Why Do Some Men Still Have ED on Testosterone?

Happy Wednesday!

Last week, I got an email from a long-time reader that really hit on a topic I hear about often.

This is such an important question because many men and women are under the impression that testosterone therapy is the magic bullet that will restore perfect erections and sky-high libido.

And while TRT can absolutely be life-changing, the reality is that erectile dysfunction (ED) is more complicated than just a testosterone number.

In fact, studies show that a significant percentage of men on TRT continue to experience ED.

Let’s break down exactly why that is and what you can do about it.

Why ED Persists Even After Starting Testosterone

First, testosterone is necessary for healthy erectile function, but it is not the only factor. Erections depend on a complex cascade of hormonal, vascular, neurological, and psychological processes.

If any link in that chain is weak, problems can persist, even when testosterone levels are technically optimized.

Clinical data show that low testosterone is strongly associated with ED.

Restoring testosterone improves sexual desire in most men and improves erections in some, but not all.

Why? Because ED is often multifactorial.

Cardiovascular health, estradiol balance, mental health, medication use, and even TRT delivery method all matter.

So if you’re on testosterone and still experiencing ED, it doesn’t mean TRT “failed.”

It usually means something else is at play that hasn’t been addressed yet.

Let’s dig into the main culprits I see most often.

The Estrogen Factor

One of the most common issues is estradiol imbalance.

Testosterone aromatizes into estradiol (E2), and estradiol is actually crucial for male sexual function. But the key is balance.

Too much estradiol (common when men use extremely high doses of injectable testosterone) can blunt the effects of testosterone and reduce erection quality.

Elevated estradiol has been shown in clinical studies to independently worsen ED severity.

Symptoms can include water retention, mood swings, and softer erections.

HOWEVER, high estradiol is not nearly as common as most people think.

In fact, most “high estrogen” symptoms men experience come from INSULIN RESISTANCE from too much body fat.

Most healthy men aromatize perfectly when they are metabolically healthy.

On the flip side, too little estradiol (often from overuse of aromatase inhibitors) can also cause ED.

Men need some estrogen for libido, endothelial function, and nitric oxide signaling.

That’s why suppressing estrogen is almost never the answer.

Smart TRT management focuses on dialing in a harmonious testosterone-to-estradiol balance, not suppressing estradiol.

Peaks, Troughs, and Delivery Method Problems

Another overlooked cause of ED on TRT is the way testosterone is delivered.

Injections, when done infrequently like once every two weeks, create massive hormone swings.

You get a huge peak after the shot and then a steep trough before the next dose .

That rollercoaster can cause periods of great performance and then days of hypogonadal symptoms, including ED.

Men who don’t absorb gels/creams well may never reach therapeutic levels, while pellet users often feel ED creep back as the pellets wear off.

In other words, the delivery method matters.

Stable levels typically indicate better erections.

Unstable levels often result in inconsistent function.

Cardiometabolic Health Still Matters

Even with perfect hormone management, many men still have vascular or metabolic issues that affect erections.

Erectile function is essentially a barometer of cardiovascular health.

Conditions like hypertension, atherosclerosis, diabetes, and obesity impair blood flow to the penis and reduce nitric oxide availability.

One study noted that men with diabetes or cardiovascular disease often only see partial improvement in ED with TRT.

Why? Because the “plumbing” is the limiting factor. 

You can have plenty of testosterone, but if blood flow is compromised, erections won’t be optimal.

This is why lifestyle interventions (exercise, weight loss, nutrition, and treating sleep apnea) are essential adjuncts to TRT.

They fix the root problems in the vascular system that hormones alone can’t solve.

Psychological Factors

Performance anxiety, depression, relationship stress, or conditioned arousal patterns (like porn-induced ED) can persist even if hormones are optimized.

In fact, some men on TRT feel more pressure to perform because they think “now I have no excuse,” which ironically increases anxiety and worsens erections.

Clinical guidelines emphasize sexual counseling as a core part of ED treatment.

Therapy helps men break the anxiety-ED cycle, communicate better with partners, and address underlying mood issues.

Sometimes the biggest breakthrough for a man on TRT isn’t a dose adjustment or a pill, it’s a conversation with a therapist who specializes in sexual health.

Medication Interference

A hidden culprit I often see is prescription drugs or lifestyle substances.

SSRIs and certain blood pressure medications are well-known to cause ED.

Alcohol, nicotine, and opioid abuse suppress sexual performance even in men with optimized hormones.

Stimulants can trigger anxiety and sympathetic overdrive, which directly inhibits erections.

So if you’re still struggling with ED on TRT, it’s worth asking what else you might be putting in your body that might be interfering?

Often, addressing these external factors is the missing piece.

Final Thoughts

A large number of men on TRT still experience ED because testosterone is only one piece of the puzzle.

Low estradiol, poor delivery methods, cardiometabolic disease, psychological stress, and medications all play a role.

The good news is that when you identify the missing piece and address it, most men can restore strong, consistent erections and a satisfying sex life.

This is exactly why Jay Campbell and I created the Quantum Testosterone Course.

We saw firsthand how many men were “stuck” on TRT.

In the course, we break down not only how to optimize your testosterone therapy, but also how to optimize estrogen and DHT, incorporate adjunct therapies like PDE5 inhibitors, improve vascular health, address psychological barriers, and build a complete system for sexual vitality.

If you’ve ever felt frustrated because TRT alone didn’t fix everything, this course was built for you.

It’s designed for men who are considering TRT and for those already on it but still struggling.

You’ll learn how to create a protocol that truly works for your body and unlocks the full benefits of optimized testosterone.

Energy, muscle, focus, and yes, rock-solid sexual performance.

Best,

Hunter Williams

Further Reading

Testosterone, sexual function & when TRT alone isn’t enough

• Corona et al., 2017 — Meta-analysis of TRT effects on sexual function (IIEF). European Urology (full text). 

• AUA Erectile Dysfunction Guideline, 2018 (notes greater PDE5i response when combined with TRT in men with T deficiency). AUA site / PDF. 

Estradiol & sexual function

• El-Sakka, 2013 — High E2 and/or low T associated with worse ED severity. Asian Journal of Andrology (PMC). 

• Finkelstein et al., 2013 — NEJM trial dissecting roles of T vs E2 in male sexual function. NEJM. 

• Carani et al., 1997 — Aromatase deficiency case: both T and E2 needed for libido/sexual activity. NEJM. 

Delivery method matters (peaks/troughs, E2, hematocrit)

• Pastuszak/Ramasamy et al., 2015 — Gels vs injections vs pellets: estradiol & hematocrit profiles differ. J Sex Med (PMC). 

• Nackeeran et al., 2022 — Network meta-analysis: hematocrit rises vary by formulation. Journal of Urology. 

Cardiometabolic health, exercise & diet

• Gerbild et al., 2018 — ~160 min/week aerobic activity for 6 months improves ED. Sexual Medicine (PubMed). 

• Esposito et al., 2006 — Mediterranean diet improved ED in men with metabolic syndrome. Int J Impot Res (PubMed). 

• Montorsi et al., 2005 — “Artery size” hypothesis linking ED and CAD. Eur Urol (PubMed).