By Dr. Jamin Brahmbhatt, CNN
(CNN) — When patients come to me with erectile dysfunction, or ED, their first concern isn’t usually about their health.
“Doctor, my partner is going to leave me,” they often say with worry.
I usually respond, “Relax, I’ve heard this a thousand times. Let’s start with a few questions.”
When a man already has high blood pressure or uncontrolled diabetes, the likely causes of ED are easier to pinpoint. But when the man is younger or otherwise appears healthy, I also look beyond the bedroom and start thinking about blood vessels — and the heart.
Those late-night supersize fries and other choices you make today may not cause a heart attack tomorrow, but they can contribute to blood vessel changes that show up earlier as ED.
That’s why I look at erectile dysfunction as a possible sign of deadlier health issues. Here’s why: The American Heart Association notes that sexual dysfunction can sometimes show up one to three years before more classic heart disease symptoms such as angina or chest pain. The American Urological Association guidelines go a step further: Men should be told ED can be a risk marker for underlying cardiovascular disease and other health conditions that may deserve evaluation and treatment.
The reasoning is most heart problems don’t start in the heart; they usually originate in the smaller blood vessels in the body. Over time, arteries can lose flexibility, the inner lining becomes less responsive, and plaque can build up from cholesterol and inflammation. Blood pressure, high blood sugar, smoking, poor sleep and stress all affect blood vessel health.
How erections work
One patient saying, “It’s not working,” can have different causes from another patient with the same symptoms.
Erections require the brain, nerves, blood vessels and muscles to work in perfect harmony. Sexual stimulation kicks off the process in the brain, triggering signals that travel down the spinal cord into the pelvic nerves. From there, chemical messengers tell the arteries supplying the penis to open so blood can rush into the spongelike chambers inside it. As they fill, the penis expands and becomes firm.
Meanwhile, that expansion compresses the veins that normally drain blood, helping trap blood long enough to maintain a rigid erection. After orgasm or when stimulation stops, the smooth muscle tightens, blood drains out and the erection goes away. If any step in that sequence is disrupted — signaling, blood flowing and then being trapped — the quality of the erection can drop.
Early detection of vascular disease
If blood vessels are starting to stiffen, narrow or lose their ability to open the way they should, erectile changes may show up early — sometimes before someone has the classic warning signs of heart disease. It’s why ED is sometimes discussed as an early sign of vascular disease — meaning disease of the blood vessels that supply blood throughout the body, including the penis.
Not every case of ED indicates heart disease, but when ED is new, persistent or progressively worsening — especially in those who say they otherwise feel fine — it can be a sign to take cardiovascular risk seriously. That’s because the same blood vessel changes that affect the heart can affect the penis, too.
Is sex safe for the heart?
For most people with stable heart health, sex is safe for the heart.
Sex can briefly raise heart rate and blood pressure. It typically requires three to five METs, or metabolic equivalents. One MET is th