Is testosterone treatment dangerous for the cardiovascular system in older hypogonadal men?

The relationship between testosterone deficiency syndrome (TDS) and men's vascular health has a great impact in the modern approach to the aging male. There is good evidence that low testosterone (T) is associated with erectile dysfunction (ED) and that ED is a strong marker for cardiovascular risk; also, TDS is frequently associated with increased cardiovascular and all-cause mortality. Noteworthy, the occurrence of increased levels of glucose, total cholesterol, low-density lipoprotein, pro-inflammatory cytokines, and myointimal carotid thickness may be associated with reduced T levels especially in cardiac older frail men. Screening for low T should be mandatory in high risk groups including those with type 2 diabetes, metabolic syndrome and obesity. The rising demand from patients to be treated for ED associated with TDS will increase the prescribing of T and facilitate future long-term studies on its impact on cardiovascular disease (CVD). Recent studies suggest warnings with regard to T prescription in older frail men, but we regret that these studies had consistent bias in inclusion criteria and statistical evaluation. Data from studies conducted in more selected populations suggest that T replacement therapy may improve multiple surrogate markers for CVD as well as reducing cardiovascular mortality. After analyzing the most important studies' limitation, we can conclude that at present there is insufficient evidence of a causal relationship between T therapy and adverse cardiovascular outcomes to support against T supplementation in older hypogonadal frail men.