Is there a relationship between testosterone levels and hypertension (high blood pressure)?

From the Guidelines

Testosterone therapy should be used with caution in men with hypertension or cardiovascular risk factors, as it may increase blood pressure and cardiovascular events, and regular blood pressure monitoring is essential. Testosterone can contribute to hypertension through several mechanisms, including sodium and water retention, increased angiotensinogen production, enhanced sympathetic nervous system activity, and endothelial dysfunction 1. The relationship between testosterone and blood pressure is complex, as both high and low testosterone levels have been associated with hypertension in different studies, suggesting an optimal physiological range may exist for cardiovascular health. Men receiving testosterone replacement therapy (TRT) should have their blood pressure monitored regularly, with checks before starting treatment, 3-6 months after initiation, and periodically thereafter. If hypertension develops during TRT, standard antihypertensive medications like ACE inhibitors, ARBs, calcium channel blockers, or diuretics can be used while continuing testosterone if clinically necessary.

Some studies have reported an association between low testosterone levels and increased cardiovascular mortality, but the evidence is not conclusive, and testosterone therapy may not necessarily reduce cardiovascular risk 1. In fact, a 2020 study found that the pooled risk for adverse cardiovascular outcomes did not differ between testosterone and placebo groups, although the incidence of cardiovascular events was slightly higher in the testosterone group (2.3% vs 1.5%) 1.

Key considerations for managing testosterone and hypertension include:

• Regular blood pressure monitoring for men receiving TRT
• Using standard antihypertensive medications if hypertension develops during TRT
• Considering reducing the testosterone dose or changing the administration method if blood pressure effects are a concern
• Assessing cardiovascular risk in all men with erectile dysfunction and considering lifestyle changes to reduce risk.

From the Research

Testosterone and Hypertension

• The relationship between testosterone and hypertension is complex, with some studies suggesting that testosterone replacement therapy (TRT) may be associated with an increased risk of hypertension 2, while others have found that TRT can actually lower blood pressure in men with hypogonadism 3.
• A study published in 2024 found that testosterone undecanoate (TU) was associated with significant reductions in systolic, diastolic, and pulse pressure in men with adult-onset testosterone deficiency, regardless of antihypertensive therapy 3.
• In contrast, a 2021 study found that testosterone treatment, with or without exercise training, was associated with an increase in ambulatory blood pressure in middle-aged and older men 4.
• Another study published in 2019 found that a subcutaneous testosterone enanthate auto-injector was associated with an increase in hematocrit and hypertension in some patients, although the majority of patients reported no injection-related pain 5.

Factors Influencing the Relationship between Testosterone and Hypertension

• Baseline blood pressure values have been found to be inversely associated with changes in blood pressure in men undergoing TRT 3.
• The presence of antihypertensive therapy has also been found to influence the relationship between testosterone and hypertension, with larger reductions in blood pressure seen in men receiving concurrent antihypertensive therapy 3.
• Exercise training has been found to have a complex interaction with testosterone treatment, with some studies suggesting that exercise can attenuate the effects of testosterone on blood pressure 4.

Clinical Implications

• The findings of these studies suggest that blood pressure should be carefully monitored in men undergoing TRT, particularly in those with pre-existing hypertension or those who are susceptible to cardiovascular disease 3, 2, 4.
• The choice of testosterone preparation and dosage regimen may also influence the risk of hypertension, with some studies suggesting that certain preparations may be associated with a lower risk of cardiovascular events 6, 5.