Can elevated prolactin itself cause ED in TRT patients?

[GeauxBears]

I've read elevated prolactin in men can cause ED and other sexual dysfunction based on its inhibitory effects on the HPTA; however, I am curious to know if fluctuations in prolactin itself can cause ED in a TRT patient?

I have a documented pituitary adenoma that has seemed non-functional for the past several years and I was placed on TRT due to having very low T numbers + the usual symptoms.

Been on a stable TRT protocol for well over a year with great success, but recently have been experiencing consistent symptoms such as loss of penile sensitivity as well as loss of erection during sex. Libido is ok, morning erections are mostly present and I can get an erection easily, but during sex it's like a switch is turned off in my brain after a few minutes and I end up losing my erection and ability to finish. It takes forever to get it back up if we want to try again. I am on 6.25mg Cialis per day in addition to TRT + AI protocol.

Checking in with Dr. Saya in a few weeks and was hoping the check-up bloodwork would show something obvious, but it looks pretty good:

Total T: 913 (348-1197)
Free T: 27.3 (8.7-25.1) HIGH
E2 (MS): 28 (8-35)
E2 Free: 0.81 (0.2-1.8) / 2.9%
E2 (Sensitive): 27 (8-35)
DHT: 79 (30-85)
Prolactin: 15.6 (4.0-15.2) HIGH
SHBG: 14.5 (16.5-55.9) LOW

The only thing that's abnormal for me is the prolactin number...I realize it's barely "high" but historically mine has been in the single digits.

Obviously I'll get Dr. Saya's perspective during our chat but any thoughts in advance as to whether this could explain my situation?

 

[johndoesmith]

I've read elevated prolactin in men can cause ED and other sexual dysfunction based on its inhibitory effects on the HPTA; however, I am curious to know if fluctuations in prolactin itself can cause ED in a TRT patient?

I have a documented pituitary adenoma that has seemed non-functional for the past several years and but I was placed on TRT due to having very low T numbers + the usual symptoms.

Been on a stable TRT protocol for well over a year with great success, but recently have been experiencing consistent symptoms such as loss of penile sensitivity as well as loss of erection during sex. Libido is ok, morning erections are mostly present and I can get an erection easily, but during sex it's like a switch is turned off in my brain after a few minutes and I end up losing my erection and ability to finish. It takes forever to get it back up if we want to try again. I am on 6.25mg Cialis per day in addition to TRT + AI protocol.

Checking in with Dr. Saya in a few weeks and was hoping the check-up bloodwork would show something obvious, but it looks pretty good:

Total T: 913 (348-1197)
Free T: 27.3 (8.7-25.1) HIGH
E2 (MS): 28 (8-35)
E2 Free: 0.81 (0.2-1.8) / 2.9%
E2 (Sensitive): 27 (8-35)
DHT: 79 (30-85)
Prolactin: 15.6 (4.0-15.2) HIGH
SHBG: 14.5 (16.5-55.9) LOW

The only thing that's abnormal for me is the prolactin number...I realize it's barely "high" but historically mine has been in the single digits.

Obviously I'll get Dr. Saya's perspective during our chat but any thoughts in advance as to whether this could explain my situation?

I find it odd you're having morning erections, but only during sex is it that you lose your erection. That seems oddly coincidental, and morning erections prove everything is functioning properly.

While high range prolactin can cause issues, I doubt it's the culprit here. I'd say it's more likely psychological.

 

[GeauxBears]

Thanks for the reply. I'm open to it being psychological but the strange thing is (1) my libido is acceptable and (2) the lack of penile sensitivity doesn't feel psychological upon first glance. It is like I can't feel the stimulation after the initial erection is achieved, which may be why I lose the erection altogether.

As I was adjusting my protocol in the early days this kind of thing would happen as E2 was being tuned in, but I've been stable for quite some time and numbers look good I admit.

 

[Dr Justin Saya MD]

Indeed higher prolactin can cause ED even for a male on TRT (where HPTA suppression is obviously moot). With that said, 15.6 isn't *very* high and wouldn't cause problems for most (but can for some). A therapeutic trial of lowering may be the best way to determine, but more discussion would be needed in consult.

As JDS points out, the psychological component to ED is vastly underrated (and self-fulfilling). Higher prolactin makes it "easier" to experience ED from other causes as well (including psychological) as it can induce a prolonged semi-refractory period.

 

[GeauxBears]

Indeed higher prolactin can cause ED even for a male on TRT (where HPTA suppression is obviously moot). With that said, 15.6 isn't *very* high and wouldn't cause problems for most (but can for some). A therapeutic trial of lowering may be the best way to determine, but more discussion would be needed in consult.

As JDS points out, the psychological component to ED is vastly underrated (and self-fulfilling). Higher prolactin makes it "easier" to experience ED from other causes as well (including psychological) as it can induce a prolonged semi-refractory period.

Thanks for replying Dr. Saya. I definitely appreciate the power psychology can have on all of this stuff and am open to that being a factor here as it has been throughout my journey. My concern here is that something seems to have significantly changed despite a very stable protocol...traditionally the Cialis has been effective at keeping me "functional" in this regard and now it appears to either be losing effectiveness or being actively offset by other factors. I look forward to our consult.

 

[johndoesmith]

Thanks for the reply. I'm open to it being psychological but the strange thing is (1) my libido is acceptable and (2) the lack of penile sensitivity doesn't feel psychological upon first glance. It is like I can't feel the stimulation after the initial erection is achieved, which may be why I lose the erection altogether.

As I was adjusting my protocol in the early days this kind of thing would happen as E2 was being tuned in, but I've been stable for quite some time and numbers look good I admit.

I just can't think of any other reason why you'd have morning erections, but ED during sex.

That just screams psychological.

 

[JMP]

Have you considered backing down the dose of your AI? Your E2 sensitive is only 27. Isn't penile lack of sensitivity usually an AI issue? Very easy to blame the high prolactin number but it might have nothing to do with your problem. Would it hurt to try taking 1/2 the AI dosage per week and see if there is a difference? I doubt that your E2 will skyrocket, but maybe it would help.

 

[Dr Justin Saya MD]

Have you considered backing down the dose of your AI? Your E2 sensitive is only 27. Isn't penile lack of sensitivity usually an AI issue? Very easy to blame the high prolactin number but it might have nothing to do with your problem. Would it hurt to try taking 1/2 the AI dosage per week and see if there is a difference? I doubt that your E2 will skyrocket, but maybe it would help.

Indeed one variable to consider which can play a role for some. However, must keep in mind two other factors - low SHBG and higher E generally equals even higher prolactin.

 

[Guided_by_Voices]

I had a similar prolactin reading and I added in a small dose of Chaste Berry (per Dr. Saya's recommendation) which is a known prolactin lowerer (as is Vitamin B6) and it seems to have helped, so that is something to consider trying.

 

[Vince Carter]

side topic here the PDE5i's have been helping me get past the psychological performance anxiety and 6mg is just a miniscule dose of Cialis, as far as I'm concerned. You could be better served with 10mg, another thing is a good number of us find that Cialis takes several to as much as 8hrs to reach full effect. You can also try pairing it with some of the NO producers like Citrulline, too. I think thought that Prolactin is one of the more grey areas in HRT that there's no hard numbers to really talk about you either get super high or super low and then there's this huge swath in the middle that everyone just shrugs the shoulders over it.