Most men do not enter the healthcare system because they are worried about their long-term cardiovascular risk. They enter because something is wrong now, and often, that “something” is sexual function.
That is one of the most important themes in this conversation with Dr. Amy Pearlman, a board-certified urologist and sexual medicine specialist who has built her career around helping men understand their bodies before there is a crisis. Her message is simple but deeply needed: sexual health is not separate from overall health. It is often one of the earliest, clearest signals that something deeper is happening.
Erectile dysfunction is a perfect example. Many people think of ED as a bedroom problem, an aging problem, or a confidence problem. But very often, it is a vascular problem. The blood vessels that supply the penis are smaller than the blood vessels that supply the heart, which means they may show signs of dysfunction earlier. That is why erectile dysfunction can precede a cardiovascular event by several years.
In other words, the penis can be a canary in the coal mine.
This is why men’s sexual health is not superficial, embarrassing, or some optional side conversation that belongs outside the medical system. It is one of the most useful windows we have into a man’s vascular, metabolic, hormonal, and psychological health.
And yet, as Dr. Pearlman explains, men are often never taught how their bodies work.
They are not taught what normal sexual function looks like. They are not taught how erections happen. They are not taught how alcohol, vaping, cocaine, marijuana, poor sleep, obesity, insulin resistance, low testosterone, and poor cardiovascular health can all affect sexual function. They are not taught when to seek help, what data to track, or what interventions are available.
So they wait, and sometimes they wait for decades.
Men need an entry point into the healthcare system
One of the most striking points Dr. Pearlman makes is that men do not really have health milestones that pull them into the medical system.
Women often get connected to healthcare as teenagers through gynecology visits, contraception discussions, Pap smears, breast exams, pregnancy care, and later menopause care. That does not mean women’s health has been handled perfectly. It clearly has not. But there are touchpoints. There are moments where the system says, “You need to be seen.”
For men, that structure is largely missing. A boy sees a pediatrician. Then maybe he goes to college. Then what? Unless he has an injury, an acute illness, or a major problem, he may not see a doctor again for decades. The first major male-specific health milestone many men encounter is prostate cancer screening, often beginning in midlife. That is not exactly an inviting on-ramp into preventive care.
This matters because many of the problems that eventually become obvious in middle age begin much earlier.
Erectile dysfunction in a 25-year-old should not be brushed off as psychological without asking better questions. Low libido in a 35-year-old should not be dismissed as stress without looking at sleep, hormones, metabolic health, relationship factors, and cardiovascular risk. A man with low testosterone symptoms and a borderline “normal” lab value should not automatically be told he is fine because his number did not get flagged by the lab.
These are some of the major failures Dr. Pearlman highlights. Medical training has not done a good enough job teaching clinicians how to care for men’s health as men’s health.
Obviously, we learn about many things: prostate cancer, sperm physiology, male bodies in general, but many clinicians are never taught how to talk to a young man about erectile quality, penile curvature, pornography, marijuana, ejaculation, fertility, testosterone, anabolic steroid use, or sexual confidence.
So when men ask normal questions, they often get vague answers. Or worse, they get dismissed. Why then would we expect him to come back?
Sexual function is cardiovascular function
Erections are not magic. But they do require healthy blood vessels, healthy nerve signaling, adequate nitric oxide, responsive smooth muscle, hormonal support, psychological arousal, and tissue that is still capable of expanding and trapping blood. That means erectile function is not just a “sex” issue. It is a whole-body health signal.
This is why Dr. Pearlman sees sexual health as a gateway into preventive medicine.
If a man comes in because his erections are not what they used to be, that is not just a prescription opportunity. It is an opportunity to ask better questions. Does he have a primary care doctor? What is his blood pressure? What is his cholesterol? What is his A1c? How is his sleep? Is he snoring? How much alcohol is he drinking? Does he vape? Does he use marijuana or other substances? How does he train? What does he eat in a day? How much protein is he getting?
That may sound broad, but that is the point. Sexual function sits at the intersection of vascular health, metabolic health, hormonal health, nervous system health, and emotional health.
And the cardiovascular connection is not just theoretical. Erectile dysfunction can show up years before a major cardiovascular event. In some research, ED has been reported two to three years before a heart attack and one to two years before a stroke. That does not mean every man with ED is about to have a cardiac event, but it does mean ED should not be dismissed as random, embarrassing, or inevitable.
A large meta-analysis of more than 150,000 men found that erectile dysfunction was associated with a 43 percent higher risk of cardiovascular disease, a 59 percent higher risk of coronary heart disease, a 34 percent higher risk of stroke, and a 33 percent higher risk of all-cause mortality. Those are not small numbers. They tell us that ED is often not an isolated problem. It is often part of the same vascular story that eventually shows up as heart disease.
Dr. Pearlman’s pen analogy makes this easy to understand. The arteries that supply the penis are much smaller than the arteries that supply the heart. So if the vascular system is starting to lose function, the smaller vessels may reveal the problem first, and the penis may give us an earlier warning sign.
There is even research showing that the blood vessels in the penis may lose their ability to relax earlier than other arteries in the body. In one study, researchers tested blood vessels from different parts of the body, including penile arteries, aortic tissue, and arteries from the gut. While aging affected vascular function throughout the body, the penile vasculature appeared to show earlier dysfunction. That helps explain why erectile changes can appear before more obvious cardiovascular symptoms.
This also helps explain why medications like PDE5 inhibitors, including tadalafil and sildenafil, are not simply “sex drugs.” They work through vascular biology. They help preserve nitric oxide signaling, which supports blood vessel relaxation and blood flow. That does not mean they should be treated as magic cardiovascular prevention drugs, but the vascular connection is real.
A 2024 meta-analysis of more than 1.2 million people found that regular PDE5 inhibitor use was associated with a 22 percent lower risk of major adverse cardiovascular events and a 30 percent lower risk of all-cause mortality.
The same processes that damage the heart can damage erections. Poor endothelial function, insulin resistance, inflammation, obesity, sleep apnea, nicotine exposure, poor fitness, and poor metabolic health do not stay politely confined to one organ system.
Dr. Pearlman’s examples make this practical. Cocaine and nicotine are vasoconstrictors. They narrow blood vessels. If erections depend on blood flow, then the connection is not hard to understand. The goal is not to shame men. It is to explain the mechanism clearly enough that they can make a more informed decision.
That is what good medicine should do. Explain.
And when you explain sexual function through the lens of blood flow, young men listen. Because now the conversation is not only about preventing disease 30 years from now, but also about something they care about today. Sexual health can become the doorway into a larger conversation about blood pressure, glucose control, fitness, sleep, nutrition, smoking, vaping, alcohol, hormones, and long-term cardiovascular resilience.
Testosterone is not just a number on a lab report
The testosterone conversation is one of the most misunderstood areas in men’s health.
Part of the problem is that “normal” lab ranges are enormous. A man can fall inside the reference range and still not be functioning well. A 25-year-old man with a total testosterone of 300 ng/dL may not trigger a bright red warning flag on a lab report, but that does not automatically mean he is thriving.
This is where Dr. Pearlman’s clinical philosophy matters. She does not treat numbers in isolation. She treats people.
That does not mean being reckless. It means understanding that testosterone is not just a lab value. It is a hormone that affects energy, libido, erectile function, mood, motivation, bone health, muscle, metabolic health, and overall quality of life. So the real question is not simply, “Is the number technically normal?” The better question is, “Does this number make sense for this man, in this context, with these symptoms, goals, risks, and priorities?”
The research supports that more nuanced view. One large age-related model of male testosterone found that average total testosterone peaks around age 19 and is only modestly lower by age 40, with much more variation showing up after that. In other words, healthy aging does not automatically mean testosterone should collapse. What changes is that men become more variable. Some maintain strong levels for decades, while others fall much earlier.
Data from young and middle-aged men in NHANES show the same general pattern. Testosterone tends to drift down with age, but there is massive overlap between decades. Many men in their 40s have higher testosterone than men in their 20s. That tells us something important: age-specific ranges matter, but lifestyle and metabolic health matter too.
Excess body fat, poor sleep, insulin resistance, chronic stress, alcohol, medications, and overall health status can all influence testosterone. So can sex hormone-binding globulin, or SHBG, which affects how much testosterone is available to tissues. Two men can have the same total testosterone number and feel very different depending on free testosterone, receptor sensitivity, symptoms, and the rest of their physiology.
For testosterone therapy, context is everything. Is the man interested in current or future fertility? That changes the discussion immediately, because exogenous testosterone can suppress the body’s own signaling system and reduce sperm production. Does he have untreated sleep apnea? What is his hematocrit? What is happening with his lipids? What are his estrogen levels? Does he have cardiovascular risk factors? What has he already tried? How symptomatic is he? What is he hoping to improve?
That is the difference between thoughtful testosterone care and the cartoon version of the conversation.
It’s also worth emphasizing that testosterone therapy is not the same thing as abusing anabolic steroids. It is not the same as stacking multiple black-market compounds at extreme doses. It is not the same as a young man taking unknown products from the internet without labs, fertility testing, dosing oversight, or medical supervision.
Medically supervised testosterone therapy aims to restore men with true deficiency back into a physiologic range while monitoring for side effects. Anabolic steroid abuse often pushes androgen exposure far beyond physiologic levels, usually without medical supervision, and often with multiple compounds layered together. These are not the same risk category, and collapsing them into one conversation creates confusion.
The cardiovascular data also deserve a more measured discussion than people usually hear. Older headlines made testosterone sound broadly dangerous, but more recent randomized trial data have been more reassuring in appropriately selected men with hypogonadism.
A large individual-patient-data meta-analysis found no evidence that testosterone increased short- to medium-term cardiovascular risk in men with hypogonadism, although the authors were clear that longer-term safety data are still needed. Another more recent meta-analysis of randomized controlled trials similarly found no increase in cardiovascular events or mortality in men receiving testosterone replacement compared with placebo.
We should also emphasize the other side of the coin: Low testosterone is not benign simply because a clinician is uncomfortable prescribing. Low-T states are associated with worse body composition, more visceral fat, insulin resistance, inflammation, endothelial dysfunction, lower bone density, lower sexual function, and worse quality of life. Observational data also link low testosterone with higher cardiovascular and all-cause mortality.
Dr. Pearlman’s harm-reduction point is especially important. If a man is going to use testosterone anyway, pretending that refusal equals prevention is naïve. Many men will simply go somewhere less safe. They may order products online, use unknown doses, skip labs, ignore fertility, and stack compounds without understanding the consequences.
The goal is not to hand testosterone to every man who asks for it. The goal is also not to dismiss every symptomatic man because his lab number barely falls inside a broad reference range. The goal is precision, context, monitoring, and informed decision-making.
Erectile fitness should start before erectile dysfunction
We should not wait until men have erectile dysfunction before we talk about penile health. We do not wait until someone is frail to tell them to build muscle. We do not wait until someone has heart disease to tell them to exercise. So why would we wait until erectile function declines before discussing how to maintain it?
Dr. Pearlman describes the penis as erectile tissue that needs regular blood flow to stay healthy. Daily erections matter because they help preserve tissue quality, length, girth, and responsiveness. When erections disappear for long periods, the tissue can change. Men may lose size, the tissue may become less elastic, and function may decline.
This is where tools like daily tadalafil, erection rings, penis pumps, traction devices, and emerging wearable technologies enter the discussion. Some of these tools treat dysfunction. Some help preserve tissue. Some give men objective data. Some may help restore lost size. Some may help men understand whether lifestyle choices are affecting sexual function.
The data is still emerging in some areas, and Dr. Pearlman is careful to say when something is a data-free zone. But her broader point is strong: men deserve access to tools, education, and options before they are desperate.
A daily medication like tadalafil may help support erectile function by preserving nitric oxide signaling. A penis pump may help pull blood into the tissue and stretch it, especially in men who have lost size or have gone long periods without erections. A traction device may help men with Peyronie’s disease, which is scar tissue in the penis that can cause curvature, shortening, pain, or changes in function.
And wearable technology may give men something they have never really had before: a way to track erectile function objectively.
That is where the conversation gets exciting. If a man can track nocturnal erections, firmness, duration, and frequency, he can begin to see patterns. What happens when he drinks? What happens when he sleeps poorly? What happens when he uses marijuana? What happens when he improves his fitness or starts medication?
That is personalized medicine in real time, and it may help men make changes long before a major health event forces them to.
Women’s sexual health deserves the same curiosity
Although much of this episode focuses on men’s health, Dr. Pearlman also makes an important point about women: women have erectile tissue too.
Most people are taught to think of the clitoris as the small external structure that is visible from the outside. But that is only part of the story. The clitoris is much larger than what most people see, with internal erectile tissue that extends around the vaginal canal. Like the penis, this tissue responds to arousal and blood flow.
That matters because female sexual pleasure is often discussed in a way that is too narrow, too vague, or too focused on dysfunction after the fact.
Dr. Pearlman’s view is much more practical. Women need to understand their anatomy. Couples need to understand that arousal takes blood flow, stimulation, time, and nervous system engagement. Sexual function is not just a male issue, and it is not just a psychological issue. It is physical, vascular, hormonal, neurological, relational, and emotional.
Again, the theme is to normalize the conversation before there is a crisis. Women are often told what is wrong with their bodies, but not how their bodies actually work. Men are often told to perform, but not how to maintain the tissue and systems that make performance possible. Both approaches fail people.
A better model starts with education, curiosity, and agency.
- What is normal for you?
- What has changed?
- What do you want to improve?
- What data can you gather?
- What tools are available?
- What can be optimized safely?
That is a much better conversation than simply waiting until something breaks.
Action checklist
Start treating sexual health as a marker of overall health. If erections, libido, sensation, orgasm, or sexual satisfaction change, do not dismiss it as “just aging” or “just stress.” It may be a useful signal about vascular, metabolic, hormonal, sleep, or psychological health.
For men, consider getting baseline data earlier than you think you need it. That may include testosterone, free testosterone, SHBG, estradiol, hematocrit, lipids, A1c, blood pressure, and, if future fertility matters, a semen analysis.
If erectile function changes, ask bigger questions. Look at sleep apnea, alcohol, nicotine, vaping, marijuana, cardiovascular fitness, insulin resistance, obesity, blood pressure, cholesterol, training, nutrition, and medication use.
Do not confuse medically supervised testosterone therapy with unsupervised anabolic steroid abuse. The dose, compound, context, monitoring, and fertility goals all matter.
If fertility may matter later, do not ignore sperm health. Testosterone can suppress sperm production, and baseline semen analysis or sperm banking may be worth discussing before starting therapy.
Think in terms of erectile fitness, not just erectile dysfunction. Regular erections, healthy blood flow, and preserved tissue quality matter. Daily tadalafil, erection rings, vacuum pumps, traction devices, or wearable tracking may be useful tools depending on the person and the goal.
Be careful with penile injury. Sex can create microtrauma, especially with partial erections or risky positioning. Pain, curvature, shortening, or new lumps should be evaluated by a qualified urologist.
Women should learn their anatomy too. The clitoris is not just a small external structure. It includes internal erectile tissue, and blood flow, arousal, stimulation, and nervous system state all influence sexual function.
Stop treating sexual health as embarrassing. It is health. And for many people, it may be one of the earliest and most motivating clues that the body is asking for attention.
