How to manage my loss of erections and rapid ejaculation?

Question

Hello, Doctor,

I am a male who has been experiencing a loss of morning erections and increasingly rapid ejaculation. Recent blood tests showed normal total testosterone at 18 nmol/L, with low-normal LH and FSH, low-normal SHBG, an elevated prolactin level at 526 mIU/L, HbA1c at the upper limit of normal at 42 mmol/mol, and a borderline-high TSH of 4.3 mU/L.

Given this pattern, I think elevated prolactin, along with possible early insulin resistance or subclinical thyroid dysfunction, explains these symptoms even though total testosterone is within range. Please tell me,

Why am I having such symptoms?
What further investigations would you usually recommend in this situation, such as repeating prolactin under optimal conditions, assessing free testosterone, checking free T4, or considering pituitary imaging?
What would be the typical stepwise management approach before considering any form of hormonal treatment?

Kindly help.

Answer 1

Hello,

Welcome to icliniq.com.

I read your query and can understand your concern.

This pattern can explain your symptoms even with a normal total testosterone. Mild hyperprolactinaemia can suppress hypothalamic-pituitary signalling, leading to issues like

Reduced dopaminergic tone.
Loss of morning erections.
Reduced libido.
Ejaculatory dysfunction without overt hypogonadism.

Your low-normal LH (luteinizing hormone), or FSH (follicle-stimulating hormone), with low-normal sex hormone-binding globulin (SHBG) suggests functional, or central) suppression, which can be worsened by early insulin resistance and subclinical hypothyroidism, both of which can raise prolactin and impair sexual function independently of testosterone levels.

You can take the following steps for your treatment,

Repeat fasting morning prolactin (8 to 10 am, rested, no stress/sex/exercise).
Check macroprolactin.
Calculate or measure free testosterone.
Repeat thyroid-stimulating hormone (TSH) with free thyroxine (T4).

You have to be careful about medications, sleep, stress, and weight. If prolactin remains elevated ( more than 500 to 600 mIU/L persistently) or symptoms progress, consider pituitary magnetic resonance imaging (MRI).

For the management, you can take the following steps,

Maintaining weight.
Glycaemic control.
Maintaining sleep.
Stress control.

You should also treat reversible causes like hypothyroidism if confirmed. Hormonal therapy is not first-line in treatment. You can take a dopamine agonist only if hyperprolactinaemia with symptoms is present. You also have to reassess sexual function, and reserve testosterone therapy only if consistently low free testosterone with symptoms despite correction of secondary factors.

I hope this information helps you.

Feel free to ask further queries.

Thank you.