Scientists compared every main treatment for low testosterone in men with obesity, and only one approach improved erections
Low testosterone is common in men carrying extra weight, and it often brings tiredness, low sex drive and erection problems. Men who have it are offered very different fixes: diet and exercise programs, testosterone shots or gels, pills that push the body to make more of its own, and now weight-loss drugs. A research team pulled together 23 randomized trials of these approaches to compare them head to head. Only one combination came out ahead on the measure many men care about most.
That combination was testosterone therapy plus a structured lifestyle program. It produced the biggest estimated rise in testosterone levels, and it was the only approach that significantly improved scores on a standard questionnaire of erectile function.
Testosterone on its own did some things well. It trimmed waist size and added lean muscle. But it also raised hematocrit, the share of the blood made up of red cells, which makes blood thicker and is one reason doctors monitor men on testosterone. None of the approaches significantly lowered HbA1c, the main long-term measure of blood sugar.
The analysis focused on what doctors call functional hypogonadism linked to obesity: low testosterone that comes with excess weight and can reverse when the weight comes off. It is different from low testosterone caused by damaged testes or a pituitary problem.
The study was a network meta-analysis, a method that compares treatments even when they were never tested against each other directly, by linking trials through shared comparison groups. In total, the 23 trials included 1,899 men. The erectile function comparison drew on 11 trials with 1,057 men, and the blood sugar comparison on 15 trials with 1,011 men.
The second finding is a caution. The researchers rated their confidence in many of the comparisons as low or very low, because the trials were small, different from each other, and few compared treatments directly. No single strategy won on every outcome.
“Treatment for functional hypogonadism in men with obesity should be guided by an integration of clinical symptoms, patient priorities, and biochemical testosterone assessment and monitoring,” the researchers write.
For men told their testosterone is low, a few practical points follow. Guidelines generally call for confirming a low result with two separate early-morning blood tests before starting treatment, because levels swing during the day. If weight around the middle came with the low result, it is worth asking whether it could be the reversible kind. And testosterone from outside the body suppresses sperm production, so men who want children should raise that before the first prescription. Testosterone is more complicated than it looks, as research on how libido changes with age and on men taking testosterone without a diagnosis has shown.
There are limits to what this shows. The trials varied in length, dose and who they enrolled, and many were small. The analysis covers only men whose low testosterone is tied to obesity, so it does not apply to other causes. Indirect comparisons in a network meta-analysis are weaker evidence than two treatments tested against each other in a single trial.
Source
Yang L, He X, Wang S, Li T, Huang W, Feng Q. “Treatment strategies for functional hypogonadism in obese men: a systematic review and network meta-analysis.” The Journal of Sexual Medicine, 2026.
DOI: 10.1093/jsxmed/qdag272
