Cholesterol and Testosterone: The Relationship
High cholesterol levels do not directly impact testosterone production in adult males, and the relationship between these two parameters is complex and likely mediated by other factors, particularly obesity. While testosterone is synthesized from cholesterol, neither dietary cholesterol intake nor serum total cholesterol levels show a meaningful association with testosterone levels in men.
The Evidence on Cholesterol and Testosterone Levels
Direct Relationship Studies
The most recent and comprehensive evidence demonstrates no association between cholesterol and testosterone:
A 2023 cross-sectional study of 1,996 men from NHANES 2013-2014 found that neither dietary cholesterol intake nor serum total cholesterol levels were associated with total testosterone levels, even after adjusting for multiple confounding factors including energy intake, body mass index, physical activity, and comorbidities 1.
A 2010 NHANES III study of 1,457 men confirmed that testosterone levels did not differ across quintiles of cholesterol concentration (Q1: 5.25 ng/ml vs Q5: 5.05 ng/ml; p-trend = 0.32), and testosterone levels were not affected by cholesterol-lowering drug use 2.
The Obesity Confounding Factor
The apparent relationship between cholesterol and testosterone is largely explained by obesity:
A 1991 study of 3,562 white and 500 black men found a positive correlation between testosterone and HDL cholesterol (r = 0.22-0.26), but adjusting for body mass index reduced this association by approximately 30%, suggesting the relationship is not causal 3.
In men with obesity, testosterone deficiency occurs due to increased aromatization of testosterone to estradiol in adipose tissue, with subsequent estradiol-mediated negative feedback suppressing pituitary luteinizing hormone secretion 4.
Remnant Cholesterol as an Exception
- A 2025 study found that remnant cholesterol (RC) showed a direct relationship with low testosterone (OR = 1.02,95% CI: 1.01-1.03, P < 0.001), with body mass index and insulin resistance partially mediating this relationship 5.
Clinical Implications for Testosterone Replacement Therapy
Effects of Testosterone on Lipid Profiles
Physiologic testosterone replacement therapy has a neutral effect on lipid profiles and does not worsen cholesterol levels:
Meta-analysis of intramuscular testosterone esters showed HDL levels were reduced in only 3 studies and unchanged in 15 studies; total cholesterol was reduced in 5 studies, increased in 2, and unchanged in 12 studies 4.
Only supraphysiologic doses of testosterone (600 mg per week) were associated with significant HDL reduction, while physiologic replacement doses showed no change or minimal reduction in HDL, often accompanied by reductions in total cholesterol 4.
Transdermal testosterone administration showed no significant difference in lipid levels or apolipoprotein during 36 months of treatment in a double-blind, placebo-controlled study of 108 healthy men 4.
Testosterone Deficiency and Dyslipidemia
Testosterone deficiency itself is associated with adverse metabolic effects:
Testosterone deficiency in males is associated with dyslipidemia, increased abdominal fat mass, impaired glucose control, and reduced insulin sensitivity 4.
Testosterone replacement in men with obesity and hypogonadism has been associated with improvements in triglyceride levels, HDL cholesterol, fasting plasma glucose, and insulin resistance 4.
Common Pitfalls to Avoid
Do not assume that high cholesterol will suppress testosterone production - the evidence shows no direct causal relationship 1, 2.
Do not withhold testosterone therapy in hypogonadal men due to concerns about worsening lipid profiles - physiologic replacement has a neutral or potentially beneficial effect on cholesterol 4.
Do not overlook obesity as the primary driver when both low testosterone and dyslipidemia are present - weight loss through low-calorie diets and exercise should be the first intervention in obesity-associated secondary hypogonadism 4.
Do not use statin therapy as a means to lower testosterone - cholesterol-lowering drugs do not affect testosterone levels 2.
Clinical Algorithm
When encountering a patient with both dyslipidemia and concerns about testosterone:
Measure morning total testosterone (8-10 AM) on two separate occasions to confirm hypogonadism (levels <300 ng/dL) 4.
Assess for obesity - if BMI >30 or waist circumference elevated, recognize that obesity is likely driving both conditions 4, 3.
For obesity-associated hypogonadism, initiate weight loss interventions first - low-calorie diet and regular exercise can improve testosterone levels without medication 4.
If testosterone replacement is indicated, proceed without concern for worsening lipids - physiologic replacement has neutral effects on cholesterol 4.
Continue statin therapy as indicated for cardiovascular risk - testosterone therapy may actually improve the lipid profile in hypogonadal men 4.
Monitor remnant cholesterol in men with low testosterone as an emerging cardiovascular risk marker, though the clinical significance requires further investigation 5.