THE TRUTH ABOUT TESTOSTERONE & HEART DISEASE
As expected, headline news stories on November 5, 2013, parroted a study proclaiming that aging men on testosterone therapy suffered a greater risk of heart attack. This was actually the second study within a short period of time that brought this topic to the delight of our omnipresent media. Within a span of less than two months, ads have appeared in our nation's major newspapers, on the Internet and on television encouraging those men on testosterone therapy who have suffered a heart attack or stroke to notify the law offices of so and so. This is nothing new. We have all witnessed the legal profession's zeal to encourage the public to sue whenever there is even a remote chance of an association between a given therapy and an unfavorable outcome. Especially when one considers how greatly flawed was this last study, this case is amongst the most ludicrous I've ever witnessed. There have been countless studies over the years demonstrating the cardiac benefits of testosterone therapy-- not to mention its many positive effects on the well-being of men treated with hormone replacement therapy.
Med Page Today ArticleBeing a board certified internist, cardiologist and anti-aging medical specialist places me in a prime position to comment on this very topic. Due to negative press about "steroids and sports", both physicians and the lay public have been confused about a therapy that has withstood an incredible amount of scrutiny over the years. I have been practicing both invasive and non-invasive cardiology since 1986 with a huge emphasis on prevention, by dint of a healthy diet, appropriate supplementation, exercise and stress management. In 2000, I incorporated an anti-aging aspect into my practice and have treated countless men and women with bio-identical hormone replacement. Although hormone replacement therapy remains a personal choice, those of us practicing longevity medicine generally support the use of supplemental hormones on carefully selected patients. This is totally due to the many health benefits conferred by such therapy. Fortunately, due to our fellowship training and our board certification process, we have been well-trained as to both initiate therapy and to monitor our patients on an ongoing basis.
Space does not permit me to give a truly comprehensive review of the medical literature on the association between LOW testosterone and increased risk of heart disease, but please note the following:
* Men with coronary heart disease had a significantly lower total testosterone and free testosterone 
* Men with low testosterone levels have an increased mortality due to heart disease. [2, 3]
* Men with coronary disease under the age of 45 had total and free testosterone levels significantly lower than age-matched controls 
What does the literature say about testosterone replacement and heart disease?
* Testosterone replacement has been shown to increase coronary blood flow in patients with coronary disease 
* Testosterone has been shown to improve chronic angina by increasing exercise tolerance vs. the controls getting a placebo 
* Testosterone replacement has been shown to decrease inflammation and lower total cholesterol 
* Testosterone replacement has been shown to be helpful in patients in severs heart failure 
The eight studies cited above are just a few examples of the numerous studies in the medical literature that have shown that low testosterone is associated with an increase risk of heart disease and that testosterone replacement therapy decreases the risk of heart disease. Moreover, testosterone replacement therapy is often beneficial in patients actually afflicted with coronary disease.
So how did these two recent studies conclude that male patients treated with testosterone replacement therapy had a higher probability to develop heart disease? There are FOUR major flaws with these two recent trials:
1) Estrogen levels were not measured in the subjects of these studies. It is a known fact that high estrogen levels in males has been found to increase the risk of heart attack and stroke    
2) Erythrocytosis / polycythemia or elevated red blood cell counts can result with testosterone therapy as with other conditions such as cigarette smoking. Such a condition could lead to heart attacks and thrombosis (blood clots).  It is therefore imperative that these levels be checked before initiating therapy and be carefully monitored on an ongoing basis. Such levels were NOT measured in these two trials.
3) In both studies not all patients had follow-up testing of testosterone levels. Therefore, dosages of testosterone may have been higher than needed. Levels of testosterone greater than that needed for hormone replacement therapy may actually induce damage to the coronary arteries and lead to heart disease. 
4) Testosterone can convert to dihydrotestoterone (DHT) in some male subjects which has been shown to enhance arterial thickening. Such a phenomenon can lead to plaque formation and both coronary disease and disease in the carotid arteries. Generally speaking, the higher the dose of testosterone prescribed, the more it is converted into DHT.
In conclusion, given the plethora of medical studies supporting the beneficial cardiac effects of properly prescribed testosterone, it is fairly obvious that these two medical trials are poorly designed and their conclusion flawed. Some of the patients did not have repeat testosterone levels measured, and such patients may well have had levels above that warranted for hormone replacement therapy. In addition, DHT, estrogen levels and levels of circulating red blood cells were not addressed.
Hormones in the body act as a symphony and this important connection was not considered in these two trials. Properly prescribed testosterone therapy by board-certified anti-aging specialists and those well versed in sex hormone physiology can generally be considered a safe, effective therapy benefitting both the heart and numerous other body systems as well.
1) English, K., et al., "Men with coronary artery disease have lower than men with levels of androgens than men with normal coronary angiograms,"Eur Heart Jour 2000; 21(11):890-4
2) Vermeulen, A., "Androgen replacement therapy in the aging male---a critical evaluation," Jour Clin Endocrinol Metabol 2001; 86:2380-90
3) Malkin, C., et al "Low serum testosterone and increased mortality in men with coronary heart disease," Heart 2010; 96:1821-25
4) Turhan, S., et al., "The association between androgen levels and premature coronary artery disease in men," Coron Artery Dis 2007; 18(3):159-62
5) Channer, K., et al., "Cardiovascular effects of testosterone: implications of the "male menopause?" Heart 2003
6) English, K., et al., Low-dose transdermal testosterone therapy improves angina threshold in men with chronic stable angina," Circulation 2000; 102(16):1906-11
7) Malkin, C., et al., “The effect of testosterone replacement on endogenous inflammatory cytokines and lipid profiles in hypogonadal men," Jour Clin Endocrinol Metab 2004; 89(7):3313-18
8) Toma, M., et al., "Testosterone supplementation in heart failure," Circulation 2012; 5:315-21
9) Abbott, A., et al., “Serum estradiol and risk of stroke in elderly men," Neurology 2007; (8):563-68
10) Mohamad, M., "Serum levels of sex hormones in men with acute myocardial infarction," Neuro Endocrinol Lett 2007; 28(2):182-86
11) Tripathi, Y., et al., Serum estradiol and testosterone levels following acute myocardial infarcton in men,' Jour Physiol Pharmacol 199842(2):291-94
12) Sudhir, K., et al., “Cardiovascular actions of estrogens in men," Jour Clin Endocrinol Metab 1999; 84(10):3411-15
13) Bassil, N., et al., Erythrocytosis in Hematopathology. 2nd Ed. His, E., (Ed.) Philadelphia: Elsevier/ Saunders, 2012
14) Skogastiema, C., et al., “A supraphysiological dose of testosterone induces nitric oxide production and oxidative stress," Eur Jour Prev Cardio March 7, 2013
*Originally Published Saturday, March 29, 2014