As a physician specializing in testosterone replacement therapy for men with hypogonadism, I am frequently asked whether TRT increases cardiovascular risk. This question has long been debated, and until recently, answers have been clouded by contradictory data and limited randomized trials. Fortunately, two major meta-analyses published in 2024 have brought welcome clarity. These studies provide compelling, evidence-based insights into the cardiovascular safety of TRT in men with confirmed low testosterone levels.
The Studies
The first study, titled “Cardiovascular Outcomes of Hypogonadal Men Receiving Testosterone Replacement Therapy,” was published in Endocrine Practice in late 2024. This systematic review and meta-analysis focused exclusively on men with well-defined testosterone deficiency, pooling data from 26 randomized controlled trials and including over 10,000 patients. The researchers evaluated key cardiovascular endpoints including all-cause mortality, cardiovascular death, myocardial infarction, stroke, atrial fibrillation, congestive heart failure, pulmonary embolism, and venous thromboembolism. The findings were consistent and reassuring. There were no statistically significant differences in any of these outcomes between the TRT-treated groups and the placebo groups. Importantly, this study looked at different types of patients separately and found that the results were consistent across groups. The studies it included were also very similar to each other, which makes the overall findings more reliable.
The second meta-analysis, titled “Association between Testosterone Replacement Therapy and Cardiovascular Outcomes: A Meta-analysis of 30 Randomized Controlled Trials,” was published in Progress in Cardiovascular Diseases. This study incorporated a slightly larger patient population of over 11,500 men, with a mean age around 62. It also evaluated odds ratios for key outcomes, including myocardial infarction, stroke, all-cause mortality, and cardiovascular mortality. As with the first study, the results were neutral across the board. Once again, the data suggest that TRT, when prescribed appropriately to hypogonadal men, does not appear to elevate cardiovascular risk.
Study Comments
The convergence of these findings from two large and well-designed meta-analyses gives clinicians a solid foundation for evidence-based decision-making. The consistent message is that testosterone replacement, in properly selected men with true testosterone deficiency, does not increase the risk of major cardiovascular events or early death – at least in the short to medium term. These conclusions stand in contrast to earlier observational studies that raised concerns about increased cardiovascular risk, particularly in older men. Those earlier studies were often limited by confounding factors, such as comorbid illness, poor patient selection, or lack of testosterone level confirmation.
That said, both meta-analyses do have limitations that deserve mention. Most of the included randomized trials followed patients for less than two years. While that duration is sufficient to detect short-term cardiovascular events, it leaves the question of long-term safety unanswered. Furthermore, many of the studies excluded patients with advanced cardiovascular disease or other high-risk conditions, which limits generalizability to sicker populations. Another limitation is that most of the trials involved close monitoring and appropriate dose titration, which may not always be replicated in real-world practice.
Cardiovascular Related Effects of TRT
Biologically, the data make sense. Low testosterone has been linked to adverse cardiovascular risk markers, including insulin resistance, dyslipidemia, increased visceral fat, and endothelial dysfunction. In contrast, restoring testosterone to physiologic levels has been associated with improved HDL cholesterol, decreased inflammatory markers, and enhanced vascular function. Preclinical models support these observations, showing that testosterone can improve nitric oxide availability and reduce arterial stiffness. In patients with heart failure, several trials have shown that TRT improves exercise tolerance, lean body mass, and cardiac output – factors that may translate into survival benefit in certain subgroups.
Welcome Regulatory Changes
These findings have also impacted regulatory guidance. In 2014 and 2015, the FDA added boxed warnings to testosterone products citing possible increased risk of myocardial infarction and stroke. However, based on emerging data, the FDA updated product labeling in early 2025. The language suggesting increased cardiovascular risk was removed for men with confirmed hypogonadism, while a caution was added regarding potential increases in blood pressure with certain formulations. This represents a shift toward a more nuanced and evidence-driven regulatory stance, aligning with current data.
Treatment Guidelines
So what does this mean for our practice? First and foremost, patient selection remains key. TRT should only be initiated in men with symptomatic hypogonadism. Men with normal levels or non-specific symptoms should not be treated, as the risk-benefit ratio is unfavorable in those cases. At baseline, I evaluate each patient’s cardiovascular history, PSA, blood pressure, hematocrit, and lipid profile. These labs are repeated at regular intervals and testosterone dosing is adjusted to achieve mid-normal levels, not supraphysiologic concentrations.
In men with cardiovascular risk factors or a history of heart disease, I proceed with greater caution. I often start at lower doses and titrate more slowly. I also emphasize shared decision-making, explaining both the current evidence and its limitations. Patients appreciate honesty, and most find it reassuring to hear that high-quality studies have not shown increased risk when TRT is used appropriately.
It’s worth noting that while the studies reviewed above suggest cardiovascular neutrality, some safety signals have emerged in other trials – specifically, increased rates of atrial fibrillation, polycythemia, and possibly thromboembolism in certain populations. For this reason, I always monitor hematocrit closely and adjust dosing if levels rise too much. Patients at risk for clotting disorders or with a history of blood clots should be carefully evaluated before starting therapy.
In summary, the best available data suggest that testosterone replacement therapy, when properly prescribed and monitored in men with true hypogonadism, is not associated with an increased risk of cardiovascular events or mortality. These findings are consistent across multiple meta-analyses of randomized controlled trials and support what many of us in clinical practice have observed: TRT, when done responsibly, can significantly improve quality of life, energy, libido, body composition, and emotional well-being without adding undue cardiovascular risk.
As always, I encourage fellow clinicians to stay informed, use clinical judgment, and keep patients at the center of every decision. New research continues to emerge, and we will adapt as needed. For now, the evidence supports what we’ve long believed: testosterone therapy can be both effective and safe for the right patients.
Author
Scott Rollins, MD, is Board Certified with the American Board of Family Practice and the American Board of Anti-Aging and Regenerative Medicine. He specializes in bioidentical hormone replacement for men and women, thyroid and adrenal disorders, fibromyalgia and other complex medical conditions. He is founder and medical director of the Integrative Medicine Center of Western Colorado (www.imcwc.com) and Bellezza Laser Aesthetics (www.bellezzalaser.com). Call (970) 245-6911 for an appointment or more information.
