TRT and Cardiovascular Health

The relationship between testosterone replacement therapy and cardiovascular health has been one of the most studied — and most debated — questions in men's medicine over the past two decades. Early retrospective studies raised concerns; more recent large-scale randomised trials have substantially refined the picture.

The pivotal TRAVERSE trial, published in the New England Journal of Medicine in 2023, enrolled over 5,200 men with hypogonadism and cardiovascular risk factors. Over an average follow-up of 33 months, TRT did not increase the rate of major adverse cardiovascular events (MACE) compared to placebo. This was a landmark finding that gave clinicians much greater confidence in prescribing TRT to appropriately selected patients.

There are specific cardiovascular considerations that require monitoring. TRT reliably raises haematocrit, which can increase blood viscosity. In men with pre-existing polycythaemia or significant cardiovascular disease, this warrants careful management. We monitor haematocrit quarterly and keep targets below 52%. For patients with borderline levels, dose reduction or therapeutic phlebotomy are standard interventions.

On the positive side, restoring testosterone to physiological levels is associated with improvements in several cardiovascular risk factors. Multiple studies have reported reductions in total cholesterol, LDL, and inflammatory markers alongside improvements in insulin sensitivity and body composition — all relevant to long-term cardiovascular risk. The metabolic benefits of TRT in men with metabolic syndrome or type 2 diabetes are particularly well documented.

The key clinical principle is patient selection and ongoing monitoring. TRT in appropriately screened men, managed with regular laboratory assessment, has a favourable safety profile. Men with a recent (within six months) myocardial infarction or stroke, untreated obstructive sleep apnoea, or uncontrolled heart failure are not candidates for treatment until those conditions are stabilised. Our intake process is designed to identify these contraindications before treatment begins.