From the Guidelines
Testosterone replacement therapy (TRT) does not appear to increase the risk of pulmonary embolism (PE) or deep venous thrombosis (DVT) in men, according to the most recent evidence. The study by the American College of Physicians, published in the Annals of Internal Medicine in 2020 1, found that testosterone was not associated with an increased risk for pulmonary embolism or deep venous thrombosis in the few observational studies that reported that outcome.
When considering TRT in patients with a history of PE, it is essential to weigh the benefits of therapy against the potential risks. The evidence suggests that TRT can be safely used in these patients, but with careful monitoring and risk assessment. Some key points to consider include:
- Starting with transdermal formulations (gels or patches) rather than injectable testosterone, as they provide more stable hormone levels and potentially lower thrombotic risk
- Regular monitoring, including complete blood count, testosterone levels, and hematocrit/hemoglobin levels every 3-6 months, with dose adjustments if hematocrit exceeds 54%
- Considering prophylactic anticoagulation or aspirin therapy while on TRT for patients with multiple risk factors for thrombosis
- Encouraging lifestyle modifications like regular exercise, maintaining healthy weight, and avoiding smoking to further reduce thrombotic risk
It is crucial to note that the study by the American College of Physicians found that most studies did not identify an increased risk for death or cardiovascular events associated with testosterone, and some reported decreased risk 1. However, one retrospective cohort study found that participants had an increased risk for a combined end point of all-cause mortality, myocardial infarction, and ischemic stroke compared with those not treated with testosterone, after adjustment for potential confounders 1.
Overall, the current evidence suggests that TRT can be safely used in patients with a history of PE, but with careful monitoring and risk assessment. The benefits of TRT in improving sexual functioning and quality of life should be weighed against the potential risks, and individualized treatment plans should be developed for each patient.
From the Research
TRT and Pulmonary Embolism: An Overview
- The relationship between Testosterone Replacement Therapy (TRT) and pulmonary embolism has been explored in several studies, with varying findings.
- A case study published in the European journal of internal medicine 2 reported a case of pulmonary embolism associated with the use of anabolic steroids, including testosterone, in a 56-year-old man.
- However, a retrospective cohort study published in Chest 3 found no significant association between TRT and the incidence of deep vein thrombosis (DVT) and pulmonary embolism in men with low serum total testosterone levels.
Study Findings
- A study published in Medical hypotheses 4 suggested that testosterone therapy may interact with previously undiagnosed thrombophilia-hypofibrinolysis, leading to hospitalization for DVT-pulmonary emboli.
- A systematic review and meta-analysis published in the Asian journal of andrology 5 found that TRT did not influence the risk of arterial thrombosis, stroke, myocardial infarction, venous thromboembolism, pulmonary embolism, and mortality in men with pre-treatment total testosterone <12 nmol l-1.
- Another study published in BJU international 6 found no difference in event-free survival with regard to thromboembolism between men using TRT and a control group, but reported a higher risk of obstructive sleep apnoea in TRT users.
Key Points
- The evidence suggests that the relationship between TRT and pulmonary embolism is complex and may depend on various factors, including individual patient characteristics and underlying health conditions.
- While some studies have reported a potential increased risk of thromboembolic events with TRT, others have found no significant association.
- Further research is needed to fully understand the relationship between TRT and pulmonary embolism, as well as other cardiovascular events.