Testosterone Supplementation and Intraocular Pressure
Yes, there is a clinically significant correlation between testosterone supplementation and increased intraocular pressure, particularly in women and female-to-male transgender individuals, though the evidence in cisgender men is less clear.
Evidence for the Correlation
In Women and Female-to-Male Transgender Persons
The strongest evidence demonstrates that testosterone increases IOP in women:
In postmenopausal women, esterified estrogens combined with methyltestosterone significantly increased mean IOP from 15.0 mm Hg to 18.2 mm Hg (p<0.0001) after a median of 11.3 months, with the increase becoming statistically significant within 3 months 1. Importantly, IOP returned to baseline after discontinuation of therapy.
In female-to-male transgender persons, testosterone therapy resulted in significantly higher IOP levels compared to both healthy women and men (p=0.025) 2. Additionally, serum testosterone levels positively correlated with IOP measurements (r=0.504, p=0.028).
Observational data in menopausal women showed that higher testosterone levels were associated with higher IOP both in those receiving hormone replacement therapy (r=0.48, p=0.02) and those not receiving it (r=0.42, p=0.003) 3.
Genetic predisposition studies found that in women, higher bioavailable testosterone (OR 2.05 per nmol/L) and free testosterone (OR 1.79 per ng/dL) were significantly associated with increased risk of open-angle glaucoma 4.
Mechanisms
The correlation appears to involve both IOP-dependent and IOP-independent mechanisms:
- Testosterone increases retinal nerve fiber layer thickness, ganglion cell complex thickness, and macular thickness 2
- Changes in ocular blood flow parameters correlate with serum testosterone levels 2
- Rare but severe presentations include ciliochoroidal effusion syndrome with secondary angle closure that resolved upon testosterone cessation 5
Clinical Monitoring Implications
While established testosterone therapy guidelines 6 do not specifically mention IOP monitoring, the FDA label for testosterone 7 does not list ocular effects among standard monitoring parameters. However, given the evidence:
Clinicians should consider baseline and periodic IOP measurements in patients receiving testosterone supplementation, particularly:
- Women receiving testosterone (any indication)
- Female-to-male transgender individuals on testosterone therapy
- Patients with pre-existing glaucoma risk factors
- Those reporting visual symptoms
Key Monitoring Points
- Measure IOP at baseline before initiating testosterone therapy
- Reassess IOP at 3-6 months (when increases become statistically significant) 1
- Include IOP checks in annual monitoring visits
- Educate patients about visual symptoms: blurred vision, eye pain, halos around lights
- Consider ophthalmology referral if IOP increases >4 mm Hg or exceeds 21 mm Hg
Important Caveats
The evidence in cisgender men receiving physiologic testosterone replacement is limited and less clear. Most studies showing IOP increases involved:
- Supraphysiologic testosterone doses 2
- Women or transgender individuals 4, 2, 1
- Combined estrogen-testosterone preparations 1
The risk appears highest in women and those receiving higher-than-physiologic testosterone doses, but any patient on testosterone therapy who develops visual symptoms warrants immediate IOP assessment and consideration of therapy modification or discontinuation.