Sexual Health Is a Vital Sign. We Just Don't Treat It Like One.
Hawaii, 2016. Tilda just turned two. She’s sitting on a beach towel eating sand, completely unconcerned with the fact that her parents’ entire life is in a shipping container somewhere between Arizona and New York.
My wife and I ended up in Maui for four weeks. Not a vacation. We just didn’t have anywhere to live while the moving truck crawled across the country. I had opened a new office for a startup. The kind of job where your phone goes off before your alarm, and you answer both. Twelve-hour days. Midnight calls. My calendar looked like a losing game of Tetris.
We had been trying for a second child for about a year. Nothing.
You might see the three-year gap between our kids and think we planned it like consultants. We didn’t. After a year of trying, we booked a fertility specialist. Find out what’s up. See what we can do.
The appointment couldn’t happen before the move. So instead of a doctor’s office, we got Maui. No office. No Slack. No midnight calls. Just a toddler, the ocean, and more sleep than I’d had in two years.
We didn’t need the appointment.
I can’t claim scientific certainty. I was 37. Not a bad age for this. Some would call it my prime. I’d agree. Still am, for the record. But my body couldn’t do one of its basic jobs while I was running it into the ground. The moment the stress lifted, it worked.
That was the first time I got it, even if it took years to really sink in. Sexual function isn’t separate. It’s not its own category. It’s a readout. Maybe the most honest one your body gives you. It tracks your heart, your hormones, your stress, your sleep. All of it. One signal.
You’ll tell a colleague your resting heart rate. Compare VO2 max over dinner like it’s a golf handicap. Post CGM graphs on social media.
But this? Nobody says a word.
The Cardiovascular Early Warning System
Here’s the number that changed how I think about this topic: erectile dysfunction predicts cardiac events 2 to 5 years before they happen.
Not months. Years ahead.
A meta-analysis covering 92,757 participants found that men with ED had a 44% higher risk of cardiovascular events, a 62% higher risk of heart attack, and a 39% higher risk of stroke [1]. This held up after adjusting for age, diabetes, hypertension, smoking, and cholesterol. ED operated as an independent risk factor. That means it predicted cardiac events on its own, even when you accounted for all the usual suspects.
In younger men, the numbers are staggering. A Mayo Clinic study found that men under 50 with ED had a 50-fold increased risk of developing coronary artery disease over 10 years [2]. I had to read that twice. Not 50 percent. Not double. 50 times.
The mechanism is simple. Penile arteries are 1 to 2 millimeters wide. Coronary arteries are 3 to 4. Atherosclerosis, the slow buildup of plaque, hits the smallest pipes first [3]. Same disease. Earlier warning. The plumbing clogs by size.
Think about what gets checked at your annual executive physical. Cholesterol. Blood pressure. Glucose. Liver enzymes. The usual Framingham risk factors. Standard checklist for decades. But nobody adds sexual function. In people with moderate risk, ED predicts heart trouble as well as some of those classic markers [1]. We spend thousands on check-ups and skip the one signal that flags heart events years before a stress test does.
This isn’t only a male story. In women, the same vascular machinery is involved, but in the opposite direction. A meta-analysis of 54 studies covering 148,946 participants found that cardiovascular disease increases the risk of female sexual dysfunction by 1.5-fold [5]. Hypertension, stroke, and prior heart attack all damage sexual function through the same endothelial pathway. In men, the dysfunction comes first and warns of heart disease. In women, heart disease comes first and affects sexual function: different sequence, same biology. Either way, sexual function and cardiovascular health are reading from the same page.
The Hormonal Dashboard
Your reproductive hormones are real-time readouts. Not just for fertility. For everything.
In men, testosterone declines by about 1% per year after age 30. That’s the baseline. Chronic stress and sleep debt accelerate the decline. So does overtraining. A controlled study put healthy young men on five hours of sleep per night for one week and measured what happened. Testosterone dropped 10 to 15% [6]. One week. That’s not aging. That’s a normal work schedule for many people reading this right now.
I wish more executives knew about the cortisol-to-testosterone ratio. When cortisol is high and testosterone is low, your body is in survival mode. Not performance. Sports scientists use this ratio to spot overtraining in athletes. It works the same way in the boardroom. Your physiology doesn’t care about your job title.
For women, the parallel story deserves equal attention. And I want to be precise here, because this is an area where the conversation is often sloppy, and the stakes of getting it wrong are high.
Between 44 and 62% of women report cognitive complaints during perimenopause: difficulty with memory, focus, and concentration [7]. I’m saying “report” deliberately. These are subjective complaints, and the underlying mechanism is not one thing. Sleep disruption, which hits 38 to 47% of perimenopausal women [8], vasomotor symptoms, mood changes, and hormonal shifts all contribute. You can’t cleanly isolate a single cause, and anyone claiming otherwise is oversimplifying a complicated picture. Perimenopause lasts approximately 4 to 7 years according to the STRAW+10 staging criteria, the current clinical standard for staging reproductive aging [9]. Individual variation is wide.
Why does this matter for performance? Because perimenopause is one of the most overlooked disruptors in professional life. Millions of women go through it while leading teams and making big decisions, often without anyone connecting the dots. The research on sexual function as a biomarker in women is much thinner than for men. Most of what we know comes from ED studies. Women’s sexual health as a signal is understudied. Not unimportant. Just understudied. That gap needs to close.
A lasting drop in libido, for anyone, isn’t about your relationship or looks. It’s your brain-to-reproductive system axis signaling overload. Libido depends on sleep, stress, hormones, and mental health. If it drops for no clear reason, something upstream broke. Treat it as data. Not drama.
The Medication Blind Spot
This might be the most useful part of the whole newsletter.
SSRIs, selective serotonin reuptake inhibitors, are the most commonly prescribed antidepressants. Millions of professionals take them for anxiety and depression. They also cause sexual dysfunction in 30 to 50% of users [10]. If you’re on one and your libido has disappeared, it might not be the stress. It might be the treatment for the stress. Bupropion augmentation (150 to 300mg), a different class of antidepressant, reverses the sexual side effects in roughly 60% of cases [10]. That’s a specific conversation worth bringing to your doctor.
Statins get blamed for ED and don’t deserve it. A meta-analysis actually found that statin therapy improved erectile function by 3.4 points on the International Index of Erectile Function [11]. That’s about 40% of sildenafil’s effect. If someone told you statins tank your sex drive, the data says the opposite.
Beta-blockers are the antihypertensive class most likely to cause problems. Switching to nebivolol, a newer beta-blocker with vasodilating properties, restored sexual function in 69% of men within three months [12].
For women on hormonal contraception, the picture is more nuanced than social media suggests. About 15% of oral contraceptive users report decreased desire, while 85% report no change or improvement [13]. Individual variation is high. But if you’re on the pill and something changed, the connection is worth exploring with your physician.
Here’s what bothers me as a doctor. Many professionals medicate their stress response and, at the same time, shut down the one signal that would warn them the stress is too high.
That’s like putting noise-canceling headphones on a fire alarm.
One System
This sits in the Capacity pillar of my Upward ARC framework. Capacity is the total reserve you’re drawing from. Your cardiovascular fitness, your hormonal balance, how much stress you can absorb, how well you’re sleeping, and how much cognitive bandwidth you have left at the end of the day.
Sexual function taps into all of it. There’s no separate circuit. The same machinery runs your decisions, your energy, your ability to stay sharp at 4pm on a Thursday.
I learned this before I had the science. On a beach in Maui, watching my daughter eat sand, feeling my body come back online after months of burnout. Not just fertility. Sleep. Mood. Energy. Clarity. Everything came back because it was never really separate.
Try This Today
Take stock. This week, rate your sexual function on a 1-to-10 scale. Desire, function, satisfaction. Write it down. Compare it to six months ago. A year ago. If it dropped and nothing obvious changed, that’s not aging. That’s data. Track it monthly, just like you track resting heart rate.
Try the sleep test. For the next week, get at least 7 hours a night. No screens after 10pm. No alcohol within three hours of bed. One week of good sleep can reverse a 10 to 15% testosterone drop [6]. Cheapest fix you’ll find. Biggest return.
Have the medication conversation. Before your next doctor visit, write down every medication you take. Check which ones affect sexual function. Bring the list. Ask: Is there an alternative with fewer sexual side effects? Specific questions get real answers. Vague complaints get a shrug and a refill.
Treat it like any other metric. Track changes in sexual function the way you track resting heart rate or HRV. A lasting drop isn’t a personal failing. It means your system needs something. More sleep. Less training. A medication check. Lower stress. Same logic you’d use for any other number that moves the wrong way.
Tilda, Sand, and the Signal
I keep coming back to those four weeks.
There’s a version of this story about fertility. Timing, luck, and a shipping container that forced a break. That’s true. But it’s not the whole story.
The bigger story is simpler. My body had been sending a signal for a year. Loud and clear. I missed it because I was too busy proving I could handle the load. Every midnight email. Every early call. Every weekend worked. I wore it like a badge. But my body was keeping a different score.
Maui didn’t fix anything. It just got quiet enough for me to hear what was already there.
We track everything now. Steps. Heart rate zones. Sleep stages. Glucose spikes. We build dashboards for our bodies and check them before breakfast. But we leave out the one signal that ties it all together. The one that connects heart health, hormones, stress, sleep, recovery. The one that could have warned us something was off long before the blood test did.
I get why we don’t talk about it. It’s awkward. It feels private. Most people would rather not bring it into the performance conversation.
But your body doesn’t care about categories. It runs one system. It’s been reporting to you all along.
Start listening.
Stay healthy.
Andre
References
[1] Vlachopoulos, C. V., Terentes-Printzios, D. G., Ioakeimidis, N. K., Aznaouridis, K. A., & Stefanadis, C. I. (2013). Prediction of cardiovascular events and all-cause mortality with erectile dysfunction: A systematic review and meta-analysis of cohort studies. Circulation: Cardiovascular Quality and Outcomes, 6(1), 99-109.
[2] Inman, B. A., Sauver, J. L. St., Jacobson, D. J., McGree, M. E., Nehra, A., Lieber, M. M., Roger, V. L., & Jacobsen, S. J. (2009). A population-based, longitudinal study of erectile dysfunction and future coronary artery disease. Mayo Clinic Proceedings, 84(2), 108-113.
[3] Montorsi, P., Ravagnani, P. M., Galli, S., Rotatori, F., Briganti, A., Salonia, A., Rigatti, P., & Montorsi, F. (2005). The artery size hypothesis: A macrovascular link between erectile dysfunction and coronary artery disease. American Journal of Cardiology, 96(12B), 19M-23M.
[5] Zhao, S., Wang, J., Liu, Y., et al. (2024). Association between cardiovascular disease and risk of female sexual dysfunction: A systematic review and meta-analysis. European Journal of Preventive Cardiology, 31(5), 567-577.
[6] Leproult, R., & Van Cauter, E. (2011). Effect of 1 week of sleep restriction on testosterone levels in young healthy men. JAMA, 305(21), 2173-2174.
[7] Weber, M. T., Maki, P. M., & McDermott, M. P. (2014). Cognition and mood in perimenopause: A systematic review and meta-analysis. Journal of Steroid Biochemistry and Molecular Biology, 142, 90-98.
[8] Baker, F. C., de Zambotti, M., Colrain, I. M., & Bei, B. (2018). Sleep problems during the menopausal transition: Prevalence, impact, and management challenges. Nature and Science of Sleep, 10, 73-95.
[9] Harlow, S. D., Gass, M., Hall, J. E., et al. (2012). Executive summary of the Stages of Reproductive Aging Workshop +10: Addressing the unfinished agenda of staging reproductive aging. Journal of Clinical Endocrinology & Metabolism, 97(4), 1159-1168.
[10] Clayton, A. H., Croft, H. A., & Handiwala, L. (2014). Antidepressants and sexual dysfunction: Mechanisms and clinical implications. Postgraduate Medicine, 126(2), 91-99.
[11] Kostis, J. B., Dobrzynski, J. M., & Kostis, W. J. (2014). Statins and erectile dysfunction. Current Atherosclerosis Reports, 16(3), 1-7.
[12] Cordero, A., Bertomeu-Martínez, V., Mazón, P., Fácila, L., Bertomeu-González, V., Conthe, P., & González-Juanatey, J. R. (2010). Erectile dysfunction in high-risk hypertensive patients treated with beta-blockade agents. Cardiovascular Therapeutics, 28(1), 15-22.
[13] Pastor, Z., Holla, K., & Chmel, R. (2013). The influence of combined oral contraceptives on female sexual desire: A systematic review. European Journal of Contraception & Reproductive Health Care, 18(1), 27-43.
A note for new readers:
I’m a trained reconstructive facial surgeon, medical doctor, and dentist. Before launching this newsletter, I had a varied career: competitive freestyle wrestler, management consultant (McKinsey), entrepreneur (Zocdoc, Thermondo, and docdre ventures), and corporate executive (Sandoz). Today, I’m a Managing Director and Partner at BCG.
Husband of one. Father of three. Split between Berlin’s urban pulse and our Baltic Sea retreat. I’d rather be moving than sitting. Not just hobbies. Research. My body is my primary laboratory; I’ve been conducting experiments for decades.
If this is your first time here, welcome. I’m excited to share what I’ve learned and will continue to learn with you.
DISCLAIMER:
Let’s get one thing straight: None of this, whether text, graphics, images, or anything else, is medical or health advice. This newsletter is here to inform, educate, and (hopefully) entertain you, not to diagnose or treat you.
Yes, I’m a trained medical doctor and dentist. No, I’m not your doctor. The content here isn’t a replacement for professional medical advice, diagnosis, or treatment.
If you have questions about your health, talk to your physician or a qualified health professional. Don’t ignore their advice or delay getting care because of something you read in The Upward ARC. Be smart. Do your research. And, as always, take care of yourself.