Can testosterone treatment cause high blood pressure? Testosterone replacement therapy (TRT) is prescribed to men with clinically confirmed hypogonadism—abnormally low testosterone levels accompanied by compatible symptoms. Whilst TRT can improve fatigue, reduced libido, and mood disturbances, concerns exist about potential cardiovascular effects, particularly blood pressure elevation. Clinical evidence shows variable results: some studies report modest blood pressure increases, whilst others find no significant effect. Current UK guidance from the MHRA emphasises cardiovascular risk assessment and blood pressure monitoring before and during treatment. Understanding this relationship is essential for safe prescribing and patient management.

Can Testosterone Treatment Cause High Blood Pressure?

Testosterone replacement therapy (TRT) is prescribed to men with clinically confirmed hypogonadism—a condition characterised by abnormally low testosterone levels measured on at least two separate morning blood tests, along with compatible symptoms. Whilst TRT can improve symptoms such as fatigue, reduced libido, and mood disturbances, concerns exist about its potential cardiovascular effects, including its impact on blood pressure.

The relationship between testosterone therapy and blood pressure is complex and not fully understood. Clinical studies show variable results, with some reporting modest increases in blood pressure in men receiving TRT, whilst others have found no significant effect or even slight reductions. This variability may reflect differences in study populations, testosterone formulations, dosing regimens, and baseline cardiovascular health. Current evidence suggests that any blood pressure elevation associated with TRT tends to be modest, though even small changes can be clinically relevant for individuals with pre-existing hypertension or cardiovascular risk factors.

Several hypothesised mechanisms may explain how testosterone might influence blood pressure. These include potential effects on sodium and water retention through the renin-angiotensin-aldosterone system, which could increase blood volume. Testosterone may also affect vascular tone and endothelial function, though these effects appear to vary between individuals. Additionally, testosterone therapy can increase haematocrit (red blood cell concentration), which may contribute to increased blood viscosity and vascular resistance.

UK regulatory guidance acknowledges these cardiovascular considerations. The Medicines and Healthcare products Regulatory Agency (MHRA) and product information for testosterone preparations advise that TRT should only be initiated in men with confirmed hypogonadism, not for age-related decline alone. Cardiovascular risk factors—including hypertension—should be assessed and managed before and during treatment. Blood pressure monitoring is specifically mentioned in the Summary of Product Characteristics (SmPC) for testosterone products, reflecting the importance of cardiovascular surveillance during therapy.

Risk Factors and Who May Be More Susceptible

Not all men receiving testosterone therapy will experience blood pressure changes, but certain individuals may be at higher risk of developing or worsening hypertension during treatment. Understanding these risk factors is essential for appropriate patient selection and monitoring.

Men with pre-existing hypertension are particularly susceptible to further blood pressure elevation on TRT. Those with poorly controlled blood pressure at baseline should have their hypertension optimised before initiating testosterone therapy. Similarly, individuals with a history of cardiovascular disease—including coronary artery disease, heart failure, or stroke—require careful evaluation, as even modest blood pressure changes could have significant clinical implications.

Older men may be more vulnerable to cardiovascular effects of TRT, as age-related changes in vascular function and the higher prevalence of comorbidities can potentially influence blood pressure responses. Obesity and metabolic syndrome are additional risk factors; men with these conditions often have underlying insulin resistance and endothelial dysfunction, which may interact with testosterone's effects on fluid balance and vascular function.

The dose of testosterone may influence risk, with higher doses more likely to cause adverse effects, including blood pressure elevation. Different testosterone preparations may have varying effects, though evidence for formulation-specific blood pressure differences is limited.

Other susceptibility factors include:

• Chronic kidney disease, which impairs sodium excretion and is mentioned as a caution in product information

• Obstructive sleep apnoea (OSA), which should be assessed and treated before starting TRT as noted in SmPC guidance

• Elevated baseline haematocrit (>0.50), with TRT contraindicated if haematocrit exceeds 0.54

• Concurrent use of medications that affect blood pressure or fluid balance

Men with multiple risk factors require particularly vigilant monitoring and may benefit from specialist endocrinology or cardiology input before commencing TRT. The British Society for Sexual Medicine (BSSM) guidelines emphasise individualised risk assessment before initiating treatment.

Monitoring Blood Pressure During Testosterone Therapy

Regular blood pressure monitoring is a fundamental component of safe testosterone therapy. UK clinical guidelines recommend establishing baseline cardiovascular parameters before treatment initiation and implementing structured follow-up to detect any adverse changes promptly.

Before starting TRT, a comprehensive assessment should include measurement of blood pressure. In line with NICE guideline NG136, if clinic readings are elevated (≥140/90 mmHg), hypertension should be confirmed using ambulatory (ABPM) or home blood pressure monitoring (HBPM), with a diagnostic threshold of ≥135/85 mmHg. Men with stage 2 hypertension (≥160/100 mmHg) or stage 1 hypertension (≥140/90 mmHg) with additional risk factors should have their blood pressure treated before testosterone therapy is considered.

During the initial treatment phase (first 3–6 months), blood pressure should be monitored more frequently—typically at 3 months and 6 months after starting therapy. This period is when testosterone levels are stabilising and any blood pressure effects are most likely to become apparent. Monitoring should occur at consistent times relative to testosterone administration, particularly for men using intramuscular injections.

Long-term monitoring should continue at least annually for stable patients, or more frequently if blood pressure concerns arise. Many men on TRT are managed in primary care, and blood pressure checks can be incorporated into routine chronic disease reviews or medication monitoring appointments.

Home blood pressure monitoring can be valuable for men on testosterone therapy, providing multiple readings in a familiar environment and helping to identify any trends between clinic visits. Patients should be educated on proper measurement technique using a validated device, as outlined in NHS guidance.

Additional monitoring parameters that complement blood pressure assessment include:

• Haematocrit and full blood count (every 3–6 months initially, then annually)

• Lipid profile

• Prostate-specific antigen (PSA) in men over 50

• Testosterone levels to ensure appropriate dosing

• Assessment of symptoms and treatment response

Any significant blood pressure elevation warrants clinical review. Urgent same-day assessment is required for severe hypertension (≥180/120 mmHg) or signs of acute target-organ damage (e.g., chest pain, neurological symptoms, visual disturbances). TRT should be adjusted or temporarily discontinued if haematocrit exceeds 0.54.

Managing Blood Pressure While on Testosterone Treatment

When blood pressure elevation occurs during testosterone therapy, a systematic approach to management is required, balancing the benefits of TRT against cardiovascular risks.

The first step is to confirm that blood pressure elevation is genuine and sustained, rather than an isolated reading. In line with NICE guideline NG136, ambulatory or home blood pressure monitoring should be used to confirm hypertension before initiating treatment. If hypertension is confirmed, clinicians should review the patient's overall cardiovascular risk profile and consider whether the blood pressure increase is likely related to testosterone therapy or other factors.

Lifestyle modifications form the foundation of blood pressure management and should be emphasised for all men on TRT. These include:

• Dietary changes: Reducing salt intake to less than 6g per day (approximately 2.4g sodium), following a Mediterranean-style diet or the NHS Eatwell Guide

• Weight management: Even modest weight loss (5–10% of body weight) can significantly reduce blood pressure

• Regular physical activity: At least 150 minutes of moderate-intensity aerobic exercise weekly

• Alcohol moderation: Limiting intake to no more than 14 units per week

• Smoking cessation: Essential for overall cardiovascular health

Adjusting testosterone therapy may be necessary if blood pressure remains elevated despite lifestyle measures. Options include:

• Reducing the testosterone dose to achieve levels in the lower-normal range

• Considering a different formulation based on individual factors

• Temporarily discontinuing therapy to assess whether blood pressure improves

Antihypertensive medication should be initiated or optimised according to NICE guideline NG136 if hypertension is confirmed. Treatment is recommended for all patients with stage 2 hypertension (≥160/100 mmHg) and for those with stage 1 hypertension (≥140/90 mmHg) who have additional risk factors (e.g., established cardiovascular disease, target-organ damage, diabetes, kidney disease, or QRISK ≥10%). First-line agents typically include ACE inhibitors, angiotensin receptor blockers, calcium channel blockers, or thiazide-like diuretics, with selection based on age, ethnicity, and comorbidities.

When to seek specialist advice:

• Severe hypertension (≥180/120 mmHg) requiring same-day assessment

• Signs of acute target-organ damage (chest pain, neurological symptoms, visual disturbances)

• Difficulty balancing hypogonadal symptoms with blood pressure control

• Polycythaemia (haematocrit >0.54) developing alongside hypertension

Patients should be advised to contact their GP urgently if they experience:

• Severe headaches, visual disturbances, or chest pain

• Persistent dizziness or fainting

• Significant leg swelling

• Blood pressure readings at home consistently ≥180/120 mmHg

The decision to continue, modify, or discontinue testosterone therapy should be made collaboratively between the patient and healthcare team. Patients should be encouraged to report any suspected adverse reactions to testosterone therapy through the MHRA Yellow Card Scheme (yellowcard.mhra.gov.uk).

Frequently Asked Questions