I’m Thinking About Testosterone Therapy, but It Scares the Hell Out of Me


Your labs came back saying your testosterone levels are low and you’re trying to decide whether to treat it. You know you should because you feel like crap all the time, but it really scares you because you’ve read that testosterone therapy can cause heart attacks and strokes for guys with certain risk factors. How do you know whether you’re at risk?

Great question. While testosterone therapy is safe for most guys, there are a handful of men out there who need to tread very carefully.

So, what puts you at higher risk from testosterone therapy?

One condition that absolutely puts you at risk when you start testosterone therapy is if you have a pre-existing clotting disorder. You can have this your whole life and never know it until you start using external testosterone. Testosterone therapy increases your production of red blood cells. That’s not necessarily a bad thing unless you have a clotting disorder. If you do, you can have major problems. As red blood cell count increases, the blood can thicken and cause high blood pressure. Thicker blood is more likely to form clots and clots can be really dangerous for you.

How do you know if you have a pre-existing clotting disorder?

There are simple blood tests your doctor can order to rule this out. The incidence of men having blood clots on testosterone therapy is not high; Dr. Charles Glueck estimates that roughly 1-2% of men taking testosterone therapy will develop a clot. While this is a very low percentage,  if you’re in this 1%, it’s vital that you find out. There are four recommended tests to check for a blood clotting disorder.

    • Factor V Leiden
    • Prothrombin gene
    • Factor VIII
    • Factor XI

In working with various men who are undergoing testosterone therapy, I haven’t seen a lot of HRT specialists order these tests prior to starting testosterone, so this is something you need to bring up with your doctor. I have seen a few who order the tests after starting external testosterone administration, but life-threatening clots can form as quickly as a month after testosterone therapy begins, so these tests need to be done before you start.

Any other risk factors to consider?

Estrogen Levels     You need to make sure that your doctor is carefully tracking your estradiol (estrogen) levels. Most experienced HRT doctors are going to do this, but I’ve seen a few who simply don’t understand the importance. The reason it’s important is that high estradiol levels can contribute to clotting problems. Your doctor needs to keep your estradiol levels optimal.

Blood Count     Another thing you need to monitor is your red blood cell count, your hemoglobin and your hematocrit since testosterone therapy can increase all these levels. If they rise too high, you may want to consider donating blood periodically to lower them.

Blood Pressure     You need to keep track of your blood pressure. Ideally, you want it to be below 120/80.

What’s the bottom line? Is testosterone therapy safe for me or not?

There really is no clear-cut answer to that question. No two people are exactly alike. Testosterone therapy has both benefits and risks. There are studies that seem to suggest that raising testosterone to therapeutic levels can actually improve your health. There is some data out there suggesting that it can be a problem for at least some men.

The problem with trying to study the benefits and risks of testosterone therapy is that it is tough to separate correlation from causation. For example, we know that men with low testosterone are at higher risk for heart issues, obesity, diabetes, and certain cancers. But does low testosterone actually cause these conditions or is it only correlative? Will taking testosterone therapy improve these conditions or not? None of this is clear at present. Maybe 5 or 10 years from now, we’ll have the answers. But that doesn’t help you right now.

In the end, every medical decision has risk. Increasing your testosterone levels may carry some risk for some men. Doing nothing and living with low testosterone levels also carries risk.

Much of it will depend on how badly your lowered testosterone levels are affecting you. I’ve talked with guys who were almost crippled by their low testosterone. It was affecting their careers, their marriages, and whether they wanted to get out of bed in the morning. After they started testosterone therapy, they were like new men. They became energized, vibrant, more productive and happier. For them, clearly testosterone therapy was worth the small risks it might present.

The most important recommendation I can give you is to find a doctor who knows what he’s doing. One who knows which tests to administer and what he needs to monitor. That’s the single biggest risk prevention available.