Heart Health and Testosterone Replacement Therapy: What the Latest Research Really Shows

Introduction: Cutting Through Conflicting Headlines

You’ve probably seen two types of headlines about testosterone replacement therapy (TRT). One warns that it “doubles heart attack risk,” while another boldly proclaims “testosterone therapy saves your heart.” The reality lies somewhere in between—and depends on who is being treated, how they’re monitored, and what dose they receive. As a hormone replacement clinic in Hurricane, West Virginia, Total Health Pros believes that informed patients make better decisions. In this article we’ll explore how testosterone interacts with the cardiovascular system, what the latest large‑scale trials reveal, and how to balance benefits against risks.

How Testosterone Affects the Heart

Testosterone influences multiple systems that intersect with heart health. It stimulates red blood cell production, which can raise hemoglobin and hematocrit. In some men this can lead to thickened blood, increasing the risk of clotting or pulmonary embolism. Testosterone also interacts with lipids: evidence suggests that therapy can reduce total cholesterol and triglycerides within 3 months, and improve insulin sensitivity within weeks, potentially benefiting heart health. However, it may slightly lower high‑density lipoprotein (HDL) cholesterol in some individuals. The net effect varies from person to person.

The TRAVERSE Trial: Largest Study to Date

In 2023, researchers published the Testosterone Replacement Therapy for Assessment of Long‑term Vascular Events and Efficacy Response (TRAVERSE) trial, the largest randomized controlled trial assessing TRT’s cardiovascular safety. They enrolled 5 204 men aged 45–80 with documented hypogonadism and high cardiovascular risk factors (e.g., previous heart attack, stroke or diabetes). Participants were randomized to a daily transdermal testosterone gel or placebo and followed for an average of 22 months. The primary outcome—composite of cardiovascular death, non‑fatal myocardial infarction, or non‑fatal stroke—occurred in 7.0 % of the testosterone group and 7.3 % of the placebo group (hazard ratio 0.96, 95 % CI 0.78–1.17). In other words, TRT did not increase major cardiovascular events compared with placebo.

Secondary analyses revealed a few differences. There were slightly more cases of atrial fibrillation (3.5 % vs. 2.4 %), acute kidney injury (2.3 % vs. 1.5 %) and pulmonary embolism (0.9 % vs. 0.5 %) in the testosterone group. The researchers emphasised that these events were uncommon but underscore the need for careful monitoring. They also noted that the findings apply only to men with confirmed hypogonadism—not to athletes, bodybuilders or men with normal testosterone levels.

Supporting Evidence: Erectile Dysfunction Study

Other studies support these findings. A 2024 investigation examining men with erectile dysfunction and testosterone deficiency found that TRT did not increase adverse cardiovascular events compared with erectile dysfunction patients who had normal testosterone levels. This adds further reassurance that, in appropriately selected patients, testosterone therapy does not appear to harm the heart.

Metabolic Benefits: Waistlines, Lipids and Insulin

Testosterone replacement does more than raise energy and libido—it can positively influence metabolic health. Data compiled in the 2011 Onset of effects review show that waist circumference and trunk fat decrease after about three months of therapy and continue to decline over two years. Total cholesterol and triglycerides often decrease within four weeks to three months. Improvements in insulin sensitivity, glucose levels and HbA1c can appear after three to six months, with some metabolic benefits evident as early as one week due to increased insulin sensitivity. These changes may indirectly lower cardiovascular risk, especially in men with metabolic syndrome.

Guidelines, Screening and Monitoring

To ensure safety, reputable clinics follow evidence‑based guidelines. Before starting TRT, physicians should check two separate morning testosterone levels, hemoglobin, hematocrit, liver function, luteinizing hormone and PSA. They will also take a detailed cardiovascular history, measure blood pressure and review medications.

After initiating therapy, follow‑up labs are typically done at six weeks to adjust dose, again at three months, and then every three to six months. These visits monitor red blood cell counts, lipids, liver enzymes and PSA, and assess symptoms. Guidelines recommend discontinuing therapy if adverse events occur or if there is no clinical improvement after an adequate trial of around three months. The Canadian Urological Association guidelines further note that there is no need for tapering when stopping.

Lifestyle: Partnering TRT with Heart‑Healthy Habits

Hormone therapy is not a replacement for healthy living. Harvard Health recommends maintaining a healthy weight, engaging in both aerobic and resistance exercise, eating a balanced diet rich in vegetables, fruits, lean protein and healthy fats, and limiting alcohol and smoking. These behaviours not only reduce cardiovascular risk but also help testosterone work better. Adequate sleep and stress management further support hormone balance.

At Total Health Pros, our approach is holistic. We pair TRT with personalised nutrition plans, supervised fitness programs and stress‑reduction coaching. We collaborate with local cardiologists and primary care physicians to coordinate care, ensuring that lab results and treatment plans are shared.

Frequently Asked Questions

Is TRT safe if I’m on statins? Many men on testosterone also take statins for cholesterol. There are no known drug interactions, but both therapies can affect liver enzymes and lipids, so regular monitoring is essential.

Does testosterone therapy lower blood pressure? Some men experience modest improvements in blood pressure due to weight loss and improved insulin sensitivity. However, TRT alone is not a blood pressure medication. Continue your prescribed antihypertensives and discuss changes with your doctor.

Should I pause TRT before surgery? Your surgeon and hormone provider should collaborate. Some practitioners stop therapy before major surgeries to reduce clotting risk, particularly if hematocrit is elevated. Decisions are individualized.

Can TRT help women’s heart health? Research on cardiovascular outcomes in women on testosterone therapy is limited. Women prescribed testosterone for hypoactive sexual desire disorder should have regular check‑ups and cardiovascular screening as recommended by their healthcare provider.

Conclusion: A Balanced Perspective

The biggest takeaway from recent research is that properly prescribed testosterone therapy does not appear to increase heart attack or stroke risk in men with documented hypogonadism. However, it’s not risk‑free. Slight increases in atrial fibrillation and pulmonary embolism have been observed, and therapy can thicken the blood. Regular monitoring, lifestyle optimisation and collaboration with a qualified provider are essential.

If you’re curious about testosterone therapy but concerned about heart health, book a consultation at Total Health Pros. Our team will review your cardiovascular history, perform comprehensive lab testing, and work with you to craft a personalised plan that prioritises safety and long‑term well‑being.