Can low testosterone (hypogonadism) cause high blood pressure (hypertension) in me?

Can Low Testosterone Cause High Blood Pressure?

Low testosterone (hypogonadism) is associated with an increased risk of developing hypertension, but the relationship is complex and bidirectional—low testosterone appears to be a risk marker for hypertension rather than a direct cause, and importantly, testosterone replacement therapy typically lowers blood pressure rather than raising it. 1, 2

The Association Between Low Testosterone and Hypertension

Lower total testosterone levels are inversely associated with the prevalence of hypertension in middle-aged and elderly men. In a large cross-sectional study of 5,786 Chinese men, those with lower total testosterone, free testosterone, and sex hormone-binding globulin had higher rates of hypertension (37.2% prevalence). 1 This relationship was particularly strong in men over 65 years or those with BMI ≥24, while smoking and family history of hypertension strengthened the correlation. 1

In hypertensive men specifically, low testosterone predicts worse cardiovascular outcomes. Among 228 nondiabetic hypertensive patients without clinical atherosclerosis, those who experienced major adverse cardiovascular events (MACE) had significantly lower testosterone levels (3.9 vs 4.6 ng/ml). 3 Men in the lowest testosterone tertile (<4.0 ng/ml) had significantly higher risk of MACE compared to the highest tertile (>4.9 ng/ml), even after adjusting for age, blood pressure, and other risk factors. 3

The Paradox: Both Low and High Testosterone Carry Risk

The relationship between testosterone and cardiovascular risk follows a U-shaped curve—both low and high levels are associated with greater cardiovascular risk. 1 In men with grade 2 hypertension specifically, higher total testosterone was positively associated with stroke prevalence, and elevated luteinizing hormone (suggesting primary hypogonadism) correlated with cardiovascular and cerebrovascular diseases. 1

This suggests that primary hypogonadism (testicular failure with elevated LH) may be a particularly important risk marker for major cardiovascular disease in men with severe hypertension. 1

Mechanisms Linking Low Testosterone to Hypertension

Hypogonadism contributes to metabolic derangements that promote hypertension, including dyslipidemia, type 2 diabetes, obesity, and insulin resistance. 4 The mechanisms include:

• Adverse cytokine profiles produced by excess adipose tissue 4
• Abnormal lipid metabolism due to understimulated hormone-sensitive lipase 4
• Abnormal cellular respiration leading to insulin resistance 4
• Increased aromatization of testosterone to estradiol in adipose tissue, creating a vicious cycle of further testosterone suppression 5

Androgen deficiency is specifically associated with insulin resistance, type 2 diabetes, metabolic syndrome, and increased visceral fat deposition—all of which contribute to hypertension. 5

What Happens When You Treat Low Testosterone?

Contrary to warnings in some product labeling, testosterone replacement therapy typically lowers blood pressure rather than raising it. 2 In a registry study of 737 men with adult-onset testosterone deficiency treated with testosterone undecanoate:

• Median reductions in systolic BP were -12.5 mmHg, diastolic BP -8.0 mmHg, and pulse pressure -6.0 mmHg in men never on antihypertensive agents 2
• Larger reductions occurred in men with higher baseline blood pressure 2
• Only 1 of 152 men not on antihypertensives at baseline required starting them during follow-up 2
• 33 of 202 men on antihypertensives had their medications discontinued by end of follow-up 2

The blood pressure-lowering effect was inversely associated with baseline BP values—men with higher baseline pressures experienced greater reductions. 2 Importantly, hematocrit and waist circumference changes were not significantly associated with BP changes. 2

The Exception: Oral Testosterone Formulations

Newer oral testosterone formulations may cause small increases in blood pressure, particularly in men already on antihypertensive therapy. 6 With oral testosterone undecanoate (Kyzatrex™), mean 24-hour ambulatory systolic BP increased by 1.7-1.8 mmHg at 120-180 days. 6 For men on antihypertensive drugs, increases were greater (3.4 vs 0.7 mmHg at day 120). 6 However, these increases were minimal in patients not taking antihypertensive therapy. 6

Clinical Implications and Recommendations

If you have both low testosterone and hypertension, the low testosterone is likely a marker of underlying metabolic dysfunction rather than the direct cause of your high blood pressure. 1, 3, 4 However, this combination significantly increases your cardiovascular risk. 3

Testosterone replacement therapy, particularly with injectable testosterone undecanoate, may actually help lower your blood pressure while addressing other symptoms of hypogonadism. 2 The greatest blood pressure reductions occur in men with higher baseline pressures. 2

Before considering testosterone therapy, address modifiable risk factors through lifestyle changes: 5

• Weight loss through calorie-restricted diets (particularly important if obese) 5
• Regular dynamic exercise 5
• Smoking cessation 5
• Moderate alcohol consumption 5
• Mediterranean diet emphasizing fruits, vegetables, whole grains, fish, and lean proteins 5

If testosterone replacement is indicated based on confirmed biochemical hypogonadism (two morning testosterone measurements <300 ng/dL) and symptoms (particularly diminished libido and erectile dysfunction), injectable testosterone undecanoate appears to be the preferred formulation for blood pressure management. 2 Oral formulations may cause small BP increases, especially if you're already on antihypertensive medications. 6

Critical Monitoring Points

If you start testosterone therapy with concurrent hypertension, monitor: 2, 6

• Blood pressure at each visit (baseline BP inversely predicts BP response) 2
• Hematocrit levels (withhold if >54%) 5, 2
• Testosterone levels at 2-3 months, then every 6-12 months 5
• Cardiovascular symptoms 5

The relationship between testosterone and blood pressure is complex and individualized based on your baseline BP, age, BMI, smoking status, and family history. 1 The evidence suggests that correcting hypogonadism with appropriate testosterone replacement typically improves rather than worsens blood pressure control. 2