Erectile Dysfunction: The TRUTH About Cialis, Viagra & Testosterone — A Urologist Explains

In Part 2 of this conversation on men’s health and erectile dysfunction, Dr. Chhaya Makhija continues her discussion with sexual medicine specialist Dr. Katherine Klos, shifting the focus from causes to treatment.

While erectile dysfunction is commonly associated with low testosterone, this episode highlights why treatment requires a broader perspective. Hormones are only one component of a complex system involving vascular function, neurologic signaling, metabolic health, medications, and psychosocial factors.

They explore how medications such as Viagra and Cialis actually work — improving blood flow rather than desire and discuss why stimulation and intimacy remain essential. The episode also outlines what happens when oral medications are not effective, including injection therapy, vacuum devices, implantable prostheses, and newer regenerative options.

If you or someone you care about has been struggling with ED and feeling unsure about the next step, this conversation will help clarify what realistic, evidence-based treatment actually looks like.

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#ErectileDysfunction #MensHealth #LowTestosterone #TestosteroneTherapy #TRT #Cialis #Viagra

Transcript

00:00
True or false, treating the underlying cause of erectile dysfunction or ED can sometimes reverse symptoms. I feel like I'm on Jeopardy. Sometimes it can, yes.  Are Cialis and Viagra interchangeable for every patient? No.  Number three, right or wrong, testosterone is always the first line treatment for ED or erectile dysfunction.  Wrong.

00:24
one lifestyle factor you insist men address alongside the medical treatment for erectile dysfunction.  Welcome to Hormones and Hope,  a podcast where we bridge science and wellness  to help transform your health.  I'm your host, Dr. Chhaya Makhija,  or you can call me Dr. Chhaya,  a triple board certified endocrinologist and lifestyle medicine physician and founder of Unified Endocrine and Diabetes Care.

00:50
Each week we dive into the powerful intersection of clinical medicine  and real life lifestyle strategies  to help you feel stronger,  live longer,  and show up as your most vibrant self inside and out.  So let's get empowered. Welcome my friends to  our part two episode on men's health and erectile dysfunction with Dr. Catherine Close and I'm your host, Dr. Makhija.

01:16
It's been so enlightening, I would say, even for me as an endocrinologist, I get to learn from medical experts. And today Dr. Catherine is going to take us and walk us through erectile dysfunction treatment and further evaluation. If you haven't  listened to her part one episode, which was published last week, go ahead, pause and tune in because you really need to understand the background of why things happen, why it's a medical symptom and why you need to seek the right expertise.

01:46
And now let's dive into our treatment options for erectile dysfunction. Dr. Catherine, thank you again  for sharing your expertise. And whenever you're ready, we start with a rapid fire. Well, thanks for having me back. And I'm excited. I think the rapid fire is my favorite part. uh Thank you. I love that from you. All right. So number one, true or false, treating the underlying cause of erectile dysfunction or ED can sometimes reverse symptoms.

02:15
I feel like I'm on jeopardy. Sometimes it can. Yes.  Are Cialis and Viagra interchangeable for every patient? No. No. Okay. Number three. Right or wrong, testosterone is always the first line treatment for ED or erectile dysfunction.  Wrong. True or false, low testosterone automatically means a man needs testosterone therapy. False. Asterisk.

02:43
All right, we need to get into the asterisk soon. Number five, yes or no, can Clomid be used to raise testosterone while preserving fertility? Yes. Thank you. Clomid is Clomiphon citrate. Number six, or false, ED medications or erectile dysfunction medications fix desire, energy and mood. All caps. False. Number seven.

03:06
one lifestyle factor you insist men address alongside the medical treatment for erectile dysfunction? Intimacy.  Okay. All right. Thank you so much. These are very clear-cut exclamation, asterisks, caps lock answers. I love it.  Easy. I want to answer more, but I'm excited to keep going. Oh, we need to learn more details from you, Dr. Katzman.

03:31
Now getting into, this is technically our number four question for our deep dive from our part one series  is  learning about erectile dysfunction. You  walked us through the contributing factors, the evaluation that you  recommend physicians do or refer to a specialist as yourself and what exactly you are asking your patients and discussing even with couples. So now  when I see patients and I know many of the physicians who are

04:00
seeing patients with complaints of erectile dysfunction or lack of morning erection, or we are initiating this discussion with our patients, the most  instant answer or response that people or patients need is, I need a quick fix. My testosterone is low. Can you prescribe me testosterone? So can you walk us through the root cause like you discussed about erectile dysfunction versus testosterone therapy?

04:29
versus other medications that could be used for erectile dysfunction? How do you help your patient differentiate or how do you educate them on how are we going to approach this symptom? So that is a layered question, but I'm going to try to break it down. So in my practice, sometimes I'll get a man who comes in and says, I have low testosterone, fix me. More frequently, what happens is someone comes in and says, I have erectile dysfunction, details.

04:59
I want you to fix me. And my answer is, okay, great. I can give you an injection that you will inject into your penis and you will get an erection. And that usually gives us enough pause while that does work and can be highly effective, gives us enough pause  to allow me to go a little bit deeper because that's the right answer to that question. Can you give me a tip for endocrinology though?  But yes, but that's typically enough of a pause for the patient to say, okay,

05:26
What else is out there? What else could I do to maybe make some changes? So as we talked about, erectile dysfunction is so multifactorial. We've got to look at the different components of their health, whether it's lifestyle components or other medical comorbidities or medication  or biopsychosocial, social history, sexual history that may be contributing to erectile dysfunction. All right. So you've got to look at all of those things.  One of those being testosterone. Okay.

05:56
And testosterone is not directly correlated with erectile function. Now, there are a lot of caveats to that. As I alluded to  in part one, lower testosterone levels are more associated with erectile dysfunction. And we can go into the nuances of how testosterone affects erections, but it's not a one-to-one. There's a very, as you know, broad definition of what a normal testosterone is.

06:22
I see guys on the low end with a testosterone of 350 or having great erections. And similarly, I can see a guy who has a testosterone of 850, which is still normal, but high end of normal, who's not getting erections. So it's not an exact one-to-one. So giving testosterone itself, whatever modality it may be, is not going to 100 % guarantee return of erectile function. That's why it's really important to...

06:49
look into the different factors that may be contributing to erectile dysfunction and thus be modifiable to improve function without maybe over medicating someone. Yes, no worries. So now this is Nink here. Yeah, sorry, I layered it, but I just need to learn so much. But anyway, so you mentioned about the testosterone therapy and I love that you actually gave us an example of the two levels and how.

07:15
they can still either have symptoms or not have symptoms with normal testosterone. So now  if they don't get the right education or they're not, people are not seeing the right specialist, do you have any  caution word for patients who are either experiencing erectile dysfunction or for some reason, some lab that they've done  shows or reveals low testosterone to  filter marketing or promoted

07:44
TRT or testosterone clinics? Any word of caution before we get into the other medications?  That's great. I love that question because I think taking  one set of labs, not contextualizing it and extrapolating that into  what you may  need is not the appropriate course of action. I think it's important to have, typically  the way I love to do it is have at least two sets of labs to confirm or refute where you're

08:13
hormones lie as we know there's some natural fluctuation in hormones  based on lots of other things that are going on in a man's health or woman's health. So it's helpful to have that. It's also very helpful to have other background,  but taking testosterone without understanding  what it's doing in the immediate sense or what it's not doing and or what it's doing in the long term, I think is  not wise. And I also think it's important to set goals and expectations of

08:43
what we consider normal versus  what may elicit results.  I think most guys, if you gave them testosterone to a level of 1,500 would feel amazing. Yet there's some other side effects that potentially could come along with them  for the negative. The one that tends to scare patients off  is  decrease in testicular size. Because as you know, when you replace

09:08
a man's testosterone with bioidentical testosterone, so actual testosterone, whether it's transdermal, oral injectables, the body recognizes that as testosterone and says, gosh, I don't really need to do much of anything to support myself. Testosterone for  men is made in the testicles. So if the testicles aren't working, you will get tissue atrophy. It does not happen overnight, but it will happen over time. So it's really important to understand.

09:34
what your goals are. If your goals are better erections, like I said, that doesn't correlate one to one.  And if you're  going to take a medication, you've got to know what the potential more immediate side effects are  and  long-term consequences or changes that may incur. Yes. This was well explained. uh this brings about the next part of the question, which is still the same question. uh

10:00
explained testosterone, you've explained the caution of just going to random testosterone clinics without knowing what exactly is causing the problem and if the lab is appropriate and the interpretation. Now, say you have that individual with erectile dysfunction,  say some metabolic issue, and you know that  they will not benefit from testosterone. Any comments on medications like Cialis or Viagra? How do you bring

10:29
that into your conversation with your patients.  I love Cialis and Viagra.  I probably lean with that. We are learning lots of different benefits for Cialis and Viagra in general. And again, I think education and knowing the medication history is really important. So Viagra, generic name is cell benefit, was actually originally designed for chest pain and then was extrapolated to a condition called pulmonary hypertension.

10:57
And this is helpful to understand. it may seem way detail oriented, but the dosage for pulmonary hypertension of silt denifil or Viagra is 80 milligrams three times a day for three weeks. That's given to male and female patients. When men are worried about, I'm not saying overdose, but safety of using it or using it more frequently, you really have to look at the history and say, gosh, this was safe and effective in other instances.  I...

11:24
Knowing that history allows me to be more liberal in my prescribing of it. um What does it do? So it's also important to know what it does. So  Cialis and Viagra, while different in terms of their  selectivity to sub-receptors, really share the same pathophysiology. What they're trying to do is retain smooth muscle relaxation. So Cialis and Viagra are not going to give you an erection on

11:54
without any stimulation. For the medication to work, requires stimulation. So have to do stimulation, but when you have that stimulation, what they do is they try to continue that. They prevent the breakdown that would cause the artery from constricting again. We want to keep things open and dilated. So they work in a little bit of a different way, primarily with their duration of action. Viagra is faster onset, shorter duration. Cialis is

12:22
Not the same onset, but a little bit of a longer half-life. But again, they're both doing the same thing with smooth muscle relaxation. They also can have smooth muscle relaxation in other areas, which is why something like Cialis or Tadolophil is also indicated for BPH, which is a urinary complaint of men. And what it does is it helps relax smooth muscle in the prostate. We've also found that Cialis for women

12:48
as actually can be really helpful for period cramps. And there was an article that was just published,  I'm dividing into females, how Cialis may be helpful for reduction in cardiovascular events for women. There was also some observational data that shows patients who are on daily Cialis have a lower incidence of dementia and Alzheimer's. So I say all of this,  not to be a salesperson for them, but I could, but for  the safety of it and  potential

13:17
other benefits. So that's probably one of the reasons that I lead with it. I think it's for any portion of our body to have more, if we're trying to get it to work and have more blood flow there, that's only going to be helpful. I mean, there's a reason athletes do those cupping things on their body to get more blood flow to their muscles. So I love a Cialis and Viagra. They have different indications. They can have slightly different outcomes for patients, but I do think they're very safe to use.

13:47
And you may be getting a secondary benefit, whether it's cardiovascular or neurologic, the jury's still out, but there's some other potential benefits as well. So I think they can be helpful. They do nothing for hormones, as you mentioned at the beginning. They still require stimulation and intimacy, but they can increase blood flow and help maintain blood flow. Oh, very well explained.  I didn't know about the study that you're talking about in the gym. uh

14:14
Yeah, this is profound in terms of the options that and safer options that we have. So thank you for breaking both of these down. Now coming to a same clinical scenario, you talked about these two options  as pills or medications that are available. What's the difference between, because you touched that in one of the explanations,  say there is an individual,  I'm just throwing a case right now,  had some pituitary tumor,

14:43
tumor is out and now because of their signals or no hormones from coming from the pituitary which is the allelic fasace, so they're not producing enough testosterone and that secondary hypogonadism and they need testosterone replacement.  Or a legit diagnosis of primary hypogonadism with appropriate testosterone replacement. What are the options in general for individuals with hypogonadism?

15:07
other than testosterone replacement or even testosterone replacement in case they're seeking fertility at the same time? Oh, great question. So that again is something to be very mindful of and not be an aegis when someone walks into the office and say, gosh, you're coming in at 50, you have a low testosterone, I'm going to automatically give you bioidentical testosterone. So for preservation of fertility, so to have good sperm production, you

15:35
have to have intratesticular testosterone. And as we alluded to before, when you're giving bioidentical testosterone, your body recognizes that and the testicles can decrease the amount or completely stop. In worst case scenario, the amount of testosterone they're producing. So in those instances where you want preservation of fertility or some guys just don't want to take testosterone, then we have two options.

15:59
One is an oral medication, Clomid. As you mentioned, Clomid is a serum. It's called the selective estrogen receptor modulator. It feels funny saying that to an endocrinologist who knows all of those things. We're not, yeah. You're teaching many more people here.  It blocks the brain's estrogen receptors. Okay. So the body thinks there's less estrogen there. So it helps to generate more GnRH, which then helps increase FSH and LH. And as you discussed,

16:26
those are the two central hormones in your brain that spur the testicle to produce more testosterone. There's been some benefit for fertility as well. It's not complete, but in that. So that's  one option. The other option is very similar to Clomid, but it goes straight for the LH  is  HCG. So it's an injectable medication. So Clomid is an oral medication. All of these are off label.  HCG is injectable medication that  mimics the LH in your brain and it kind

16:55
tricks the body into stimulating the testicles. So both of those routes can increase a man's testosterone while preserving fertility, while preserving testicular size. Again, they still need to be monitored, as you know, in terms of blood work, et cetera, but can be very effective, especially in the younger patient population. Yeah, so we still have options. I love the way you expressed intratesticular testosterone as needed for the sperm production.

17:23
Can I ask you, I know this wasn't in my notes earlier, but end-chlomophin? Because when I'm describing chlomophin, it's not unusual to  see if it's a  urology or endocrine, because you're seeing so many men patients with the concern for estradiol levels or gynecomastia.  thoughts on end-chlomophin, which is of course off-label and bounded, but any thoughts on that?  So  end-chlomophin for those who don't know,

17:53
When you're talking about molecules, and this is where I'm  trying to think back to organic chemistry to explain it, but essentially, N-chlomophane, and I think the other one is E-chlomophane or something, they're like your hand. So they're the same molecule, but when you separate them, you put them together and they look differently. As you alluded to their compound,  N-chlomophane is supposed to have a lower side effect profile than its isomer. That's the word I was looking for, than its isomer.  I have prescribed

18:22
and clomaphane to patients. And I'll be very honest, I haven't found a huge improvement in terms  of outcomes.  Why have I prescribed it in the past? It's typically patient driven and they want to try it. Again, I'm about  being safe. If I think something's safe, I'm  very willing to try it, even if it's outside of the box. But I haven't been so convinced, again, this is just in my practice  where  that's what I gravitate towards first.

18:52
I don't know if you've seen a similar thing. Yeah, two patients recently, that's how I was asking you the question. They decided it was patient driven  and they purchased it from  reputable compounded pharmacy. But yeah, no difference. I mean, they had better improvements with Clomiphin versus N-Clomiphin, but it was just the estradiol levels of gynecomastia. The nipple tenderness was a little bit lower. Yeah, I have not seen it  be so significant.  We tend to, and you bring up a good point. When you're replacing

19:22
testosterone, you also need to monitor estrogen levels. We've brought up gynecomastia or breast grip, but we haven't really explained why. Testosterone can get converted into estradiol in the male body,  more so in fat cells, but I find, and I'm sure you find a similar thing, that it's not always reliant on obesity. There are men who have a very normal body habitus that with testosterone replacement will have higher conversion of testosterone to estradiol.

19:50
So we follow estradiol levels to make sure that they don't increase too much, that men aren't having side effects like breast growth that can be spurred by high estradiol levels. What we typically do in practice is anastrozoic, whether it's  once every two weeks or once a week or once a month, cadence depending on what we see in terms of lab measurement. And I actually have an interesting question for you and I'll put you on the spot. Have you  noticed any incidents of men with testosterone replacement?

20:19
subsequently high estrogen and then a decline in orgasmic function because of potentially elevated estradiol levels. Yes, more so  with the injection formulations because of no coverage from insurance  for the other formulations. But yes, they've been on the long, and these are more my pituitary tumor secondary hypogonadal patients. Just curious. That's something that I've paid attention to a little bit more, the impacts of estradiol levels  on men in terms of orgasmic function. So thanks for that.

20:49
Yeah, long standing. Yeah, if we've been on it for a longer time. Yes. Yeah. Great points here. A lot of chemistry, which is simplified here. I love it. It's going to be very helpful for our medical students too. So now with our, you know, last part of this treatment is very specific to your field. And I may not have any expertise here is because you do procedures, you know, you are a surgeon.

21:15
What are the other options for any of these conditions? Be it, you you've tried replacements, you've tried pharmacological options for erectile dysfunction. What's out there in terms of procedural surgical interventions? I know in  one of the  starting comments, or was it in one of the questions, you said, well, I offer them testicular injections, but they're like, oh, do I have any other options? I'm curious about all those.  Great question. And there are  options in terms of treatment.

21:44
as we've talked about a lot and we spent a lot of time on, which is good, is oral medication. Why is that good? Because that's what's most prevalent. And for most guys, they'll have a great amount of success with that. But what happens when oral medications fail? And they're, again, and we've done our appropriate work of, we've addressed lifestyle components, metabolic components, et cetera. So what do we have additionally? And there are some more traditional approaches, potential for erectile treatment. And then there's some.

22:12
off-label less traditional, not as well studied. So in terms of the traditional wrap, if oral medications fail, if you're talking about a non-pharmacological treatment, which does have excellent success rates, is a vacuum penile pump. So not a surgical implantable penile pump, which is different. I'll talk about that in a second, but a vacuum pump. It's as barbaric as it sounds, and then it looks like the hose from your vacuum and you stick it on the shaft of the penis. And what it does is actually mechanically

22:42
increases the blood flow into the penis and to keep the blood flow there, there's a ring that's placed at the base of the penis. So success rates for that are actually quite high. The challenge with using it is  the actual physical mechanical part of it, getting the correct seal. It's awkward and slightly cumbersome.  It can result in some bruising or a little bit of discomfort, but it is an option. Okay.

23:07
So that's one of our non-pharmacologic, or yes, non-pharmacologic options. This is in-office or the person though has to go? No, they do it at home. This is like, they just take it home. You can order it off the internet. They're different kinds. You want to get one that's medical grade because it will limit the vacuum suction because you don't want to get it, you know, don't want to have too much. So that's something that  men can try. It's typically helpful to do a teaching session if they're uncomfortable in the office, but

23:35
You could order a medical grade one off the internet and try it on your own. From an additional medication intervention standpoint,  the  next line therapy is probably these injections. So if you hear the ads on TV or on the radio that allude to,  can guarantee you to get an erection. Come to our clinic and we're going to guarantee an erection. That's typically because they're going to give you an injection. Now.

23:59
has a lot of caveats. The injection goes into the penis. It's actually a really small needle and when guys are comfortable with it, it's not a painful experience.  the injection has to be used like an on-demand oral medication. So when you want interaction, whether it's for masturbation,  for penetration, you have to give yourself an injection.  And  those injections can be different medications. They're more traditionally a combination of three different medications.

24:27
alprosodil, papavarin, and fintolamine. So these three together that are compounded and you inject a varying amount, they have excellent results, all right? Meaning they can get rigid erection that lasts a long time. So again, patient satisfaction is quite high, but sometimes the barrier of just active injecting it into their penis is challenging. There's also, just so I flag all of them, there's a little  medication that you can put actually into the urethra and that dissolves into the penis.

24:57
It has left less efficacy and can be a bit painful and not as common now that we have a few more options out there. Again, traditional. When those things aren't working or pre-viagra sialis, the advenol of all of these PD-5 inhibitors was a surgery, all right? So a surgery where it's an implantable penile prosthesis. The penis, if you think about it, is essentially three cylinders.

25:23
two that are your main erectile bodies and the lower one that's your urethra. In an IPP or implantable penile prosthesis surgery, what happens is that the two cylinders that are your main erectile bodies or erectile tissues are replaced with plastic tubes. And those plastic tubes are then filled via an actual pump in your scrotum. So it's like this, when I was a kid, you had those Nike Reebok shoes that you pumped up. It's the same sort of thing in your scrotum. uh

25:52
it transfers water from a reservoir in your lower abdomen into the tubes into your penis. You get an erection. There's some other nuances to it, but that was the more traditional procedure done for men with erectile dysfunction that predated the commonality of Vibra and Cialis. Now it's 2026 and there are a lot of regenerative medical techniques out there. In the space of erectile dysfunction, there are

26:18
Timerally two,  one that's more common, the other one's a little less common. The more common one is low-intensity shockwave therapy. As urologists, use shockwave for kidney stones. That's a high-intensity,  small focal zone  mechanism.  And that same sort technology was translated, low-intensity,  larger focal zone to  attack.

26:42
penis and the shaft of the penis and the pudendal nerve. What does it do? It does kind of two things. It helps mechanically break up fibrosis that we talked about that may occur in the sinusoidal aspect of the cavernousal tissue. It's also, this is a very simplified version, is a little bit of microtrauma to the area that allows for tissue repair and potentially improvement of tissue quality. That is non-invasive. It does not hurt. It's done in an office setting.

27:08
So that's one of the newer regenerative technologies. The other one is PRP, where you harvest plasma cells from your own body and inject them into the erectile tissue. That one's a little less common in sexual health centers, but it is something out there to at least be aware of. Who knows where things will be in five years, but there's a wide variety of options. It's really important to tailor it to what your baseline is and what your goals are. Sorry, there was a lot of talking.

27:36
No, it was so much. was, you as you were describing it, was like, you know, there is, I'm happy that we are in 2026. Yes, we, you know, we take pride in thinking that, you know, women's health is now out, out. Yes. And we, everyone's getting loud about it and, you know, just more discussions and more options. This was like a plethora of options right here for men's health and erectile dysfunction. So, because, you know, every urologist is not.

28:04
offering this kind of an expertise. I haven't seen as many and that's I was excited to have you on uh our podcast. But now, knowing that you're in California, I'm pretty sure many patients are going to benefit. So you covered treatment,  medical options, why testosterone would be safe and what kind of patients were to say no, no to the testosterone and what are the caveats. You gave  us  five thumbs up for Cialis and Viagra.

28:33
And you know why? The reasoning, the evidence behind it was expressed so beautifully. And then with all the procedural or surgical options or interventions. So Dr. Klaus, before we wrap up our part one and part two today on erectile dysfunction on male's health, please let us know via practice how individuals who need to get this right medical expertise or even their partners, how can they reach you, any of your social media platforms? How can someone become your patient?

29:02
Thanks so much for having me. As you can tell, I'm very passionate about this and I really like talking about it. So thank you for giving me a platform to do that.  I am with practice Rachel Rubin MD. There's a direct form on our website to go to. um I'm at Dr. Katherine Kloss on Instagram.  We're kind of as a practice at Dr. Rachel Rubin. So we're all combined together, but that practice website is the best way to get a hold of me and get into our office. I feel like

29:30
I'm so fortunate to do what I do and  I love patient care. So the more patients we can educate and help, the better. And thank you for someone like yourself for doing all that you're doing to get this out, get the word out there. Well, my pleasure. I love the camaraderie and great talking to you. I hope we can have uh another discussion, another topic.  I'm sure people will love it. I think I finally heard their DMs and their emails. So thank you so much for sharing this and uh yeah, we'll see you soon. Thank you.

30:00
Thank you. you're feeling generous. Want more tools to support your hormones and health? Head over to unifiedandocrinecare.com. We've got free guides, resources, and more waiting for you. Until next time, stay curious, stay kind to your body, and keep your hormones happy.