Testosterone's Effect on Blood Pressure
Based on current evidence, testosterone replacement therapy at physiologic doses does not significantly increase blood pressure in most men and may even have neutral or beneficial effects on cardiovascular health. 1
Effects of Testosterone on Blood Pressure
Evidence from Clinical Guidelines
The New England Journal of Medicine guidelines indicate that contrary to common belief, testosterone therapy does not appear to increase blood pressure or cardiovascular risk when used at physiologic replacement doses 1. In fact, the guidelines state:
- "Few, if any, data support a causal relation between higher testosterone levels and heart disease" 1
- "Existing evidence suggests a neutral or possible beneficial effect" on cardiovascular disease 1
- Studies have shown that testosterone therapy may actually improve coronary artery diameter and blood flow 1
Different Formulations and Dosages
The effect of testosterone on blood pressure appears to be influenced by:
Dosage:
- Physiologic replacement doses typically show no significant blood pressure changes 1
- Supraphysiologic doses (well above normal range) may have different effects
Formulation:
- Transdermal administration (patches, gels) shows minimal effects on cardiovascular parameters 1
- Injectable testosterone may have different effects depending on dosage
Recent Research Findings
Recent studies show mixed results:
A 2024 study found that testosterone undecanoate was associated with significant reductions in systolic, diastolic BP and pulse pressure in hypogonadal men, regardless of antihypertensive therapy 2
Conversely, a 2021 study of oral testosterone undecanoate showed small increases in ambulatory blood pressure (3.8 mmHg systolic) after 4 months of therapy 3
Another 2021 study of a different oral testosterone formulation showed smaller increases (1.7-1.8 mmHg systolic) 4
Special Populations
Transgender Men
In transgender men receiving testosterone therapy:
- Slight but significant increases in BMI (1.3-11.4%) were observed 5
- Three out of seven studies detected modest or clinically irrelevant changes in blood pressure 5
- In one study, two patients developed hypertension that resolved after stopping testosterone therapy 5
Clinical Implications and Monitoring
Who May Be at Higher Risk
Patients who may experience blood pressure changes with testosterone therapy include:
- Those with higher baseline blood pressure 4
- Patients on antihypertensive medications 4
- Individuals who develop significant increases in hematocrit (>6%) 3
Monitoring Recommendations
When prescribing testosterone therapy:
- Monitor blood pressure regularly, especially in the first 4-6 months
- Track hematocrit levels, as increases may correlate with blood pressure changes 3
- Be particularly vigilant in patients with pre-existing hypertension or cardiovascular disease
Conclusion
While individual responses may vary, the preponderance of evidence from clinical guidelines suggests that physiologic testosterone replacement therapy does not significantly increase blood pressure in most men. Some formulations may cause small increases, while others may actually decrease blood pressure in certain populations. The relationship between testosterone and blood pressure appears to be complex and may depend on baseline characteristics, formulation, and dosage.