When men begin to experience signs and symptoms of low testosterone, such as loss of libido, waning muscle strength, encroaching abdominal fat, tiredness, brain fog, and erectile dysfunction, some seek out testosterone replacement therapy (TRT). After all, all those internet, television, and radio ads can’t be wrong, right? Got low T? Replacement therapy can solve your problems and make you feel like a man again.
Although TRT may seem like a great way to boost your T levels, there are some things you should know about testosterone therapy and the heart.
Use of testosterone replacement therapy
Given the high interest among aging men to take testosterone therapy, understanding the risk is important and should be discussed thoroughly between doctors and their patients. In fact, while reported rates of low testosterone among men have been static, prescriptions for TRT have climbed over the past two decades.
This rise in TRT reflects how the hormone is being increasingly prescribed and used for indications outside of the FDA approved reasons. According to the FDA, those reasons are as follows: “Testosterone is FDA-approved as replacement therapy only for men who have low testosterone levels due to disorders of the testicles, pituitary gland, or brain that cause a condition called hypogonadism. Examples of these disorders include failure of the testicles to produce testosterone because of genetic problems, or damage from chemotherapy or infection.”
Testosterone therapy and the heart
According to the findings of a new study from researchers at McGill University in Montreal, men who took testosterone therapy were at an increased risk of mini strokes (TIAs), stroke, or cardiac arrest during the first two years of taking the therapy. Data from about 15,400 British men aged 45 and older who had age-related low testosterone levels were evaluated for the study.
When compared with men who did not take testosterone replacement therapy, those who did had a 21 percent higher risk of cardiovascular events, including stroke, mini-stroke, or heart attack. This increased risk declined after two years of the hormone therapy.
One of the study’s authors, Dr. Christel Renoux, of the departments of epidemiology, biostatistics, and occupational health and the department of neurology and neurosurgery at McGill, explained that the evidence on long-term clinical benefits of using testosterone therapy in healthy men who have “modestly declining levels” of the hormone is limited. “We strongly recommend that clinicians proceed with caution when considering prescribing [testosterone therapy].”
Not all studies say TRT carries a cardiovascular risk. Some research suggests its use is associated with a lower risk of death from any cause, although past evaluations have noted an increased risk.
Between January 1, 1999 and December 31, 2010, for example, more than 44,300 men with androgen deficiency (serum testosterone less than 300 ng/dL) were evaluated. Of these, 8,808 (19.8%) had ever taken TRT and 35,527 (80.2%) had not. At a mean follow-up of 3.4 years, the risk of cardiovascular events was lower in the men who took TRT than those who did not.
More recently, in a May 2019 article appearing in Nature Reviews Cardiology, the authors noted that the true impact of testosterone replacement therapy on cardiovascular health remains uncertain.
In fact, the experts made the following observations:
- Some retrospective studies have shown a greater risk of cardiovascular events in men who are taking TRT, and the risk rises early after treatment begins
- Meta-analyses of randomized, controlled trials have demonstrated conflicting findings, and this is likely due to various causes, including studies that have been too short to adequately evaluate cardiovascular events
- The first trial (TRAVERSE) that is considered to be properly powered to evaluate cardiovascular findings among men using testosterone replacement therapy was initiated in 2018, and it will be approximately 10 years before the results become available
Until medical professionals have more information about testosterone and the impact on the heart, the authors recommend that physicians make their decisions about prescribing testosterone therapy on a case-by-case basis, especially in light of any personal or family history of cardiovascular problems. Doctors also should thoroughly discuss the risks and benefits of TRT with their patients.
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Cheetham TC et al. Association of testosterone replacement with cardiovascular outcomes among men with androgen deficiency. JAMA Internal Medicine 2017 Apr 1; 177(4): 491-99
Food and Drug Administration. FDA drug safety communication: FDA cautions about using testosterone products for low testosterone due to aging; requires labeling change to inform of possible increased risk of heart attack and stroke with use.
Gagliano-Juca T, Basaria S. Testosterone replacement therapy and cardiovascular risk. Nature Reviews Cardiology 2019; 16: 555-74
Loo SY et al. Cardiovascular and cerebrovascular safety of testosterone replacement therapy among aging men with low testosterone levels: a cohort study. American Journal of Medicine 2019 Apr 3