Is testosterone therapy recommended for patients with hypertension?

Testosterone Therapy in Patients with Hypertension

Testosterone therapy can be administered to patients with hypertension, but requires careful monitoring of blood pressure and cardiovascular risk factors, with a waiting period of 3-6 months after any cardiovascular event before initiating treatment. 1

Assessment Before Initiating Testosterone Therapy

When considering testosterone therapy in hypertensive patients, the following evaluations are essential:

• Cardiovascular risk assessment: Evaluate all fixed (age, gender) and modifiable risk factors (dyslipidemia, hypertension, diabetes, smoking) 1
• Blood pressure control: Ensure BP is adequately controlled, ideally <130/80 mmHg 1
• Laboratory testing:
  • Hemoglobin/hematocrit (baseline and monitoring) 1
  • PSA for men over 40 years 1
  • Estradiol in patients with breast symptoms 1
  • Lipid profile 1

Contraindications and Precautions

• Recent cardiovascular events: Wait 3-6 months after any cardiovascular event before starting testosterone therapy 1
• Uncontrolled hypertension: Optimize BP control first 1
• Fertility concerns: Testosterone therapy should not be prescribed to men trying to conceive 1

Treatment Approach

1. Lifestyle modifications first:

   • Weight loss for overweight/obese patients
   • Increased physical activity
   • Sodium restriction
   • These may improve both testosterone levels and blood pressure 1

2. Testosterone formulation selection:

   • Transdermal preparations may be preferred over injectable forms for hypertensive patients due to more stable serum levels 2
   • Avoid alkylated oral testosterone due to liver toxicity 1

3. Dosing considerations:

   • Target testosterone levels in the middle tertile of normal range (450-600 ng/dL) 1
   • Use minimal effective dose 1

Monitoring Protocol

• Blood pressure: Monitor closely, especially during first 3 months of therapy 3, 4
• Hematocrit/hemoglobin: Check at baseline, 3-6 months after starting therapy, and then annually 1
  • If hematocrit exceeds 54%, reduce dose or temporarily discontinue therapy 1
  • Patients with increases in hematocrit >6% may experience greater BP increases 4
• Lipid profile: Monitor for changes in HDL and LDL cholesterol 5
• Cardiovascular symptoms: Instruct patients to report any chest pain, shortness of breath, dizziness, or transient loss of consciousness 1

Evidence on Testosterone and Blood Pressure

Recent evidence suggests that testosterone therapy may actually have beneficial effects on blood pressure in some hypogonadal men:

• A long-term observational registry study found that testosterone undecanoate was associated with significant reductions in systolic and diastolic BP, regardless of antihypertensive therapy 3
• Greater BP reductions were observed in men with higher baseline BP 3
• Some patients on antihypertensive medications were able to discontinue these medications during testosterone therapy 3

However, other studies have shown modest increases in BP with testosterone therapy:

• A study of oral testosterone undecanoate showed small increases in 24-hour ambulatory BP after 4 months of therapy (3.8 mmHg systolic, 1.2 mmHg diastolic) 4
• Patients with the greatest increases in hematocrit experienced larger BP elevations 4

Important Caveats

• Patient counseling: Inform patients that current evidence cannot definitively state whether testosterone therapy increases or decreases cardiovascular risk 1
• Avoid in specific conditions: Non-dihydropyridine CCBs (diltiazem, verapamil), clonidine, and alpha-blockers should be avoided in patients with heart failure and hypertension 1
• Special populations: In transgender men, testosterone therapy has been associated with modest increases in BMI, hemoglobin/hematocrit, and LDL-cholesterol, and decreases in HDL-cholesterol 5

By carefully selecting appropriate patients, monitoring blood pressure and hematocrit, and using appropriate testosterone formulations and dosing, testosterone therapy can be safely administered to many hypertensive patients with testosterone deficiency.