Background: We aimed to investigate the relationship between erectile dysfunction (ED), the atherogenic index of plasma (AIP) and the testosterone-to-estradiol (T/E2) ratio. Given the role of metabolic and hormonal imbalances in ED, we sought to determine whether these parameters could serve as potential biomarkers for ED risk assessment. Methods: A retrospective included 117 ED patients and 115 controls. Participants’ demographic, clinical and biochemical data were collected, including body mass index (BMI), lipid profile and hormone levels. The AIP was calculated as log10 (triglyceride (TG)/high-density lipoprotein cholesterol (HDL-C)) and the T/E2 ratio was determined. Univariate and multivariate logistic regression analyses were conducted to assess the associations between these factors and ED. Results: ED patients had significantly higher AIP levels (0.639 ± 3.02) compared to controls (0.131 ± 0.15, p < 0.001). Additionally, the T/E2 ratio was significantly lower in ED patients (10.96 ± 5.97) than in controls (17.31 ± 8.12, p < 0.001). Obesity, as indicated by a higher BMI, was also strongly associated with ED (p < 0.001). Multivariate analysis identified BMI Odds Ratio (OR: 1.354, p < 0.001), E2 levels (OR: 1.080, p < 0.001) and AIP (OR: 2.31, p < 0.001) as independent predictors of ED. Conclusions: We suggest that both metabolic and hormonal imbalances contribute to ED pathophysiology. The increased AIP levels observed in ED patients highlight the potential role of lipid metabolism dysfunction and atherosclerosis in erectile function impairment. The reduced T/E2 ratio indicates the influence of hormonal imbalance, particularly the detrimental effects of increased aromatization of testosterone into estradiol. Given that AIP and T/E2 are associated with cardiovascular and endocrine health, they may serve as valuable biomarkers for early ED risk assessment. These results emphasize the importance of lifestyle interventions, weight management and metabolic optimization in preventing and managing ED.