Dr. Kris Case: A Much Younger Partner, Hormones and Erections

Many patients walk in and say, "My partner is a lot younger than me, doctor," and then pause for a moment, as if waiting to see how I will look at them. This case was one of them, and it reminded me that sex for middle-aged men is never just about hormones.

Background

He was a man in his early 50s who looked after himself well and exercised regularly. His partner was about two decades younger. The relationship was good and his partner was very caring. But recently he had been getting tired easily, his desire had dropped, and his erections were inconsistent: sometimes good, sometimes fading partway through.

What he said again and again was, "I'm afraid they'll be disappointed," and "I don't want to lose them." I noticed that this fear weighed on him more than the symptoms themselves.

What I found

I didn't start by prescribing. I started by looking for all the causes first.

• Assessing the symptoms with the IIEF-5 questionnaire, and asking about morning erections, sleep and work stress.
• Checking his heart and blood vessels: blood pressure, blood glucose and lipids, because ED is often vascular and can appear years before heart disease. His cholesterol was above the target range.
• Checking hormones with two morning blood tests on different days, plus SHBG. The results confirmed that his testosterone was genuinely below the normal range and matched his symptoms (read: blood tests before starting TRT).
• Psychological factors: the pressure to "prove himself" every time had added performance anxiety during sex.

In short, his problem had several layers: low testosterone, early vascular risk, and anxiety that made everything worse.

Care

1. TRT according to the indications. Once low testosterone with symptoms was confirmed, we discussed the benefits, risks and monitoring before starting a long-acting testosterone injection as assessed by the doctor (read: what TRT is and who it suits). I told him plainly that TRT is not an anti-ageing drug and is not suitable for men with normal hormone levels.
2. Erection medicine at the start. A PDE5 inhibitor at a suitable dose, after checking there were no contraindications such as nitrate use.
3. Looking after his blood vessels: adjusting diet and sleep and monitoring his cholesterol, because this treats the root cause in the long term.
4. Talking about expectations. I invited him to consider that his partner might not want "the stamina of a 20-year-old", but closeness and attention. I suggested he talk with his partner openly.
5. Follow-up every 3 months in the first year, checking haematocrit, PSA and hormone levels (read: TRT side effects).

At follow-up he said he had more energy and was sleeping better, and, more importantly, that he and his partner had had their first real conversation about this worry. Results of treatment differ from person to person, and not everyone needs hormones.

What I learned

• An age gap is not a medical problem, but the fear of not being enough for your partner can genuinely affect the body.
• TRT must start from blood results, not from feelings. AUA and Endocrine Society guidelines require low morning testosterone to be confirmed at least twice, together with symptoms. The TRAVERSE trial (2023) gives more confidence that TRT in men with genuinely low testosterone does not increase major cardiovascular events, but close monitoring is still needed.
• ED is a window into heart health. Good treatment looks at the whole person, not just the penis.
• The partner is part of the treatment. Talking openly can relieve more pressure than some medicines.

If you are going through the same thing

Start by checking the symptoms of low testosterone and reading ED: causes and treatment. If your symptoms persist, don't buy hormones or medicines to use on your own, because they may mask a hidden disease. At Dr. Kris Clinic, I help find the cause, assess whether TRT is right for you, and plan safe follow-up. Consultations are available at the clinic and online, including in English.