TRT and Heart Health: What’s the Link?

MBChB, MRCGP

Medical director

Millions of men worldwide are seeing the benefits of testosterone replacement therapy (TRT) to improve symptoms of low testosterone, such as erectile dysfunction and a flagging sex drive.

However, there are many reasons why you shouldn’t ignore a drop in testosterone, and the one you may not have considered is your heart health.

Low testosterone and heart health
How can you tell if your testosterone level is low?
Is TRT safe for your heart?
Does TRT reduce heart attacks and strokes?
Can I improve my testosterone level and heart health naturally?
Can testosterone (anabolic) steroids cause heart problems?
Can you take testosterone therapy if you have heart disease?

What role does testosterone play in heart health?

Testosterone plays an important role in the cardiovascular system. It directly affects the cells and function of your heart, including cardiac output. It helps improve coronary and peripheral blood flow by regulating vasodilation (widening of the blood vessels), which also reduces blood pressure.

Is low testosterone bad for your heart?

Decades of research have shown that testosterone deficiency (TD) is linked to an increased risk of cardiovascular events in men, including heart attacks and stroke [1].

This link is associated with several interrelated mechanisms in the body:

Cardiovascular health — low testosterone (or low T) can impair vasodilation, leading to higher blood pressure — a risk factor for heart attacks and stroke.
Lipid profile — low testosterone is associated with an unhealthy balance of fats in the blood, which can contribute to atherosclerosis — a buildup of fatty plaques in the artery walls.
Insulin sensitivity and diabetes — TD is linked to insulin resistance, which can lead to the development of type 2 diabetes, a major risk factor for heart disease.
Inflammation and endothelial dysfunction — testosterone has anti-inflammatory effects in the body. A deficiency may cause chronic inflammation, which can damage the endothelium (the inner lining of the blood vessels) and promote atherosclerosis.
Body composition — low testosterone can cause a decline in lean muscle mass and an increase in body fat, particularly visceral fat, which is stored around the internal organs.

How can you tell if your testosterone is low?

The only way to know for certain if you have testosterone deficiency (TD — also known as hypogonadism) is with a Testosterone Blood Test.

A helps you check your testosterone level. You’ll also get actionable advice, so you can take steps to improve it if necessary.

Testosterone declines naturally in men by around 1% per year from around the age of 30 [2]. However, if your testosterone level is too low for your age, it can have a significant impact on your health and quality of life.

Is TRT safe for your heart?

Current evidence suggests that men who take TRT to treat TD are at no greater risk of heart attacks, stroke, or other cardiovascular events than men who don’t take this treatment [3].

There has been some caution amongst doctors in prescribing TRT because of conflicting evidence on heart disease risk. However, the handful of earlier studies suggesting a link between TRT and increased cardiovascular disease risk have been heavily criticised.

British Society for Sexual Medicine (BSSM) guidelines point to numerous flaws in this research, including [4]:

Inadequate diagnosis of TD in study participants
Little evidence of effective treatment levels being achieved
Failure to rule out that increased cardiovascular risk was linked to low testosterone and not its treatment

A European Medicines Agency (EMA) review also found no grounds for concern over TRT prescribing in Europe [5].

TRT may cause increased levels of haemoglobin and haematocrit, which can thicken the blood and make it more prone to clotting [6]. However, it’s typically the result of taking too much testosterone or aiming for unnaturally high levels rather than restoring a healthy level.

Does TRT reduce heart attacks and strokes?

Given the link between low T and heart disease, it may seem logical to assume that TRT could improve heart health. And the latest research suggests that testosterone therapy may reduce the risk of heart attacks and stroke.

One study found a 33% reduction in cardiac events in a group of men treated with TRT compared to men with low testosterone who did not receive treatment [7].

There’s also encouraging evidence that TRT can help improve some heart disease risk factors including:

Type 2 diabetes
High blood pressure [8]
Metabolic syndrome
Obesity

A study of pre-diabetic, testosterone-deficient men found a 40% reduction in progression to type 2 diabetes over two years, plus an additional benefit in BMI waist circumference [9].

Can you improve your heart health and testosterone level naturally?

Your lifestyle can impact your testosterone level and heart health. Making healthy changes may help boost your testosterone naturally and manage risk factors for heart disease.

Healthy changes include:

Drinking alcohol within the recommended limits
Getting good-quality sleep
Maintaining a healthy weight
Managing stress
Stopping smoking
Taking regular exercise

Man performing tricep pulldown at the gym

Can anabolic steroids cause heart problems?

The illicit use of anabolic steroids is associated with an increased risk of health complications, including cardiovascular events [10].

However, taking medically prescribed TRT to normalise your T levels is not the same as taking anabolic steroids. Anabolic steroids are a synthetic form of testosterone. They have limited medical uses and are sometimes taken in large doses, without medical advice.

This form of use is typically practised by bodybuilders and athletes who want to enhance their performance and build muscle. However, steroid abuse can have many serious side effects.

Heart-related effects of steroid abuse include:

Cardiac arrhythmias (irregular heartbeats)
Coronary artery disease
Dyslipidaemia — an unhealthy balance of fats in the blood
High blood pressure
Polycythaemia — the blood becomes thicker because of a higher concentration of red blood cells, which can cause life-threatening blood clots

A combination of these factors can significantly increase your risk of heart attacks and strokes.

Can you take testosterone therapy if you have heart disease?

There’s no strong evidence to suggest that TRT would be harmful to men with a history of heart disease. However, health experts recommend against taking TRT if you have [11]:

Had a heart attack or stroke within the last six months
Severe chronic heart failure
Polycythaemia (a condition where you have too many red blood cells)
Prostate cancer

For men with stable heart disease, the benefits of TRT may outweigh the risks, but it’s essential to have a discussion with your doctor before starting treatment.