Do antihypertensive (blood pressure lowering) medications cause low testosterone levels?

Antihypertensive Medications and Testosterone Levels

Yes, certain antihypertensive medications can cause low testosterone levels, particularly beta-blockers and thiazide diuretics, while ACE inhibitors and ARBs have minimal impact on testosterone.

Medication Classes and Their Effects on Testosterone

High Risk for Testosterone Reduction

• Beta-blockers (metoprolol, propranolol, atenolol)

  • Commonly implicated in both erectile dysfunction and testosterone reduction 1
  • Mechanism: Decreased peripheral vasodilation and reduced cardiac output
  • The JNC-7 guidelines specifically note that beta-blockers can cause sexual dysfunction 2

• Thiazide diuretics (hydrochlorothiazide, chlorthalidone)

  • High association with erectile dysfunction and can lower testosterone levels 1
  • In the TOMHS study, participants on chlorthalidone reported significantly higher incidence of erection problems compared to placebo 2
  • Mechanism: Reduced blood volume and effects on vascular smooth muscle

Lower Risk for Testosterone Reduction

• ACE inhibitors and ARBs

  • Generally considered to have minimal impact on sexual function 1
  • However, one study showed lisinopril (an ACE inhibitor) decreased free testosterone in male hypertensive patients 3
  • The 2017 ACC/AHA guidelines note these medications have fewer sexual side effects 2

• Calcium Channel Blockers (CCBs)

  • Generally better tolerated regarding sexual function 1
  • However, research on amlodipine showed dose-dependent reduction in testosterone levels in animal studies 4

Clinical Implications

1. Testosterone and Cardiovascular Risk

   • Low testosterone is associated with increased risk for cardiovascular events in hypertensive patients 5
   • A study showed hypertensive subjects who developed major adverse cardiovascular events had lower total testosterone concentration (3.9±0.7ng/ml vs. 4.6±1.5ng/ml) 5

2. Management Approach for Patients with Concerns

   • If sexual dysfunction or low testosterone appears after starting antihypertensive therapy, consider switching medications 2
   • The JNC-7 guidelines recommend discontinuing the offending agent and restarting treatment with another agent 2
   • Consider ACE inhibitors or ARBs as alternatives to beta-blockers or thiazides 1

Monitoring and Treatment Considerations

• Medication Selection Algorithm:

  1. For patients with hypertension and concerns about sexual function or testosterone levels:

     • First-line: ACE inhibitors or ARBs
     • Second-line: Dihydropyridine calcium channel blockers
     • Avoid if possible: Beta-blockers and thiazide diuretics

  2. For patients already experiencing sexual dysfunction or low testosterone on antihypertensive therapy:

     • Switch from beta-blockers or thiazides to ACE inhibitors, ARBs, or CCBs
     • Monitor testosterone levels and sexual function after medication changes

• Important Caveat: The 2017 ACC/AHA guidelines emphasize that phosphodiesterase-5 inhibitors can be safely coadministered with most antihypertensive medications for patients experiencing erectile dysfunction 2, 1

Conclusion

When selecting antihypertensive medications, consider their potential impact on testosterone levels and sexual function. Beta-blockers and thiazide diuretics are most likely to cause problems, while ACE inhibitors, ARBs, and calcium channel blockers generally have fewer adverse effects on testosterone levels and sexual function.