Latest / Heart Health, Reimagined with Dr. Mona Shah, MD / Testosterone, Your Heart, and What Actually Works

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Testosterone, Your Heart, and What Actually Works · Heart Health, Reimagined with Dr. Mona Shah, MD

• 0:00
  SPEAKER_00: Testosterone is everywhere right now.
• 0:03
  SPEAKER_00: Men are being told low testosterone is making them tired, overweight, weak, depressed, and putting their heart at risk.
• 0:12
  SPEAKER_00: Women are being prescribed testosterone too.
• 0:15
  SPEAKER_00: And at the same time, people are still worried that testosterone itself can cause heart attacks, blood clots, high blood pressure, or other cardiovascular problems.
• 0:26
  SPEAKER_00: So which is it?
• 0:28
  SPEAKER_00: Is low testosterone actually dangerous?
• 0:30
  SPEAKER_00: Does testosterone's replacement protect your heart?
• 0:34
  SPEAKER_00: And if your testosterone is low, is taking testosterone even the only way to raise it?
• 0:40
  SPEAKER_00: I'm Dr.
• 0:41
  SPEAKER_00: Mona Shaw, a preventative cardiologist, board certified in holistic medicine and in cardiac CT.
• 0:47
  SPEAKER_00: And testosterone might be the single most talked-about hormone I get asked about in this job.
• 0:53
  SPEAKER_00: Today, we are going to start through all of that.
• 0:57
  SPEAKER_00: First, what does low testosterone actually mean?
• 1:00
  SPEAKER_00: Second, what does testosterone replacement genuinely improve?
• 1:05
  SPEAKER_00: Third, what did the major traverse trial actually show about cardiovascular safety?
• 1:11
  SPEAKER_00: And fourth, what are the risks I care about?
• 1:15
  SPEAKER_00: What other options exist besides TRT?
• 1:18
  SPEAKER_00: And what do we know about testosterone in women?
• 1:21
  SPEAKER_00: And one important clarification before we start, I don't prescribe testosterone or other hormone therapies.
• 1:27
  SPEAKER_00: My role as a cardiologist is to help patients understand the cardiovascular side of that decision.
• 1:35
  SPEAKER_00: I'm looking at blood pressure, your red blood cell count, which we call hematocrit, clotting risk, sleep apnea, existing cardiovascular disease, metabolic health, and whether there are cardiac reasons to be more cautious.
• 1:50
  SPEAKER_00: And one more thing: restoring truly low testosterone back into a normal physiologic range is completely different from pushing testosterone far above normal with bodybuilding or anabolic steroid doses.
• 2:06
  SPEAKER_00: Those are not the same thing.
• 2:08
  SPEAKER_00: More is not better.
• 2:10
  SPEAKER_00: So, does low testosterone itself hurt the heart?
• 2:14
  SPEAKER_00: The answer is more complicated than low T causes heart disease.
• 2:19
  SPEAKER_00: Men with low testosterone do tend to have more obesity, insulin resistance, diabetes, metabolic syndrome, frailty, and chronic illness.
• 2:30
  SPEAKER_00: Some observational studies have found higher rates of heart attack, stroke, and death in men with lower testosterone.
• 2:39
  SPEAKER_00: But when researchers carefully account for age, obesity, diabetes, and other illnesses, much of that relationship becomes weaker.
• 2:48
  SPEAKER_00: In the UK Biobank, which followed more than 200,000 men, lower testosterone was associated with a higher overall risk of death.
• 2:58
  SPEAKER_00: But after full adjustment, it was not independently associated with more heart attacks, strokes, or cardiovascular death.
• 3:06
  SPEAKER_00: In simpler terms, low testosterone often travels with poor health, but that does not mean it caused it.
• 3:13
  SPEAKER_00: Still, truly low testosterone can matter on its own.
• 3:18
  SPEAKER_00: And before treating it, we first need to establish that someone actually has hypogonadism, which simply means the body is not making enough testosterone on its own.
• 3:28
  SPEAKER_00: For men, that generally means symptoms plus low testosterone confirmed on two morning blood tests.
• 3:36
  SPEAKER_00: And I'll be honest, this is not what I'm seeing happen out there right now.
• 3:40
  SPEAKER_00: I have patients almost every single day who get testosterone prescribed online after a quick questionnaire and a single blood draw, sometimes not even a morning one, no real confirmation of symptoms, and no real discussion of why their testosterone might actually be low in the first place.
• 3:56
  SPEAKER_00: That is not the same thing as a real diagnosis.
• 3:59
  SPEAKER_00: And it worries me from a cardiovascular standpoint because it skips almost everything I just described.
• 4:05
  SPEAKER_00: If I'm reviewing someone from a cardiovascular perspective, I want to know those total testosterone results.
• 4:13
  SPEAKER_00: And I generally like to check SHBG2, which stands for sex hormone binding globulin, a protein that affects how much of your testosterone is actually available for your body to use, along with a calculated free testosterone level.
• 4:30
  SPEAKER_00: So I'm not just relying on one number.
• 4:33
  SPEAKER_00: Then I want to ask why.
• 4:35
  SPEAKER_00: And this is a conversation to have with your own prescribing doctor.
• 4:39
  SPEAKER_00: Obesity, sleep apnea, chronic illness, certain medications like opiates or steroid medications such as prednisone, a pituitary issue, or previous anabolic steroid use.
• 4:52
  SPEAKER_00: Because sometimes treating the underlying problem is more important than just easily prescribing testosterone.
• 4:58
  SPEAKER_00: When a man truly has low testosterone, confirmed this way, testosterone replacement can provide legitimate benefits.
• 5:07
  SPEAKER_00: Testosterone replacement comes in a few different forms: injections, gels, patches, and pellets.
• 5:13
  SPEAKER_00: Pellets are compounded and inserted under the skin, and because they are compounded, dosing is not regulated the same way.
• 5:20
  SPEAKER_00: Absorption can be unpredictable, and levels can spike well above a normal range before tapering off.
• 5:27
  SPEAKER_00: That is a delivery method I'm most cautious about from a cardiovascular standpoint, especially given how much it can drive up your red blood cell count.
• 5:37
  SPEAKER_00: Testosterone can improve libido and sexual function, help anemia, and support lean muscle mass, bone density, and body composition, along with some metabolic measures.
• 5:51
  SPEAKER_00: But expectations need to be realistic.
• 5:53
  SPEAKER_00: Testosterone does not automatically fix fatigue, depression, or erectile dysfunction.
• 5:58
  SPEAKER_00: It is not a guaranteed weight loss treatment.
• 6:01
  SPEAKER_00: The largest benefit tends to occur in men who actually have symptoms and clearly low testosterone to begin with.
• 6:09
  SPEAKER_00: If you like this kind of information, make sure you subscribe.
• 6:13
  SPEAKER_00: Every week I put out videos where we go beyond the basic numbers and talk about cardiovascular prevention, advanced labs, heart scans, imaging, lifestyle, medications, early detection, and how all those pieces fit together to understand your actual risk.
• 6:29
  SPEAKER_00: My goal is to take the studies and the science and make them practical so you understand what they actually mean for your health.
• 6:36
  SPEAKER_00: And if you know someone who's thinking about testosterone, already taking it, or just wondering whether a lone number really matters, please share this video with them.
• 6:47
  SPEAKER_00: Now let's talk about the trial that changed a testosterone conversation.
• 6:52
  SPEAKER_00: For years, there was concern that testosterone replacement might increase heart attacks and strokes, much of it based on older observational studies.
• 7:01
  SPEAKER_00: So the FDA required a large randomized cardiovascular safety trial called Traverse.
• 7:07
  SPEAKER_00: It enrolled more than 5,200 men with symptoms of low testosterone confirmed on two morning measurements, all of whom already had cardiovascular disease or were at high risk for it, and followed them on testosterone gel or placebo for almost three years.
• 7:27
  SPEAKER_00: The main result was remarkably simple.
• 7:30
  SPEAKER_00: A heart attack, stroke, or cardiovascular death occurred in 7.0% of the testosterone group and 7.3% of the placebo group.
• 7:42
  SPEAKER_00: Essentially the same.
• 7:43
  SPEAKER_00: That was very reassuring.
• 7:45
  SPEAKER_00: But I want to be precise about what it means.
• 7:49
  SPEAKER_00: Traverse did not show that testosterone prevents heart attacks or treats cardiovascular disease.
• 7:55
  SPEAKER_00: It showed that appropriately prescribed testosterone did not cause more major cardiovascular events than placebo during the period studied.
• 8:06
  SPEAKER_00: And safety is not the same thing as prevention.
• 8:09
  SPEAKER_00: And testosterone was not completely risk-free.
• 8:13
  SPEAKER_00: There were some more cases of atrial fibrillation and abnormal heart rhythm.
• 8:19
  SPEAKER_00: There were more cases of pulmonary emboli, which is the blood clot in your lungs, and there were somewhat more episodes of acute kidney injury.
• 8:28
  SPEAKER_00: These were secondary findings, and the trial was not designed to prove testosterone caused each one.
• 8:35
  SPEAKER_00: So I think of these as things worth watching, not proof that testosterone caused them.
• 8:41
  SPEAKER_00: But I wouldn't ignore them.
• 8:43
  SPEAKER_00: We also know testosterone can raise blood pressure.
• 8:47
  SPEAKER_00: In 2025, after reviewing Traverse, the FDA removed the previous boxed warning language about increased cardiovascular outcomes while requiring new blood pressure warnings and made further labeling updates the following year as more evidence came in.
• 9:06
  SPEAKER_00: So the message was never testosterone is completely safe.
• 9:10
  SPEAKER_00: It was the best randomized evidence does not show more major heart attacks and strokes in appropriately selected men.
• 9:19
  SPEAKER_00: But there are still things we need to monitor.
• 9:22
  SPEAKER_00: And one of the most important things I monitor is hematocrit, which simply tells us what percentage of your blood is made up of red blood cells.
• 9:30
  SPEAKER_00: Testosterone tells a bone marrow to make more red blood cells, and in some men it makes too many, which is one of the most common side effects of testosterone.
• 9:40
  SPEAKER_00: Observational data suggests that men whose hematocrit rises significantly on testosterone have more cardiovascular and blood clotting events than men whose levels stay lower.
• 9:52
  SPEAKER_00: That does not prove the hematocrit itself to cause those events, but it is enough that I take it seriously, checking it before treatment starts and monitoring it afterward.
• 10:03
  SPEAKER_00: If it gets too high, simply donating blood or getting a phlebotomy while staying on the same dose is not the reassuring fix a lot of people assume it is.
• 10:13
  SPEAKER_00: It can mask a real problem instead of addressing it.
• 10:16
  SPEAKER_00: And that is something worth taking seriously, not brushing it off as routine.
• 10:21
  SPEAKER_00: A lot of men also ask me about Clomid and HCG instead of testosterone itself.
• 10:28
  SPEAKER_00: Both work by pushing your own body to make more testosterone rather than replacing it.
• 10:33
  SPEAKER_00: But neither has ever been tested in a real cardiovascular outcomes trial the way testosterone has with Traverse.
• 10:40
  SPEAKER_00: So I can't tell you that they protect your heart, and I can't tell you they cause heart attacks either.
• 10:45
  SPEAKER_00: The one plausible concern with Clomids specifically is clotting risk, tied to its estrogen-like effect, though that signal is small in the limited data we have.
• 10:56
  SPEAKER_00: Both can also raise estradiol, sometimes enough to need a medication like anastrazole, which has its own trade-offs.
• 11:04
  SPEAKER_00: Either way, that is a conversation for the doctor prescribing it.
• 11:08
  SPEAKER_00: It's also worth asking whether testosterone can be improved without medication at all.
• 11:14
  SPEAKER_00: Sometimes it absolutely can.
• 11:16
  SPEAKER_00: If low testosterone is being driven by obesity, meaningful weight loss is probably the strongest lifestyle intervention.
• 11:23
  SPEAKER_00: As visceral fat and metabolic health improve, testosterone often rises too.
• 11:29
  SPEAKER_00: Resistance training and physical activity matter too.
• 11:33
  SPEAKER_00: Not because a hard workout gives you a temporary testosterone spike, but because a real longer-term benefit comes from improving body composition and metabolic health.
• 11:43
  SPEAKER_00: Sleep matters too.
• 11:45
  SPEAKER_00: Sleep apnea is linked to lower testosterone.
• 11:48
  SPEAKER_00: Heavy alcohol use is another well-established and reversible cause.
• 11:52
  SPEAKER_00: Severe calorie restriction and chronic overtraining can suppress it.
• 11:57
  SPEAKER_00: And correcting a true zinc or vitamin D deficiency can help if someone is actually deficient.
• 12:03
  SPEAKER_00: I would be skeptical of the endless list of testosterone-boosting supplements like ashwagandha, fenugreek, or tongat ali.
• 12:12
  SPEAKER_00: The studies are small, the effects are modest and inconsistent at best, and they are not substitutes for figuring out why testosterone is low in the first place.
• 12:21
  SPEAKER_00: Now let's talk about women, because testosterone is not just a male hormone.
• 12:26
  SPEAKER_00: Women make testosterone too.
• 12:28
  SPEAKER_00: And testosterone therapy in women is getting a tremendous amount of attention right now as the broader conversation around menopause and women's hormones care is finally getting the attention it deserves.
• 12:40
  SPEAKER_00: When it comes specifically to testosterone, though, I think we need to separate enthusiasm from evidence.
• 12:47
  SPEAKER_00: Right now, the strongest evidence we have supports testosterone for one specific problem, inappropriately selected postmenopausal women, persistent low sexual desire that is causing real distress.
• 13:01
  SPEAKER_00: Doctors sometimes call this hypoactive sexual desire disorder, but it is really all of that means.
• 13:07
  SPEAKER_00: A low testosterone blood test by itself does not diagnose that condition and is not a reason by itself to prescribe testosterone.
• 13:15
  SPEAKER_00: If testosterone is being used in a woman, a baseline testosterone level is useful primarily so treatment can be monitored and levels can be kept within the normal female physiologic range.
• 13:26
  SPEAKER_00: Checking that same SHBG marker I mentioned earlier can also help make sense of the numbers.
• 13:32
  SPEAKER_00: The goal is not to push a woman's testosterone into a male range.
• 13:37
  SPEAKER_00: At physiologic female doses, testosterone given through the skin has not shown a clear short-term cardiovascular safety problem.
• 13:46
  SPEAKER_00: But the studies are much smaller and shorter than in men.
• 13:49
  SPEAKER_00: There is nothing comparable to traverse in women, and no large randomized trial has shown that testosterone prevents heart attacks, strokes, or cardiovascular death in women.
• 14:00
  SPEAKER_00: And oral testosterone is generally not preferred because of unfavorable effects on cholesterol.
• 14:06
  SPEAKER_00: Too much testosterone in women can cause acne, facial hair growth, scalp hair loss, and voice changes.
• 14:13
  SPEAKER_00: And some of those effects may not completely reverse.
• 14:16
  SPEAKER_00: So again, more is not better.
• 14:19
  SPEAKER_00: And that is a perfect transition to one of the most important distinctions in this entire video.
• 14:25
  SPEAKER_00: Physiologic testosterone replacement is not the same thing as anabolic steroid abuse.
• 14:31
  SPEAKER_00: If someone truly has hypogonadism and testosterone is restored into a normal physiologic range, that is completely different from someone with normal testosterone taking many, many times replacement doses to build muscle.
• 14:46
  SPEAKER_00: At supraphysiologic doses, the cardiovascular data are much more concerning.
• 14:51
  SPEAKER_00: Long-term anabolic steroid use has been associated with markedly unfavorable cholesterol changes, high blood pressure, more coronary plaque, abnormal heart rhythms, thickening and weakening of the heart muscle, cardiomyopathy, heart failure, and blood clots.
• 15:10
  SPEAKER_00: So when someone says testosterone is safe, my response is what testosterone, what dose, in whom, for what reason are we restoring a genuine deficiency into the normal range, or pushing a normal person far above normal?
• 15:28
  SPEAKER_00: Those are entirely different situations.
• 15:31
  SPEAKER_00: So where does all of this leave us?
• 15:33
  SPEAKER_00: Low testosterone can matter, a genuinely low testosterone level should not be dismissed.
• 15:39
  SPEAKER_00: And appropriately selected patients can absolutely benefit from treatment.
• 15:45
  SPEAKER_00: My honest bottom line as a cardiologist, I'm a real fan of testosterone therapy for the right man when it genuinely makes sense, when everything is actually being checked, and when we keep levels in a normal range rather than pushing it into supraphysiologic territory.
• 16:01
  SPEAKER_00: Monitor properly, I think it can make a real difference.
• 16:05
  SPEAKER_00: So don't let hesitation keep you from having this conversation if you think you might be a candidate.
• 16:12
  SPEAKER_00: But a low testosterone number does not automatically mean you need testosterone.
• 16:17
  SPEAKER_00: Confirm it.
• 16:18
  SPEAKER_00: Confirm the symptoms, look for the cause, address reversible problems, and then decide what treatment actually makes sense.
• 16:25
  SPEAKER_00: If testosterone replacement is appropriate, the cardiovascular data are reassuring.
• 16:31
  SPEAKER_00: Traverse did not show more heart attacks, strokes, or cardiovascular deaths over almost three years, though it has not been proven to prevent cardiovascular disease either.
• 16:41
  SPEAKER_00: For women, testosterone can have a legitimate role too.
• 16:46
  SPEAKER_00: And I want to be just as clear here.
• 16:49
  SPEAKER_00: I am just as much a fan of testosterone for the right woman as I am for the right man.
• 16:54
  SPEAKER_00: As long as it is done properly, a real baseline is checked, levels kept in the normal female range, and monitored over time.
• 17:03
  SPEAKER_00: Don't let the more limited data talk you out of having the conversation if you think you might be a candidate.
• 17:12
  SPEAKER_00: But right now, the evidence is strongest for appropriately selected postmenopausal women with this stress string, low sexual desire.
• 17:20
  SPEAKER_00: It has not been proven as a cardiovascular prevention treatment, anti-aging treatment, or general energy booster.
• 17:27
  SPEAKER_00: The right hormone and the right person for the right reason at the right dose can be extremely useful.
• 17:32
  SPEAKER_00: That's precision medicine.
• 17:34
  SPEAKER_00: It is very different from chasing a laboratory number or pushing hormone levels higher simply because we can.
• 17:41
  SPEAKER_00: If you found this helpful, subscribe and share it with someone who is thinking about testosterone or already taking it.
• 17:48
  SPEAKER_00: Because knowing your hormone number is only one piece of the picture.
• 17:52
  SPEAKER_00: What ultimately matters is understanding your actual cardiovascular risk and doing something meaningful about it.
• 17:59
  SPEAKER_00: If you already know you have plaque or you want to understand what to actually do once you find out, that is exactly what my plaque prevention video covers next, is on your screen now.