Testosterone and Cardiovascular risk

There is so much we do not know. That’s true of a lot of things. Consumers of healthcare and mental healthcare have to be their own advocate. Generally, health literacy in the US is quite poor and mostly inadequate for people making the decisions that they make. Only 12% of Americans would be considered to be literate in terms of their healthcare. 1

Most studies either leave out a lot of information or have some other problem(s) with them that raise questions. It’s easy to take the conclusions at face value only to discover there were flaws in the methodology or some other aspect of the study.

Testosterone has side effects that we know and likely ones we don’t know. We also know that for some people testosterone is life-saving. Knowing as much as a person can know ahead of time is important. There are risks and potential benefits. For some people the risks outweigh the benefits and for other people, the benefits far outweigh the risks. There are studies that come out in both directions about testosterone in cisgendered men and we have a handful of studies that say it is safe in transgender men.

There are two recent studies that seem important related to testosterone. (2) (3)
A meta analysis of over 8700 male veterans with low testosterone having coronary angiography where over 1200 started testosterone. (2) Risks for the no testosterone group was about 20% and 25.7 in those were were prescribed testosterone. The mean age was 60.6 years. These were older men with comorbid health problems. Only 13 of the 123 MIs or strokes were gel users but can’t really say much from that. Injected testosterone causes peaks and troughs unlike gels or cream.

No data on how the T was prescribed or used, no follow up monitoring of levels in over half of the studies; and the control group had higher levels of T than the group prescribed T. Who knows for how long they had lower t or what the impact of that was. Really, it’s not clear what the levels ultimately mean because the range in normal levels is vast. Finally, there was no information on estradiol levels. Bodies are complex systems. Interestingly, the human body converts testosterone into estrogen. At too high a level it is thought to cause heart attacks in people predisposed to heart disease and to cause clotting problems that can cause strokes. Aging men convert more exogenous T into estradiol. (4)

In the second one, men taking testosterone were significantly more likely to have a heart attack, a myocardial infarction, in the three months following starting on testosterone. (3)
The risk of MI was increased by 36% and for men over 65 the risk of MI was twice as high.
The study was a population of records for over 55,000 men in large healthcare database. These men were compared to over 167,000 men recently prescribed sildenafil (Viagra) or tadalafil (Cialis). Younger men with pre-existing heart disease and older men had a substantially great risk of a heart attack within 90 days of beginning treatment.

Studies in the past showed the testosterone had a protective effect(5) or testosterone balance that was balanced with estrogen was heart protective. (5a)

Other studies in the past showed the opposite. (6) Higher serum testosterone levels were associated with a reduced risk of fatal and non-fatal cardiovascular events in older men. Both high and low levels are associated with cardiac risk.

Many people feel the study is flawed and refer to is as junk science. This is not a randomized, placebo, double-blind study. Is it replicable. he study raises lots of questions about methodology etc. Why a control group of people on sildenefil?

To start, what kind of T? bio-identical or not? Dosage? Frequency? What was the method of delivery? Injectable, pill, gel, creme or patch? Were the men monitored by lab work and dosages adjusted or did they just a prescription and sent off? What was the level of T in those who had Is compared to those who did not? Pre and post T levels. What rationale for starting t in the first place. How about other risk factors for MI that we already know about? Exercise, race/ethnicity, SES…were the doctors trained to prescribe and monitor?

Generally T increases energy, people will do more including more sex and other vigorous activity. Viagra focuses on sexual activity, not other vigorous activity which is one of the reasons they chose it as a comparison.

Then is this data transferable to trans men and gender queer people? Who knows? Anyone stating an opinion is doing just that. There is so little that we know as fact.

There are multiple studies that state that T is safe for transmen long term.
(7)

Effects of T Assuming an individual wishes to transition:
(everyone’s body responds differently so these are general)

Positive side effects of T
stop periods, cessation of menses
increased ability to reach orgasm
increase clitoral growth
increased muscle mass
changes face shape to more masculine face
increased confidence, increased alertness


Negative side effects of T

acne; acne that scars, higher levels of hematocrit, hair loss, screw ups lipid profile-cholesterol issues-decreases good cholesterol, decreased insulin sensitivity-although it is also reported to improve metabolic syndrome, aromatased estrogen can be bad for bones, decreased insulin sensitivity
atrophied ovaries-theoretical risk connected to cancer; increased likelihood of PCOS although many trans men have PCOS prior to transition; changes in breast tissue theoretical risk in breast cancer, vaginal atrophy-loss of elasticity, drier and thinner tissue so pain and increased risk of tearing.
oily skin, increased weight, increased sweating, increase in snoring, insomnia
harder time accessing emotions
body odor changes, increased odor
significant drug -drug interactions, SSRIs, blood pressure medication, antifungals, can drop blood sugar levels, alcohol, seizure medications, etc.

Varies by person whether it’s good or bad or neutral
reduced fertility-possible permanent loss of fertility
hirsutism, increase in facial and body hair, changes in texture of hair
changes in sexual orientation/preferences/behaviors
effects of mood-generally inhibits depression, some people feel more aggressive, many people feel more even, more stable
increased libido, most folks think this is good
redistribution of fat
lowered voice, change in larynx
skin changes, veins more prominent
increase in the size of the brain
increased appetite

There are MANY less common side effects but if you are one of the people who gets that side effect, it’s a real problem for you. These include peripheral edema, hypertension, erythrocytosis-increased clotting factor so can cause heat attack or strokes, abnormal liver enzymes, liver damage, sleep apnea-an person stops breathing during sleep, liver problems, endometrial hyperplasia-precursor to uterine cancer, uterine bleeding, headaches can worsen or develop,

Going off of T a starting list
Expect your moods to shift, your energy to decrease, your sex drive to decrease. Possible your entire sense of self changes and people may feel a loss and not like themselves. Testosterone is thought to decrease depression and keeps moods more even or enhanced in many people. We do not know what ultimately changes regarding mood and brain issues. We don’t know what is permanent in term of changes in cognitive style or accessing emotions.

Some of testosterone’s effects are completely permanent (voice deepening, hair growth, hair loss, clitoral enlargement).
Most permanent effects can be reversed by surgery or electrolysis (to remove body hair).
Periods return
Body shape changes, lose muscle mass, fat redistributes.

At the time someone starts T, they generally believe it is going to be helpful. If an individual has come out as trans and goes off T there are many social issues that arise that are equal to or more significant than the physical changes from stopping T. (The trans community can be hostile or unaccepting of people who detransition. People can lose the community they created after losing their family or their previous community. It’s a multiplied loss. People can also feel as though they failed in their transition.)

1) America’s Health Literacy: Why We Need Accessible Health Information
http://www.health.gov/communication/literacy/issuebrief/
2) Vigen R, O’Donnell CI, Barón AE, Grunwald GK, Maddox TM, et al. Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels. JAMA 2013; 310:1829-1835.

3) Finkle WD, Greenland S, Ridgeway GK, et al. Increased risk of nonfatal myocardial infarction following testosterone therapy prescription in men. PLoS One 2014; DOI:10.1371/journal.pone.0085805.t001
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0085805

4) Lakshman KM, Kaplan B, Travison TG, et al. The effects of injected testosterone dose and age on the conversion of testosterone to estradiol and dihydrotestosterone in young and older men. The Journal of clinical endocrinology and metabolism. Aug 2010;95(8):3955-3964.

5) Ohlsson C, Barrett-Connor E, Bhasin S, et al. High serum testosterone is associated with reduced risk of cardiovascular events in elderly men. Journal of the American College of Cardiology. Oct 11 2011;58(16):1674-1681.

Shores MM, Smith NL, Forsberg CW, Anawalt BD, Matsumoto AM. Testosterone treatment and mortality in men with low testosterone levels. The Journal of clinical endocrinology and metabolism. Jun 2012;97(6):2050-2058.

Mathur A, Malkin C, Saeed B, Muthusamy R, Jones TH, Channer K. Long-term benefits of testosterone replacement therapy on angina threshold and atheroma in men. European journal of endocrinology / European Federation of Endocrine Societies. Sep 2009;161(3):443-449.

6) Basaria S, Coviello AD, Travison TG, Storer TW, Farwell WR, et al. (2010) Adverse Events Associated with Testosterone Administration. New England Journal of Medicine 363: 109–122.

(7) Asscheman et al. 2011, A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones, European J. of Endocrinology, 164(4):635-42.

Traish & Gooren 2010, Safety of physiological testosterone therapy in women: lessons from female-to-male transsexuals (FMT) treated with pharmacological testosterone therapy, J. of sexual medicine, 7(11):3758-64.

Mueller et al. 2010, Effects of intramuscular testosterone undecanoate on body composition and bone mineral density in female-to-male transsexuals, J. of sexual medicine, 7(9):3190-8.

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About gendertherapist

Psychotherapist in San Francisco. I am a gender specialist.
This entry was posted in Gender Dysphoria, regret, side-effects, testosterone, transgender. Bookmark the permalink.

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