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T levels were then measured in stored blood samples from initial study visits and analyzed for differences between the two groups. Additional longitudinal studies have similarly found that neither high nor low T levels predict incident myocardial infarction 14–16. The Rancho Bernardo study followed 1000 men aged 40–79 years over a 12-year period and found no association between plasma T levels and either extant CVD or subsequent cardiovascular morbidity and mortality . These longitudinal analyses, therefore, relate endogenous T levels to the development of disease over time.
Because men with diabetes already face high risks of heart disease, doctors are extra cautious. The combination of obesity, low testosterone, and high cholesterol creates a cycle that increases heart risk. Some studies show mild decreases in LDL cholesterol (the "bad" cholesterol) and neutral effects on triglycerides. While TRT can change cholesterol levels—sometimes lowering HDL or affecting LDL—the actual impact on heart attacks and strokes is less clear and may be neutral. The Endocrine Society and the American Urological Association recommend that doctors use testosterone therapy only in men with clear clinical symptoms and low measured testosterone. In 2023, a major clinical trial called the TRAVERSE study looked specifically at whether TRT increased heart problems in men with low testosterone and high cardiovascular risk. That is why researchers study both cholesterol levels and real events, like heart attacks and strokes, to understand the full picture.
In contrast, another recent meta-analysis that included the largest number of studies so far did not find any association between TRT and CVD risk. Accordingly, clinical intervention studies have been performed to investigate whether TRT can mitigate CVD risk factors among men with low endogenous T concentrations; however, none of these have been powered to examine CVD event rates. In aggregate, though there have been mixed results regarding the relationship between low endogenous T levels and incident CVD, these studies suggest that, if anything, higher T levels may be protective.
Most of these studies have also demonstrated an inverse relationship between T levels and both plasma triglycerides 32–34,36 and total cholesterol 32,34. Although cross-sectional studies have demonstrated higher prevalence of CVD among men with low endogenous androgens, limited clinical data have not shown that testosterone replacement therapy (TRT) reduces CVD risk. Further, observational data suggest that men with low circulating T levels may be at greater risk for cardiovascular disease (CVD). We also take a closer look at effects of testosterone on lipids and HDL in particular, to see if this explains the cardiovascular effects seen in clinical studies.
A combination of healthy fats, regular exercise, proper diet, weight management, and lifestyle modifications can help counteract any potential reductions in HDL. A combination of a balanced diet and regular exercise can help achieve and sustain a healthy weight. Maintaining a healthy weight is crucial for optimal lipid balance. The degree of change often depends on factors such as dosage, duration of therapy, lifestyle habits, and individual metabolic responses. Managing SHBG is difficult, as there body typically tries to make more or less depending on many factors. The primary way to treat triglycerides is through diet.
Food and Drug Administration (FDA) in 2015 to require a warning label about possible heart risks for prescription testosterone products. A 2013 study of older men, many with existing health problems, reported a higher rate of heart attacks in those taking testosterone compared to those who were not. But a change in cholesterol does not always mean a person will develop heart disease. First, it is important to separate cholesterol changes from actual heart disease outcomes. For patients and doctors, knowing these differences is important for choosing the right therapy and planning regular cholesterol monitoring.
If you’re feeling off – whether it’s low energy, reduced sex drive, mood changes, or other signs of hormonal imbalance – it could be time to take a closer look at your testosterone levels, too. For this reason, regular monitoring of cholesterol levels is essential during TRT. Its effects on lipid health are most notable when testosterone deficiency is driving broader metabolic issues. By increasing lean muscle mass and reducing fat mass, testosterone therapy may help improve insulin sensitivity and decrease visceral fat – two factors strongly tied to poor lipid profiles. In general, the effects on cholesterol are small and often within a clinically acceptable range, especially when TRT is monitored by a healthcare provider. Too little can impair hormone production, and too much can lead to other health issues that may ultimately disrupt testosterone regulation. In fact, high cholesterol levels – particularly elevated LDL – are more often linked to metabolic dysfunction and hormonal imbalance.

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