Can testosterone treatment cause heart palpitations? Testosterone replacement therapy (TRT) is prescribed to men with clinically confirmed hypogonadism to address symptoms such as fatigue, reduced libido, and mood disturbances. Whilst TRT offers therapeutic benefits, concerns exist regarding its cardiovascular effects, including the potential for heart palpitations—sensations of a rapid, fluttering, or pounding heartbeat. Recent research suggests a small increased risk of atrial fibrillation with TRT, which may manifest as palpitations. Testosterone influences cardiovascular physiology through effects on haematocrit levels and fluid retention. The MHRA and EMA advise careful cardiovascular risk assessment before initiating treatment, particularly in patients with pre-existing cardiac, renal, or hepatic disease.

Can Testosterone Treatment Cause Heart Palpitations?

Testosterone replacement therapy (TRT) is prescribed to men with clinically confirmed hypogonadism—a condition characterised by abnormally low testosterone levels. Whilst TRT can improve symptoms such as fatigue, reduced libido, and mood disturbances, concerns exist about its cardiovascular effects, including the potential for heart palpitations.

Heart palpitations are sensations of a rapid, fluttering, or pounding heartbeat. They may feel as though the heart is skipping beats or beating irregularly. The relationship between testosterone treatment and palpitations is complex. While large-scale clinical trials have not established a definitive causal link for all cardiovascular events, recent research suggests a small increased risk of atrial fibrillation with TRT, which can manifest as palpitations.

Testosterone can influence cardiovascular physiology primarily through its effect on haematocrit levels (the proportion of red blood cells in the blood), potentially leading to increased blood viscosity. Elevated haematocrit is a recognised side effect of TRT that may increase cardiovascular strain. Additionally, testosterone therapy can cause fluid retention and oedema in some patients, which may contribute to cardiac symptoms.

It is important to note that palpitations are common in the general population and can arise from numerous causes unrelated to testosterone, including anxiety, caffeine intake, alcohol, thyroid disorders, and underlying cardiac conditions. The Medicines and Healthcare products Regulatory Agency (MHRA) and the European Medicines Agency (EMA) have reviewed the cardiovascular safety of testosterone products, and prescribers are advised to assess cardiovascular risk before initiating treatment, with particular caution in patients with pre-existing cardiac, renal or hepatic disease.

Recognising Heart Palpitations During Testosterone Therapy

Recognising palpitations early is essential for appropriate management and reassurance. Patients on testosterone therapy should be aware of the typical characteristics of palpitations and how to distinguish them from more serious cardiac symptoms.

Palpitations may present as:

• A sensation of the heart racing or beating very fast (tachycardia)

• A fluttering or quivering feeling in the chest

• The feeling that the heart has skipped a beat or added an extra beat

• An awareness of the heartbeat that is unusually strong or forceful

These sensations may occur at rest or during physical activity and can last from a few seconds to several minutes. They may be accompanied by feelings of anxiety or unease, though this can be both a cause and a consequence of the palpitations themselves.

It is important to differentiate benign palpitations from symptoms that may indicate a more serious underlying arrhythmia or cardiac event. Warning signs that warrant urgent medical attention include palpitations associated with:

• Chest pain or tightness

• Shortness of breath or difficulty breathing

• Dizziness, light-headedness, or fainting (syncope or pre-syncope)

• Severe fatigue or weakness

Patients should be encouraged to keep a symptom diary, noting the frequency, duration, and context of palpitations (e.g., time of day, activity level, recent caffeine or alcohol intake). This information can be invaluable during clinical assessment. If palpitations are persistent, frequent, or associated with any of the warning signs listed above, patients should contact their GP or NHS 111 for urgent advice. In cases of severe symptoms such as chest pain or loss of consciousness, emergency services (999) should be contacted immediately.

Risk Factors and Who May Be More Susceptible

Not all patients on testosterone therapy are equally susceptible to cardiovascular side effects, including palpitations. Understanding individual risk factors is crucial for safe prescribing and monitoring.

Pre-existing cardiovascular disease is a significant risk factor. Men with a history of ischaemic heart disease, heart failure, arrhythmias, or stroke may be at higher risk of adverse cardiovascular events during TRT. The British Society for Sexual Medicine (BSSM) and UK product information advise caution when prescribing testosterone to such patients, and a thorough cardiovascular assessment is recommended before treatment initiation.

Age is another important consideration. Older men, particularly those over 60 years, are more likely to have underlying cardiovascular pathology, even if asymptomatic. Clinical guidelines recommend careful evaluation of cardiovascular risk in this population.

Polycythaemia (elevated red blood cell count) is a well-recognised side effect of testosterone therapy. Increased haematocrit can lead to hyperviscosity of the blood, potentially increasing the risk of thrombotic events and placing additional strain on the cardiovascular system. Regular monitoring of haematocrit is therefore essential, particularly in the first year of treatment.

Other risk factors include:

• Obesity and metabolic syndrome, which are associated with increased cardiovascular risk

• Hypertension (high blood pressure), which requires careful monitoring during TRT as per product information

• Obstructive sleep apnoea, which can worsen with TRT and independently increases cardiovascular risk

• Smoking and excessive alcohol consumption

• Family history of premature cardiovascular disease

• Fluid retention and oedema, which may exacerbate heart failure in susceptible individuals

Patients with multiple risk factors require particularly close monitoring. Shared decision-making between the patient and clinician, weighing the potential benefits of TRT against cardiovascular risks, is essential. In some cases, alternative management strategies for hypogonadism symptoms may be more appropriate.

When to Seek Medical Advice About Palpitations on Testosterone

Knowing when to seek medical advice is vital for patient safety. Whilst occasional, brief palpitations may not be cause for alarm, certain situations require prompt clinical evaluation.

Patients should contact their GP or prescribing clinician if they experience:

• New-onset palpitations after starting testosterone therapy or following a dose adjustment

• Palpitations that are frequent (occurring daily or multiple times per week)

• Episodes that are prolonged (lasting more than a few minutes)

• Palpitations that cause significant anxiety or distress

• Any pattern or trigger that is concerning to the patient

For urgent but non-life-threatening concerns, patients can contact NHS 111 for advice. Emergency medical attention (via 999 or attendance at A&E) is required if palpitations are accompanied by:

• Chest pain, pressure, or tightness—these may indicate myocardial ischaemia or infarction

• Severe shortness of breath—suggesting possible heart failure or pulmonary complications

• Loss of consciousness or near-fainting—which may indicate a serious arrhythmia

• Sudden onset of confusion or neurological symptoms—raising concern for stroke

When a patient presents with palpitations, the clinician will typically perform a thorough clinical assessment, including a detailed history, physical examination, and 12-lead electrocardiogram (ECG) in line with NICE guidance. Blood tests may be arranged to check haematocrit, electrolytes (particularly potassium and magnesium), thyroid function, and testosterone levels.

Depending on the findings, further investigations may include:

• Ambulatory ECG monitoring (Holter monitor or event recorder) to capture intermittent arrhythmias

• Echocardiography to assess cardiac structure and function

• Exercise stress testing if ischaemic heart disease is suspected

In some cases, temporary cessation or dose reduction of testosterone therapy may be advised whilst investigations are undertaken. Patients should never stop prescribed medication without medical guidance, but should feel empowered to discuss concerns with their healthcare team.

Managing Cardiovascular Health During Testosterone Treatment

Proactive management of cardiovascular health is essential for all patients receiving testosterone therapy. A comprehensive, individualised approach can minimise risks and optimise treatment outcomes.

Pre-treatment assessment is the foundation of safe prescribing. Before initiating TRT, clinicians should:

• Conduct a full cardiovascular risk assessment, including blood pressure measurement and evaluation of cardiovascular history

• Perform baseline blood tests, including full blood count (to assess haematocrit), lipid profile, fasting glucose or HbA1c, and liver and renal function

• Consider a baseline ECG based on clinical judgement, particularly in those with cardiovascular risk factors

• Assess prostate health with PSA testing and digital rectal examination where appropriate

Regular monitoring during treatment is crucial. The British Society for Sexual Medicine (BSSM) and European Association of Urology (EAU) recommend:

• Haematocrit monitoring at 3, 6, and 12 months, then annually—if haematocrit exceeds 0.54 (54%), dose reduction or temporary cessation may be necessary

• Blood pressure checks at each follow-up

• Lipid profile and metabolic parameters monitored annually

• PSA and prostate assessment according to guidelines

• Symptom review, specifically asking about palpitations, chest pain, breathlessness, or oedema

If erythrocytosis (elevated haematocrit) develops, clinicians should evaluate for contributing factors such as obstructive sleep apnoea or smoking, consider adjusting the testosterone formulation or dose, and in some cases, temporary cessation and venesection may be appropriate.

Lifestyle modifications play a vital role in cardiovascular health:

• Smoking cessation—smoking significantly increases cardiovascular risk

• Moderate alcohol consumption—excessive intake can trigger palpitations and worsen cardiovascular health

• Regular physical activity—at least 150 minutes of moderate-intensity exercise per week, as per NHS guidelines

• Healthy diet—emphasising fruits, vegetables, whole grains, and limiting saturated fats and salt

• Weight management—achieving and maintaining a healthy BMI

• Stress management—chronic stress and anxiety can contribute to palpitations

Patients should be educated about the signs and symptoms requiring medical attention and encouraged to maintain open communication with their healthcare team. Patients should report suspected side effects, including palpitations, via the MHRA Yellow Card Scheme. In cases where cardiovascular risks are deemed too high, alternative approaches to managing hypogonadism symptoms should be explored. Testosterone therapy can be beneficial when appropriately prescribed and monitored, but patient safety must always remain the priority.

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