Erectile Dysfunction After 35: Causes, Tests and Modern Treatments

Sexual Health · 8 min read · Published 2026-05-12

A Symptom, Not a Diagnosis

Erectile dysfunction (ED) affects more than 40% of men over the age of 40, yet remains one of the least openly discussed health concerns. What most men don't realise is that ED is rarely a standalone issue. It's usually the visible tip of a larger physiological story — vascular, hormonal, metabolic, or psychological.

Treating it well means understanding the cause, not just masking the symptom.

The Five Most Common Causes We See

1. Vascular. The penile arteries are among the smallest in the body. They're often the first to show signs of atherosclerosis, years before a heart attack or stroke. ED can be an early warning of cardiovascular disease.

2. Hormonal. Low testosterone, elevated oestradiol, or thyroid dysfunction can each contribute.

3. Metabolic. Insulin resistance, type 2 diabetes, and obesity damage blood vessels and nerves.

4. Psychological. Anxiety, depression, relationship stress, and performance anxiety — particularly common in younger men.

5. Medication-related. Antidepressants, beta-blockers, and certain blood pressure medications are common culprits.

In most men we assess, ED has more than one contributing cause.

Tests That Actually Help

A proper ED workup goes well beyond a quick testosterone check. We recommend:

• Full male hormone panel: total and free testosterone, SHBG, oestradiol, LH, FSH, prolactin
• Metabolic markers: fasting glucose, HbA1c, fasting insulin
• Cardiovascular markers: lipid panel, ApoB, hs-CRP, blood pressure
• General health: full blood count, kidney and liver function, vitamin D, ferritin
• Thyroid: TSH, free T4, free T3

This level of detail uncovers the root cause and identifies risks that need addressing regardless of ED.

Modern Treatment Options

Treatment should always match the cause. Common approaches include:

• PDE5 inhibitors (sildenafil, tadalafil): The most established treatment. Effective for most men, particularly when vascular function is largely intact.
• Testosterone optimisation: When low testosterone is confirmed, restoring it often improves erections, libido, and overall response to PDE5 inhibitors.
• Lifestyle medicine: Weight loss, smoking cessation, alcohol reduction, sleep optimisation, and zone 2 cardio can meaningfully restore function.
• Daily low-dose tadalafil: Increasingly used not only for ED but for improved vascular and prostate health.
• Shockwave therapy and PRP: Emerging options for vascular ED, though the evidence remains mixed.
• Psychological support: Where performance anxiety or relationship factors dominate, CBT and sex therapy are highly effective.

Why Doctor-Led Care Matters

Online ED clinics will happily ship medication without a meaningful assessment. The risk isn't just side effects — it's missing the cardiovascular or metabolic disease that ED was warning you about. A 45-year-old presenting with ED has a measurably higher cardiovascular risk than one without.

A proper assessment takes an hour, costs less than most men spend on a weekend, and can genuinely change the trajectory of your health.

The Honest Conversation

The best thing you can do is bring this up early, not after years of avoidance. ED is medical, treatable, and almost always reversible when investigated properly.

If you'd like to understand what's actually going on, a comprehensive men's health assessment is the right starting point.

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