TRT and Heart Health: Blood Pressure, Cholesterol, and Mood

Published: Oct 8, 2025 | By: Dr. Baghel | Category: TRT and Men’s Health

If you are a man in North Carolina considering testosterone replacement therapy (TRT), there is a good chance your first worry is your heart. That concern makes sense. For years, headlines suggested that testosterone therapy might cause heart attacks and strokes, and in 2015, the FDA added a boxed warning to every testosterone product on the market. The fear stuck

The good news: in 2023, the largest randomized controlled trial ever conducted on TRT and cardiovascular risk produced clear results. The TRAVERSE trial enrolled over 5,200 men aged 45 to 80 who already had heart disease or were at high risk for it. After a mean follow-up of 33 months, testosterone replacement therapy did not increase the rate of heart attack, stroke, or cardiovascular death compared to placebo. In February 2025, the FDA responded by removing the boxed cardiovascular warning from all testosterone product labels.

That does not mean TRT is free of cardiovascular considerations. Blood pressure, red blood cell counts, heart rhythm, and blood clots each deserve attention during treatment. This article covers what the evidence actually shows about TRT and heart health, what you can monitor at home, and when to contact your clinician.

Red blood cell counts deserve their own explanation. I cover that in my guide to high hematocrit on TRT. For the broader question of who TRT makes sense for, see who benefits most from TRT.

Key Takeaways

• The TRAVERSE trial found no increased risk of major cardiovascular events (heart attack, stroke, or cardiovascular death) in men with low testosterone treated with TRT, even among those with existing heart disease.
• The FDA removed its boxed cardiovascular warning for testosterone products in February 2025, while adding a new warning about blood pressure increases.
• Blood pressure monitoring matters. TRT can raise blood pressure modestly in some men, particularly when hematocrit (red blood cell concentration) increases.
• Heart rhythm and clot risk are real but uncommon. The TRAVERSE trial found small increases in atrial fibrillation and pulmonary embolism in the testosterone group.
• Home monitoring and regular blood work are the most effective tools for catching problems early and keeping TRT safe.

Why Heart Health Concerns About TRT Existed in the First Place

Understanding where the fear came from helps put the current evidence in context.

In 2013 and 2014, two observational studies reported that men taking testosterone had higher rates of heart attack and stroke. These studies received significant media attention and prompted legal advertising campaigns targeting men who had experienced cardiovascular events while on testosterone. Both studies had substantial methodological limitations, including problems with how cardiovascular events were counted and how comparison groups were constructed. Despite strong criticism from the medical community, the damage to public perception was done.

In 2015, the FDA required labeling changes for all testosterone products, adding a boxed warning about possible cardiovascular risks. The agency also mandated that manufacturers fund a large, well-designed clinical trial to settle the question. That trial became TRAVERSE.

What TRAVERSE Actually Showed

The TRAVERSE trial (Testosterone Replacement Therapy for Assessment of Long-term Vascular Events and Efficacy Response in Hypogonadal Men) was a multicenter, randomized, double-blind, placebo-controlled study published in the New England Journal of Medicine in 2023. Key details:

• Participants: 5,246 men aged 45 to 80 with confirmed low testosterone (two fasting levels below 300 ng/dL) and at least one symptom of hypogonadism
• Risk profile: All participants had either existing cardiovascular disease or multiple risk factors for it
• Treatment: Daily transdermal 1.62% testosterone gel, with doses adjusted to maintain testosterone levels between 350 and 750 ng/dL
• Duration: Mean treatment duration of approximately 22 months, with mean follow-up of 33 months
• Primary outcome: First occurrence of cardiovascular death, nonfatal heart attack, or nonfatal stroke

The results were clear. A primary cardiovascular event occurred in 7.0% of men in the testosterone group compared to 7.3% in the placebo group (hazard ratio 0.96, with a 95% confidence interval of 0.78 to 1.17). TRT met the threshold for noninferiority: it was statistically no worse than placebo for major adverse cardiovascular events.

“The TRAVERSE trial provides the most definitive evidence we have on TRT and cardiovascular safety,” says Dr. Baghel. “For men with confirmed low testosterone and genuine symptoms, the data are reassuring. At the same time, reassuring does not mean risk-free, and that distinction matters.”

What TRAVERSE Also Found

While the headline finding was positive, several secondary findings require attention:

• Atrial fibrillation: 3.5% in the testosterone group versus 2.4% in the placebo group
• Nonfatal arrhythmias warranting intervention: 5.2% versus 3.3%
• Pulmonary embolism (a blood clot in the lungs): 0.9% versus 0.5%
• Acute kidney injury: 2.3% versus 1.5%

These were secondary outcomes, not the primary endpoint, and some may be influenced by the specific population studied (older men with significant cardiovascular risk factors). Still, they are worth understanding if you are considering testosterone treatment or already taking it.

TRT and Blood Pressure: What the Evidence Shows

Blood pressure is probably the most practical cardiovascular concern for men on TRT, because it is something you can measure at home and track over time.

Does TRT Raise Blood Pressure?

The short answer: it can, but the increase is typically small. Research is mixed on whether the effect is clinically significant for most men.

In the TRAVERSE trial, the mean increase in systolic blood pressure (the top number) in the testosterone group compared to placebo was approximately 0.3 mmHg. That is a very small difference on average. However, averages can mask individual variation. Some men may see larger increases, particularly if their red blood cell concentration rises substantially.

A 2024 ambulatory blood pressure monitoring (ABPM) study of men on transdermal testosterone found a mean systolic increase of about 3.5 mmHg over 16 weeks. The FDA considered these ABPM results significant enough to add a new blood pressure warning to all testosterone product labels in February 2025, even as it removed the broader cardiovascular boxed warning.

At the same time, long-term observational data from a large registry of men treated with testosterone undecanoate (an injectable formulation) showed that blood pressure actually decreased over time, with greater reductions in men who started with higher baseline blood pressure readings. The median reduction in systolic blood pressure was 12.5 mmHg over follow-up periods extending beyond 8 years.

Why the Conflicting Data?

Several factors explain why studies produce different results:

• Baseline health: Men who start TRT with elevated blood pressure or significant obesity may respond differently than healthier men
• Hematocrit changes: When testosterone stimulates red blood cell production, the blood becomes thicker. This increase in blood volume and viscosity can raise blood pressure in some men. The connection between rising hematocrit and rising blood pressure appears strongest in certain populations
• Fluid retention: Testosterone can cause mild water retention, particularly in the first weeks of treatment. This typically stabilizes over time
• Weight and body composition changes: Over months, TRT often reduces visceral fat and improves metabolic markers. These changes can lower blood pressure long term, potentially offsetting any initial increase
• Formulation differences: Testosterone gel, injections, and oral formulations may have different effects on blood pressure due to differences in absorption patterns and peak levels

The key is balance. A modest, temporary increase in blood pressure readings during early TRT is not the same as developing high blood pressure (hypertension). The goal is to identify changes early and respond appropriately.

Who Needs Extra Caution?

If you already have high blood pressure, especially if it is not well controlled, that factor needs to be part of the conversation before starting TRT. The FDA’s updated labeling states that testosterone is not recommended for men with uncontrolled hypertension.

Other risk factors that warrant closer blood pressure monitoring:

• Existing cardiovascular disease
• Family history of heart attack or stroke at a young age
• Chronic kidney disease
• Obstructive sleep apnea (which itself can raise blood pressure and is more common in men with low testosterone)
• Men with type 2 diabetes or metabolic syndrome

“These questions are understandable, especially if you already have high blood pressure,” says Dr. Baghel. “In my practice, we check baseline blood pressure before starting TRT, and I ask men to take readings at home during the first few months. Most of the time, what we see is either no change or a small increase that stabilizes. But catching an outlier early is what makes monitoring so valuable.”

Blood Pressure Monitoring at Home: A Practical Guide

Home monitoring is one of the best ways to stay ahead of potential problems during TRT. It removes the “white coat effect” (higher readings caused by the anxiety of being in a medical setting) and gives your clinician a more accurate picture of your daily blood pressure.

Choosing a Cuff

• Use an upper-arm automatic cuff (not a wrist model, which tends to be less accurate)
• Look for devices validated by the Association for the Advancement of Medical Instrumentation (AAMI) or equivalent standards
• Make sure the cuff size fits your arm circumference. An undersized cuff will produce falsely high readings

How to Take an Accurate Reading

1. Sit quietly for 5 minutes before measuring. No talking, no phone.
2. Sit with your back supported and feet flat on the floor. Do not cross your legs.
3. Place the cuff on your bare upper arm, about one inch above the elbow crease.
4. Rest your arm on a table so the cuff is at heart level.
5. Take two readings, one minute apart, and record both.

When and How Often

• Baseline (before starting TRT): Take readings morning and evening for 5 to 7 days. This gives your clinician a reliable baseline.
• First 3 months on TRT: Check twice weekly (morning before medication, evening before bed).
• Months 3 to 6: Weekly checks are typically sufficient if readings have been stable.
• Ongoing: Monthly checks, or as directed by your clinician.

What the Numbers Mean

• Normal: Below 120/80 mmHg
• Elevated: Systolic 120 to 129 and diastolic below 80
• Stage 1 hypertension: Systolic 130 to 139 or diastolic 80 to 89
• Stage 2 hypertension: Systolic 140 or higher, or diastolic 90 or higher

A single elevated reading does not necessarily indicate a problem. Trends over days and weeks are more meaningful than any single number. If you notice a consistent upward trend of 10 or more mmHg systolic from your baseline, bring those numbers to your next appointment (or call sooner if readings are persistently above 140/90).

Red Blood Cells, Hematocrit, and Why They Matter for Heart Health

Testosterone stimulates erythropoiesis (the production of red blood cells in the bone marrow). This is actually one reason TRT can improve energy and reduce fatigue: more red blood cells means better oxygen delivery throughout the body. In fact, the TRAVERSE trial found that TRT significantly improved anemia in men with low testosterone.

The concern arises when red blood cell production goes too high.

What Is Hematocrit?

Hematocrit (HCT) is the percentage of your blood that consists of red blood cells. A normal range for adult men is generally 38% to 50%, though the upper limit varies slightly by laboratory. When hematocrit rises above approximately 52% to 54%, the blood becomes thicker (more viscous), and the theoretical risk of clots and cardiovascular events increases.

How TRT Affects Red Blood Cell Counts

Most men on TRT will see some increase in hematocrit. The degree of increase depends on:

• Baseline hematocrit: Men who start lower (for example, men with anemia from low testosterone) may see a larger rise
• Dose and formulation: Injectable testosterone, particularly testosterone cypionate administered at higher doses, tends to cause greater hematocrit increases than transdermal gel. This is because injections produce higher peak testosterone levels
• Individual response: Some men are more sensitive to testosterone’s erythropoietic effects than others

In the TRAVERSE trial (which used transdermal testosterone gel), only 6 participants had their medication discontinued because hematocrit exceeded 54% at the lowest dose. Time-dependent analysis in TRAVERSE did not show a statistically significant association between hematocrit changes and the risk of major cardiovascular events (hazard ratio 0.97) or venous thromboembolism (hazard ratio 0.94).

That finding is reassuring at the population level. At the individual level, it is still wise to monitor, because the study population was carefully supervised and doses were adjusted.

The Monitoring Schedule

Standard hematocrit monitoring during TRT typically follows this pattern:

• Baseline blood work (before starting TRT)
• 4 to 6 weeks after starting treatment
• 3 months after starting or after any dose adjustment
• Every 6 to 12 months once stable

If your hematocrit rises above 52%, your clinician may reduce the testosterone dose, switch formulations, or increase the monitoring frequency. If it rises above 54%, most guidelines recommend pausing or adjusting treatment until levels come down.

For more detail on the full range of TRT side effects and how responsible monitoring works, that topic has its own dedicated article.

TRT, Cholesterol, and Lipids: What Changes?

Cholesterol and lipid levels are core cardiovascular risk factors. Men considering TRT often ask whether testosterone will worsen their cholesterol profile.

What the Evidence Shows

The relationship between testosterone therapy and lipids is nuanced:

Total cholesterol and LDL (“bad” cholesterol): Research suggests TRT may produce a small reduction in total cholesterol and LDL in some men, particularly those with metabolic syndrome or obesity. The effect is generally modest.

HDL (“good” cholesterol): Some studies show a slight decrease in HDL cholesterol with TRT, though this finding is inconsistent across studies and the clinical significance is debated. The reduction, when observed, is typically small (a few mg/dL).

Triglycerides: Evidence is mixed. Some studies report modest reductions in triglycerides with TRT, particularly in men with initially elevated levels. Others show no significant change.

Overall lipid impact: The net effect on cardiovascular risk through lipid changes alone appears to be small. What likely matters more is TRT’s broader metabolic effects: reduced visceral fat, improved insulin sensitivity, and better body composition. These changes can improve the overall cardiovascular risk profile over time.

The TRAVERSE Context

In the TRAVERSE trial, baseline lipid profiles were similar between the testosterone and placebo groups, and the study’s primary finding of no increased cardiovascular events held across subgroups regardless of baseline lipid status. The study did not identify lipid changes as a driver of cardiovascular outcomes in either direction.

Practical Guidance

• Get a fasting lipid panel at baseline before starting TRT
• Recheck lipids at 3 to 6 months and annually thereafter
• If your LDL is already elevated or you take a statin, let your prescribing clinician know. TRT does not replace cholesterol management strategies, and adjustments to lipid-lowering therapy may be needed independently
• Lifestyle factors (diet, exercise, weight management) remain the foundation of healthy cholesterol levels, whether or not you are on TRT

Atrial Fibrillation, Heart Rhythm, and TRT

Atrial fibrillation (AFib) is an irregular, often rapid heart rhythm that can increase the risk of stroke, heart failure, and other cardiovascular complications. The TRAVERSE trial brought this concern into sharper focus for men on TRT.

What TRAVERSE Found

Atrial fibrillation occurred in 3.5% of men in the testosterone group compared to 2.4% in the placebo group. Nonfatal arrhythmias requiring intervention were also higher: 5.2% versus 3.3%.

These findings were unexpected. Prior to TRAVERSE, most data suggested that low testosterone was actually associated with a higher risk of atrial fibrillation, and one observational study found that normalizing testosterone levels through TRT was associated with a decrease in AFib incidence.

Putting the Numbers in Context

Several important caveats apply:

• Atrial fibrillation was a secondary outcome, not the primary endpoint. Secondary outcomes carry a higher risk of statistical noise and require more cautious interpretation.
• The study population was older (mean age 63) and had significant cardiovascular comorbidities. The rate of AFib in this population would be higher than in younger, healthier men.
• ECGs were not performed at baseline or as part of the study protocol. Atrial fibrillation was reported as an adverse event, not systematically screened for. Some cases in the testosterone group may have been pre-existing but undiagnosed.
• When data from TRAVERSE were pooled with other randomized trials, the increased risk of AFib was not statistically significant.

Who Is at Higher Risk?

Men with a history of any of the following may want to discuss AFib risk specifically with their clinician before starting TRT:

• Prior atrial fibrillation or other arrhythmias
• Heart failure
• Significant obstructive sleep apnea (which itself raises AFib risk)
• Structural heart disease
• Heavy alcohol use
• Uncontrolled high blood pressure

What to Watch For

Symptoms of atrial fibrillation can include:

• Heart pounding, fluttering, or feeling like it is “skipping beats”
• Unexplained shortness of breath
• Dizziness or lightheadedness
• Chest discomfort
• Unusual fatigue during activities that were previously easy

If you experience any of these symptoms while on testosterone therapy, contact your clinician promptly. Some consumer wearable devices (certain smartwatches) can now detect irregular heart rhythms, though they are not a substitute for medical evaluation.

Blood Clots, Pulmonary Embolism, and TRT

Blood clot formation is another area that deserves attention in the context of TRT and cardiovascular safety.

Venous Thromboembolism: What It Means

Venous thromboembolism (VTE) includes two related conditions:

• Deep vein thrombosis (DVT): A blood clot forms in a deep vein, usually in the leg. Symptoms include swelling, pain, warmth, and redness in the affected area.
• Pulmonary embolism (PE): A clot breaks loose and travels to the lungs. This can be a medical emergency. Symptoms include sudden shortness of breath, chest pain that worsens with breathing, rapid heartbeat, and coughing (sometimes with blood).

What TRAVERSE Found

Pulmonary embolism occurred in 0.9% of the testosterone group compared to 0.5% of the placebo group. This finding was consistent with prior data linking testosterone use with a modest increase in thromboembolic risk, particularly in men with underlying clotting disorders (thrombophilia).

Interestingly, time-dependent analysis in TRAVERSE did not find a direct association between hematocrit changes and venous thromboembolism risk. This suggests that the clot risk from TRT may not be entirely explained by thickening of the blood through red blood cell overproduction. Other mechanisms, including changes in clotting factor activity and blood vessel function, may play a role.

The FDA’s Current Position

The FDA’s updated testosterone product labels (February 2025) retain warnings about venous thromboembolism, including DVT and PE. The agency recommends that testosterone “be used with caution in men who have had previous thromboembolic events.”

Who Needs Extra Caution?

Men with a higher risk of blood clots include those with:

• A personal history of DVT or pulmonary embolism
• Known thrombophilia (genetic clotting disorders such as Factor V Leiden)
• Recent surgery or prolonged immobility
• Active cancer
• Significant obesity
• Family history of blood clots

If you have any of these risk factors, they do not necessarily mean TRT is off the table. They mean the decision requires careful evaluation, and monitoring during treatment may need to be more frequent.

Red Flags: When to Seek Immediate Care

• Sudden leg swelling with pain, warmth, or redness (especially one-sided)
• Sudden shortness of breath not explained by exertion
• Sharp chest pain that worsens when you breathe deeply or cough
• Rapid or irregular heartbeat with lightheadedness or near-fainting
• Coughing up blood

Any of these symptoms warrant emergency evaluation. Do not wait to see if they resolve.

The Anxiety Connection: When Worry About Heart Risk Becomes Its Own Problem

This is a topic that gets less attention but matters significantly in clinical practice.

Many men who start TRT (or who are researching it) experience health anxiety: persistent worry about physical symptoms, often focused on the heart. Years of conflicting headlines about testosterone and heart risk have made this worse. A man who reads that TRT “might cause a heart attack” may begin to interpret every normal sensation (a skipped beat, a moment of chest tightness, a slightly elevated blood pressure reading) as evidence that something is wrong.

This pattern is common, and it is not a sign of weakness. It is a predictable psychological response to uncertain health information.

How Anxiety Mimics Heart Problems

Anxiety and panic can produce symptoms that closely resemble cardiovascular events:

• Rapid heartbeat or palpitations
• Chest tightness or pressure
• Shortness of breath
• Dizziness
• Tingling in the hands or arms
• A sense of impending doom

For a man already worried about TRT and heart risk, these symptoms can trigger a cycle: anxiety causes physical sensations, the sensations increase anxiety, and the cycle escalates. Some men end up in emergency rooms believing they are having a heart attack when the underlying cause is a panic episode.

Breaking the Cycle

Objective data helps. This is one reason home blood pressure monitoring is so valuable: it gives you concrete numbers rather than relying on how you feel. If your blood pressure readings are consistently normal and your blood work is within range, those facts can counter anxious thinking.

Other strategies that can help:

• Learn the difference between anxiety symptoms and genuine cardiac warning signs. Anxiety-related chest discomfort is usually diffuse and not localized to one spot. It often improves with slow breathing or distraction. Cardiac chest pain typically feels like pressure or squeezing, may radiate to the arm or jaw, and does not improve with relaxation techniques.
• Talk to your prescribing clinician about your concerns. Naming the anxiety reduces its power.
• Consider whether therapy might help. For men whose anxiety treatment for adults in North Carolina is significant, cognitive-behavioral therapy (CBT) has strong evidence for reducing health-related worry.

“I see this regularly,” says Dr. Baghel. “A man starts TRT, reads something alarming online, and suddenly every heartbeat feels like a threat. The goal is to separate real cardiovascular signals from anxiety-driven hypervigilance. Monitoring gives us data. Therapy addresses the interpretation of that data. Both matter.”

The Complete Monitoring Plan: Blood Work, Vitals, and Timelines

Responsible TRT requires a structured monitoring plan. The goal is to catch changes early, before they become problems.

Baseline (Before Starting TRT)

• Blood pressure: Home readings over 5 to 7 days (morning and evening)
• Complete blood count (CBC): Includes hematocrit and hemoglobin
• Fasting lipid panel: Total cholesterol, LDL, HDL, triglycerides
• Comprehensive metabolic panel: Kidney and liver function
• Total and free testosterone levels: Two morning fasting draws, at least 48 hours apart
• PSA (prostate-specific antigen): Prostate cancer screening baseline
• Symptom assessment: Documenting specific symptoms of low testosterone

Weeks 4 to 6

• Testosterone level: Confirm levels are reaching the target physiologic (normal) range
• CBC with hematocrit: Check for early red blood cell changes
• Blood pressure: Review home logs

Month 3

• Testosterone level
• CBC with hematocrit
• Fasting lipid panel
• Metabolic panel (kidney and liver function)
• Blood pressure review
• Symptom reassessment: Mood, energy, sleep, libido

Months 6 to 12

• Same labs as month 3
• PSA
• Assessment of overall health, side effects, and treatment goals

Ongoing (Annually or as Directed)

• CBC, lipids, metabolic panel, PSA
• Blood pressure checks (monthly at home)
• Clinical assessment of benefits, side effects, and continued need for treatment

This cadence is not arbitrary. It is designed to detect changes in hematocrit, lipids, kidney function, and blood pressure at the intervals when they are most likely to shift. If all values remain stable after the first year, monitoring can often be consolidated, but it should never be eliminated entirely.

For a broader look at what the evaluation process involves before starting treatment, see how adult men are evaluated for low testosterone.

Lifestyle Factors That Support Healthy Blood Pressure on TRT

TRT lays a biological foundation, but it works best alongside healthy habits. For cardiovascular health specifically, these areas matter most:

Exercise

Regular physical activity is one of the most effective ways to manage blood pressure and support healthy blood pressure while on testosterone therapy. Guidelines generally recommend:

• 150 minutes per week of moderate-intensity aerobic activity (for example, walking 20 to 30 minutes most days), or 75 minutes of vigorous activity
• Resistance training 2 to 3 days per week (which also supports the muscle-building benefits of TRT)

Exercise independently lowers blood pressure by approximately 5 to 8 mmHg in men with elevated readings. Combined with TRT’s effects on body composition, regular activity creates a positive cycle.

Nutrition

A heart-healthy eating pattern supports blood pressure management regardless of TRT status. Key principles:

• Reduce sodium intake to less than 2,300 mg per day (ideally closer to 1,500 mg for men with hypertension)
• Increase potassium-rich foods: Bananas, leafy greens, sweet potatoes, beans
• Limit processed foods, which are the primary source of dietary sodium for most Americans
• Moderate alcohol intake: Excess alcohol raises blood pressure independently

Sleep

Poor sleep is both a symptom of low testosterone and a contributor to cardiovascular disease. Sleep apnea in particular is common in men with low T, raises blood pressure, and increases the risk of atrial fibrillation. If you snore heavily, wake feeling unrefreshed, or have been told you stop breathing during sleep, evaluation for sleep apnea is important before and during TRT.

For more on the relationship between sleep and mental health, see our article on guide to sleep medications and sleep peptides.

Stress Management

Chronic psychological stress contributes to sustained blood pressure elevation. Approaches like structured relaxation, physical activity, and therapy can help. If anxiety about TRT itself is part of the picture, addressing that directly (as discussed above) may lower blood pressure as a secondary benefit.

TRT and Heart Health in Men with Existing Cardiovascular Disease

One of the most important features of the TRAVERSE trial is that it specifically enrolled men with existing cardiovascular disease or high cardiovascular risk. This means the safety data are directly relevant to the population where concern was greatest.

What TRAVERSE Tells Us

Among the 5,204 men in the full analysis population, 2,847 had preexisting cardiovascular disease (prior heart attack, stroke, coronary artery disease, peripheral vascular disease, etc.), and 2,357 had elevated cardiovascular risk factors (such as type 2 diabetes, high blood pressure, or high cholesterol). The finding of no increased major adverse cardiovascular events held across both subgroups.

In fact, the testosterone group showed a nonsignificant 16% lower rate of cardiovascular death compared to placebo (hazard ratio 0.84). While this did not reach statistical significance and cannot be interpreted as a proven benefit, it further supports the conclusion that TRT does not appear to increase the risk of cardiovascular death in this population.

The Bottom Line for Men with Heart Disease

Having existing cardiovascular disease does not automatically disqualify you from TRT. It does mean:

• The decision requires a thorough risk-benefit discussion with your clinician
• Monitoring needs to be more frequent, especially during the first 6 months
• Blood pressure, hematocrit, and symptoms like palpitations or shortness of breath need prompt attention
• Coordination between your psychiatrist (or TRT prescriber) and cardiologist may be appropriate

The Integrated Approach: Why Hormones Alone Are Not Enough

A recurring theme in every article on this site, and a core principle of Dr. Baghel’s practice, is that testosterone replacement therapy works best as one part of a broader plan.

For cardiovascular health, that plan includes:

• Regular monitoring (blood work and home vital signs)
• Lifestyle optimization (exercise, nutrition, sleep, stress management)
• Mental health support (addressing anxiety, depression, or other conditions that affect how you interpret and respond to physical symptoms)
• Coordination with other providers (primary care, cardiology) when existing conditions require it

TRT can restore the hormonal foundation that supports energy, mood, and motivation to engage in healthy behaviors. But the hormone itself does not replace those behaviors. The most effective, lasting improvement in cardiovascular risk comes from addressing the biological, psychological, and behavioral factors together.

If you are in North Carolina and considering testosterone replacement therapy, or if you are already on TRT and have questions about cardiovascular monitoring, Dr. Baghel offers telepsychiatry consultations across the state through Baghel Psychiatry.

Frequently Asked Questions

Does TRT Increase the Risk of Heart Attack?

The TRAVERSE trial, the largest randomized controlled study of testosterone therapy and cardiovascular risk, found that TRT did not increase the rate of heart attack compared to placebo in men with confirmed low testosterone. The study enrolled over 5,200 men with existing heart disease or elevated cardiovascular risk and followed them for an average of 33 months. Based on these results, the FDA removed its boxed cardiovascular warning from testosterone labels in February 2025.

Will TRT Raise My Blood Pressure?

TRT can produce a small increase in blood pressure in some men, particularly when red blood cell counts rise. The TRAVERSE trial found an average systolic increase of only 0.3 mmHg compared to placebo, though individual responses vary. The FDA now requires a blood pressure warning on all testosterone product labels and recommends regular blood pressure monitoring during treatment. Home monitoring is one of the most effective ways to track your individual response.

Can TRT Cause Blood Clots?

The TRAVERSE trial found a slightly higher rate of pulmonary embolism in the testosterone group (0.9%) compared to placebo (0.5%). Current FDA labeling warns about venous thromboembolism risk, including deep vein thrombosis and pulmonary embolism. Men with a history of blood clots, known clotting disorders, or other risk factors for thromboembolism need careful evaluation before starting testosterone therapy and closer monitoring during treatment.

Does Testosterone Therapy Affect Cholesterol?

Testosterone therapy may produce modest changes in cholesterol and lipid levels, but the effects are generally small and vary between studies. Some research shows slight reductions in total cholesterol and LDL with possible small decreases in HDL. The net cardiovascular impact through lipid changes alone appears minimal. A fasting lipid panel before starting TRT and periodic rechecks during treatment help track any changes in your individual lipid profile.

What Is Hematocrit and Why Does It Matter During TRT?

Hematocrit measures the percentage of your blood made up of red blood cells. Testosterone stimulates red blood cell production, which can raise hematocrit levels. When hematocrit rises above approximately 52% to 54%, blood becomes thicker and the theoretical risk of clots increases. Regular blood work during TRT monitors hematocrit levels, and dose adjustments are made if levels climb too high. Most guidelines recommend checking hematocrit at baseline, 4 to 6 weeks, 3 months, and every 6 to 12 months thereafter.

Does TRT Cause Atrial Fibrillation?

The TRAVERSE trial reported a higher rate of atrial fibrillation in the testosterone group (3.5%) compared to placebo (2.4%). However, this was a secondary outcome in an older population with significant cardiovascular risk factors. When TRAVERSE data were pooled with other randomized trials, the increased risk was not statistically significant. Men with a history of atrial fibrillation or other arrhythmias need to discuss this finding specifically with their clinician before starting testosterone therapy.

Is TRT Safe for Men Who Already Have Heart Disease?

The TRAVERSE trial specifically enrolled men with existing cardiovascular disease or high cardiovascular risk and found no increase in major adverse cardiovascular events. This is the most relevant safety data for this population. Having heart disease does not automatically rule out TRT, but it requires a thorough risk-benefit discussion, close monitoring, and coordination between your TRT prescriber and cardiologist when appropriate.

Should I Stop TRT If My Blood Pressure Goes Up?

A modest increase in blood pressure during TRT does not necessarily mean you need to stop treatment. Consistent, significant increases (for example, sustained readings above 140/90 mmHg or a persistent rise of 10 or more mmHg systolic from your baseline) warrant a conversation with your clinician. Options may include dose adjustment, adding or adjusting blood pressure medication, or addressing contributing factors like sleep apnea, weight, sodium intake, or stress. Stopping TRT is a last resort if other interventions fail.

How Often Do I Need Blood Work on TRT?

Standard monitoring includes blood work at baseline, 4 to 6 weeks, 3 months, and every 6 to 12 months once stable. These labs typically include a complete blood count (for hematocrit), testosterone levels, a metabolic panel, fasting lipids, and PSA. Your clinician may adjust this schedule based on your individual risk profile, lab trends, and any symptoms you report.

Can Anxiety About TRT Side Effects Mimic Heart Symptoms?

Yes. Health anxiety can produce physical symptoms that closely resemble cardiovascular problems, including rapid heartbeat, chest tightness, shortness of breath, and dizziness. For men already worried about TRT and heart risk, these symptoms can trigger a cycle where anxiety creates sensations that increase anxiety further. Objective monitoring (home blood pressure logs, regular blood work) helps distinguish between anxiety-driven symptoms and genuine cardiovascular warning signs.

For More Information

• guide to testosterone therapy for North Carolina men
• TRT Side Effects and Risks: What to Watch for and How Responsible Monitoring Works
• How Adult Men Are Evaluated for Low Testosterone Before Treatment
• Testosterone, Mood Swings, and Anger: Low T vs. High T
• Balancing Hormones and Mental Health: A Psychiatrist’s Guide for Men
• Is Telepsychiatry Right for You? Key Considerations for New Patients

If you are in North Carolina and want to discuss whether TRT is appropriate for your situation, or if you have questions about cardiovascular monitoring during treatment, you can schedule a telepsychiatry consultation with Dr. Baghel.

Note: This is not medical advice or a substitute for an in-person evaluation. The information provided here is educational and does not replace individualized medical guidance. If you are experiencing a cardiovascular emergency, call 911 or go to your nearest emergency room.

About the Author

Dr. Baghel is board-certified in Adult Psychiatry and Forensic Psychiatry by the American Board of Psychiatry and Neurology. He completed his forensic psychiatry fellowship at the University of Rochester and provides telepsychiatry services throughout North Carolina, from Asheville to the Triangle to the Outer Banks. His practice integrates hormone-informed psychiatric care with lifestyle guidance and evidence-based medication management.