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Posted on Wednesday September 3, 2025 in Diagnostic & Health Screening
The questions men ask in the changing room, and in our heart clinic, reveal why cardiovascular and men’s health belong under the same roof.
An article written by Dr Edward Leatham, Consultant Cardiologist
Prostate cancer screening section endorsed by Prof Stephen Langley, Professor of Urology, Royal Surrey NHS Cancer Centre & Hospital, and Trustee of the Prostate Project · brachytherapy.uk
Read with full references & citations: https://mhaat.vercel.app/s-mens-health-cardiovascular-clinic.html
For busy people, or to tune in when on the move, a Google NotebookLM audio podcast is available as a story beneath.
There is a pattern I have noticed over many years of consulting. A man comes in for his heart — a borderline calcium score, a family history of early coronary disease, a cholesterol result his GP rightly took seriously. We work through it thoroughly. Then, as the consultation draws to a close, something shifts. He mentions almost in passing that his waist has expanded by two inches over the past few years and he cannot quite account for it. Or that things are not working the way they used to in the bedroom. Or that his mate had a PSA test and ended up going through a biopsy for a cancer that turned out to be nothing, and he wonders whether he should bother.
These questions are asked quietly, often framed as afterthoughts, by men who do not routinely see their GP and who would not dream of booking an appointment specifically to discuss them. The cardiology consultation becomes, by default, the place where they surface. That is not a complaint. It is a clinical observation that tells us something important: these men experience their health as a whole, even when medicine divides it into specialties. The cardiovascular risk, the metabolic creep around the middle, the sexual function and the prostate concern are, in their minds, part of the same story of a body getting older and possibly letting them down.
They are more right than they know. The physiological threads connecting these four domains are real, well described in the literature, and clinically actionable. That is why we built a men’s health service around them.
The controversy around PSA testing has never been a dispute about whether prostate cancer matters. It is a dispute about the arithmetic of testing men who feel entirely well. A raised PSA is not a diagnosis. It is a signal that can be generated by cancer, by benign prostatic enlargement, by prostatitis, by vigorous exercise before the blood draw, or by nothing identifiable at all. Until relatively recently, a raised result led fairly directly to a transrectal biopsy, and a substantial proportion of those biopsies found either nothing significant or a cancer so biologically indolent that detecting it caused more harm than ignoring it would have done. The false positive and overdiagnosis problem is a legitimate concern. It is why, in March 2026, the UK National Screening Committee confirmed that it does not recommend population screening for prostate cancer across the general male population.
Part of that caution reflects an evidence gap the NHS is actively trying to close. TRANSFORM, the current UK trial, is comparing PSA-alone screening against a combined PSA-and-MRI approach, to establish which offers the better balance of benefit and harm before any national screening programme is considered — but the trial isn’t due to report until the end of 2027, so this is a decision the NHS won’t revisit for at least another year or two. Even once those results are in, a population-wide MRI-based screening programme in the UK looks unlikely to be funded, given that the great majority of men screened will be entirely healthy and MRI capacity is expensive to scale nationally. The European Union, meanwhile, is moving on its own timetable rather than waiting for TRANSFORM: in September 2022 the European Commission proposed extending organised, risk-stratified cancer screening programmes to include prostate cancer, alongside lung and (in higher-incidence regions) gastric cancer, with member states now working through a stepwise rollout — including, per current clinical guidance, a PSA-then-MRI pathway.
It’s worth being clear about why a cautious national policy and an available individual test aren’t actually in conflict — they’re answering two different questions. A population screening decision asks whether an entire health system should invite every man of a certain age for testing: how many cancers would be found, how many of those would never have caused harm, how many men would go through unnecessary biopsies and anxiety, and whether the system has the funding and capacity to manage all of it well. That’s a resource and harm-benefit calculation made at scale, and it’s the right question for a body like the UK National Screening Committee to be answering on behalf of the population as a whole. An individual man weighing up a PSA test is answering something else entirely: given his own family history, ethnicity, age and personal tolerance for uncertainty, does he want this information about himself? A population-level policy can’t answer that on his behalf. The UK NSC’s caution about screening everyone doesn’t mean testing is wrong for a man who understands the trade-offs and wants to go ahead — and it doesn’t mean every man should be tested either. An informed-choice model exists precisely so that neither assumption gets made for him: he’s given the actual picture, not a default answer, and the decision stays his.
What has changed is the diagnostic pathway that now sits behind an abnormal result. Multiparametric MRI performed before any biopsy, interpreted using PI-RADS scoring, combined with PSA density adjusted for prostate gland volume, has transformed the landscape. A man with a mildly raised PSA and an MRI showing no suspicious findings is in a fundamentally different clinical position from the same man a decade ago — though it’s worth being clear that neither a normal PSA nor a clear MRI completely excludes prostate cancer, which is part of why ongoing monitoring still matters. The biopsy rate for low-risk signals has fallen considerably, and when biopsy is indicated, targeted sampling guided by MRI findings reduces both the procedure burden and the rate of clinically insignificant cancer detection.
We offer individual PSA testing as part of a broader men’s health assessment. This is not an NHS population-screening programme, and we explain the potential benefits and harms of PSA testing so that each man can make an informed choice — the test can be declined without affecting the rest of the assessment. Where a man chooses to go ahead, that sits within an informed, structured conversation about his individual risk profile — family history, ethnicity, PSA trajectory over time — and clear onward pathways to urology when they are needed. The goal is to move men from vague anxiety or complete avoidance into the kind of active, monitored relationship with their prostate health that actually serves them.
The two inches of extra waist circumference that men mention almost apologetically is, in cardiovascular terms, one of the most important physical signs in the consultation room. Visceral adipose tissue — the fat that accumulates around the abdominal organs rather than subcutaneously — is metabolically active in ways that subcutaneous fat is not. It releases inflammatory cytokines, drives insulin resistance and contributes directly to dyslipidaemia of the atherogenic pattern: elevated triglycerides, suppressed HDL, and a predominance of small dense LDL particles that are particularly efficient at penetrating the arterial wall and initiating plaque formation.
This is not simply a story about weight. Men who gain visceral fat in their forties and fifties are undergoing a metabolic shift that precedes clinically detectable type 2 diabetes by years, sometimes by a decade. Fasting glucose and HbA1c at standard thresholds will appear reassuring long after insulin resistance is already elevating cardiovascular risk meaningfully. A fasting insulin level, or better still a HOMA-IR calculation from fasting glucose and insulin together, gives a much earlier picture of where that individual sits on the trajectory from metabolic health to metabolic disease.
The connection to testosterone is real but frequently misunderstood. Low testosterone does not simply cause symptoms of tiredness and reduced libido. It is independently associated with increased visceral fat deposition, insulin resistance and unfavourable lipid profiles. The relationship runs in both directions: visceral obesity suppresses testosterone through aromatisation of androgens to oestrogen in adipose tissue, creating a self-reinforcing cycle that neither lifestyle intervention nor cardiovascular medication alone addresses completely.
Erectile function depends on healthy endothelium. The process of erection is fundamentally a vascular event: nitric oxide released from endothelial cells in the penile vasculature causes smooth muscle relaxation and arterial dilatation, allowing the corpus cavernosum to fill. When the endothelium is inflamed, stiffened or compromised by early atherosclerosis, that signal is blunted. Erectile dysfunction, in a man in his forties or fifties who has not been diagnosed with cardiovascular disease, is frequently the earliest visible manifestation of systemic endothelial dysfunction — the same process that, given years and additional risk factor exposure, will eventually affect the coronary and cerebral circulation.
The Princeton Consensus, a framework developed specifically to guide clinicians on the relationship between sexual activity and cardiovascular risk, stratifies men with erectile dysfunction by their overall cardiovascular risk profile and recommends appropriate investigation before treatment. What it makes explicit is that erectile dysfunction and cardiovascular disease are not simply associated by shared risk factors: they are expressions of the same underlying arterial pathology, often appearing sequentially with erectile dysfunction running several years ahead of symptomatic coronary disease.
For GPs and patients, the practical implication is this: a man in his late forties who presents with new erectile dysfunction and who has not had a recent cardiovascular risk assessment should have one promptly. A QRISK3 score, a full lipid profile including non-HDL cholesterol, a blood pressure measurement, HbA1c and a fasting glucose will tell you a great deal. The erectile dysfunction is not embarrassing peripheral noise — it is a clinical flag that belongs in the cardiovascular conversation, and treating it as such is both better medicine and more useful to the man sitting in the chair.
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© Surrey Cardiovascular Clinic · scvc.co.uk
Blog post:
https://www.scvc.co.uk/diagnostic-health-screening/mens-health-cardiovascular-clinic/
Referenced version (UK English only):
https://mhaat.vercel.app/s-mens-health-cardiovascular-clinic.html
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