Does testosterone increase the risk for cerebrovascular accident (CVA) or stroke?

From the Guidelines

Testosterone therapy does not significantly increase the risk of stroke in men with low testosterone levels when properly prescribed and monitored, according to the most recent and highest quality evidence. The relationship between testosterone and stroke risk is complex and depends on several factors, including age, dosage, and individual health status 1. For men with low testosterone (hypogonadism) who are prescribed appropriate doses under medical supervision, the stroke risk appears minimal.

Key Considerations

• The American College of Physicians' evidence report found that the pooled risk for adverse cardiovascular outcomes, including stroke, did not differ significantly between testosterone and placebo groups 1.
• The incidence of cardiovascular events, including stroke, was 2.3% in the testosterone group compared to 1.5% in the placebo group, although this difference was not statistically significant 1.
• Certain populations, such as older men (over 65) or those with pre-existing cardiovascular risk factors, may need to be cautious about testosterone therapy due to potential increased risks 1.

Clinical Implications

• A thorough cardiovascular risk assessment is essential before initiating testosterone therapy 1.
• Regular medical monitoring during treatment and prompt reporting of concerning symptoms like severe headache, vision changes, or weakness are crucial 1.
• The benefits of treating true testosterone deficiency often outweigh the risks when properly prescribed and monitored, emphasizing the importance of individualized care 1.

From the Research

Testosterone and Stroke Risk

• The relationship between testosterone and stroke risk is complex, with some studies suggesting an increased risk and others indicating a potential benefit of normal testosterone levels 2, 3, 4, 5, 6.
• A 2019 cohort study found that current use of testosterone replacement therapy (TRT) was associated with an increased risk of ischemic stroke, transient ischemic attack, and myocardial infarction, particularly in the first 6 months to 2 years of continuous TRT use 2.
• In contrast, a 2009 prospective observational study found that lower serum testosterone levels were associated with an increased incidence of stroke or transient ischemic attack in older men, suggesting that normal testosterone levels may have a protective effect 3.
• A 2016 study found that TRT to normal levels was associated with reduced major adverse cardiovascular events (MACE) and death over 3 years, but a stroke signal with high achieved levels suggests a conservative approach to TRT 5.
• A 2015 review of the literature found that there is no convincing evidence of increased cardiovascular risks with testosterone therapy, and that normal testosterone levels may have a beneficial relationship with cardiovascular health 6.

Key Findings

• Testosterone replacement therapy may increase the risk of cardiovascular events, including stroke, particularly in the first 2 years of use 2.
• Lower serum testosterone levels are associated with an increased incidence of stroke or transient ischemic attack in older men 3.
• Normal testosterone levels may have a protective effect on cardiovascular health, including reducing the risk of stroke 3, 6.
• The relationship between testosterone and stroke risk is complex and requires further study to fully understand the potential benefits and risks of testosterone therapy 4, 5, 6.