive outcomes in the male population: a systematic review and meta-analysis. Adv Nutr. 2025;16(8):100454. doi: 10.1016/j.advnut.2025.100454
Shukla A, Verma RK, Sharma A, et al. Efficacy and safety of a multi-herbal formulation for erectile dysfunction: a randomized controlled trial. J Ethnopharmacol. 2025;309:116236. doi: 10.1016/j.jep.2025.116236
