Testosterone in 2026: Safer Than We Feared, Not as Simple as the Ads
If you’re a man in your 40s–60s, your feeds are probably full of “low T” ads and longevity clinics promising energy, muscle, and libido in a bottle.
At the same time, we have some very new research:
2023–24 TRAVERSE trial: testosterone did not increase major cardiovascular events in men with documented hypogonadism.
2025: the FDA removed the boxed cardiovascular warning from testosterone labels but added a blood-pressure warning.
Early 2026: a Mendelian randomization study showed that men with genetically higher lifelong testosterone have a 17% higher risk of coronary artery disease, likely partly via higher blood pressure.
So is testosterone therapy now “safe,” or is high T actually bad for your heart?
Here’s how I’m thinking about the research on testosterone in men —where it clearly helps, where I’m cautious, and how this is different from the very separate (and under-served) discussion of testosterone in women.
Education only, not individual medical advice. Decisions about testing or treatment should always be made with your own clinician.
What testosterone actually does in adult men
In adult men, testosterone (and its metabolites) helps support:
Secondary sex characteristics aka puberty – facial/body hair, voice, etc.
Sexual function – libido, erectile quality, nocturnal erections
Energy and mood – low levels can feel like low drive, apathy, “flatness”
Body composition – more lean mass, less visceral fat
Bone density – prevention of osteoporosis
Red blood cell production – but too much can cause high hematocrit
The tricky part is that many midlife symptoms are nonspecific—poor sleep, stress, under-recovery from training, alcohol, and medications can all mimic “low T.”
How we actually diagnose low testosterone (not the Instagram version)
The American Urological Association guideline is still a good anchor.
Diagnosis of testosterone deficiency requires:
Compatible symptoms/signs, and
Consistently low total testosterone on blood tests
Key points I emphasize with patients:
Timing matters.
Testosterone follows a diurnal curve. We check morning, fasting levels on two separate days.
Cutoff isn’t a cliff, but we need a line.
AUA uses total testosterone <300 ng/dL as a reasonable cutoff to support the diagnosis.
Context matters.
Heavy training, caloric restriction, poor sleep, alcohol, and chronic illnesses can all suppress T.
In obese men, low total T with normal free T and high estradiol is common; the fix is often weight loss, sleep, and treating sleep apnea, not immediately starting lifelong hormones.
Before committing to hormone therapy, we establish:
Clear symptoms plus
Repeatedly low morning T plus
We’ve already addressed sleep, alcohol, meds, and overweight.
The big 2026 update: TRAVERSE + FDA label changes
For years, the worry was: Will TRT cause heart attacks and strokes?
TRAVERSE in a sentence
TRAVERSE randomized >5,200 men aged 45–80 with documented hypogonadism and high cardiovascular risk to testosterone gel vs placebo for a median of ~22 months.
Primary outcome (MACE: cardiovascular death, heart attack, stroke):
7.0% in testosterone group vs 7.3% in placebo → non-inferior (no excess major events).
Signals to respect: atrial fibrillation, acute kidney injury, and pulmonary embolism were numerically higher with testosterone, though still relatively uncommon.
No significant increase in prostate cancer or major prostate events was seen over the trial period.
What the FDA did with that
In 2025, the FDA
Removed the boxed warning of increased risk of adverse cardiovascular outcomes from all testosterone products.
Kept the limitations: products are still approved only for men with confirmed hypogonadism—not for “normal aging.”
Added/strengthened warnings about increased blood pressure.
My read: In properly selected men with true hypogonadism, TRT looks cardiovascularly safe overall, but it’s not free of risk signals (AFib, BP, hematocrit, etc.) and it’s not a longevity drug for everyone with a birthday.
Wait—didn’t 2026 data say higher testosterone raises heart risk?
Yes, and this is where nuance matters.
A 2026 Mendelian randomization analysis found that men with genetically higher lifelong testosterone levels had about a 17% higher risk of coronary artery disease, probably partly because higher T raises blood pressure.
An accompanying editorial in JCEM made the key point: MR of endogenous testosterone is not the same thing as exogenous TRT in carefully treated hypogonadal men.
How I explain this to patients:
If your body naturally runs very high T, that may come with a slightly higher CAD risk over a lifetime.
That does not mean we should keep men in a deficient state out of fear of “too much T.”
It does reinforce that we shouldn’t chase supraphysiologic levels, especially in men with higher cardiometabolic risk.
In other words: normalize, don’t supercharge.
When I actually consider testosterone therapy for men
Here’s the rough framework I use:
Confirm the diagnosis.
Symptoms + two low morning total T values (usually <300 ng/dL) ± free T, with a plausible cause.
Address reversible factors first.
Weight, sleep, sleep apnea, alcohol, medications, overtraining.
Screen for things TRT could worsen or complicate.
Untreated severe sleep apnea.
High baseline hematocrit.
Active prostate cancer or high PSA.
Desire for near-term fertility.
If we proceed, we treat it like a real hormone, not a supplement.
Target: bring levels into a normal physiologic range, not “as high as possible.”
Routinely monitor: hematocrit, lipids, blood pressure, PSA, symptoms, and side effects.
Common side effects I warn people about:
Acne, oily skin, balding acceleration in predisposed men
Increased hematocrit
Worsening or unmasking sleep apnea
Testicular atrophy, infertility while on therapy
Small risk of edema, mood changes, and (per TRAVERSE) slightly increased AFib/PE signals
Gels, injections, pellets: does the form matter?
I won’t go deep into regimens here, but a few high-level points:
Topical gels/creams – smoother levels, easy to titrate, but risk of transfer to partners/kids and daily hassle.
Injectables (shorter- or longer-acting esters) – cheaper, strong effect, but more peaks/troughs and more erythrocytosis.
Pellets – convenient (3–6 months) but harder to adjust and remove; I’m cautious in men new to therapy.
Who shouldn’t see testosterone as the first lever?
Groups where I’m especially cautious about “TRT as a quick fix”:
Men with borderline-low T and sleep deprivation, overtraining, or heavy alcohol.
Men trying to conceive in the next 1–2 years
For men who have clear hypogonadism but want to preserve or improve fertility, we sometimes use low-dose hCG (human chorionic gonadotropin) to stimulate the testes to make their own testosterone and sperm, either instead of TRT or alongside it, rather than shutting the system down with exogenous testosterone alone.
Men chasing longevity hacks with already-normal T – I’m not convinced we have data to support “optimization” from 550 → 900 ng/dL as a cardiometabolic strategy; MR data actually push the other way.
Quick teaser: what about testosterone in women?
Women absolutely have—and need—testosterone, just at much lower levels than men.
The 2019 Global Consensus Position Statement (Endocrine Society + multiple international societies) concluded that:
The only evidence-based indication for testosterone therapy in women is hypoactive sexual desire disorder (HSDD) in postmenopausal women, where it provides a moderate improvement in desire and satisfying sexual events.
There is insufficient evidence to recommend testosterone in women for fatigue, mood, cognition, weight loss, or disease prevention.
Key 2026 realities:
The U.S. still has no FDA-approved testosterone product for women; clinicians use low-dose male formulations off-label, aiming for physiologic premenopausal levels.
The FDA has just given guidance for the development of a female-specific testosterone formulation (AVA-291), so this may change in the coming years.
Meanwhile, many women are navigating a “Wild West” of compounding pharmacies, wellness clinics, and aggressive marketing.
How I summarize testosterone for men in 2026
For my midlife male patients, the TL;DR is:
True hypogonadism is real, underdiagnosed, and treatable. In the right men, TRT can meaningfully improve symptoms and metabolic health.
TRAVERSE and the 2025 FDA label change are reassuring for properly indicated TRT—but they don’t justify casual, supraphysiologic use.
Genetic data that “high T raises CAD risk” are a caution against over-replacement, not a reason to keep truly hypogonadal men low.
Lifestyle (sleep, training, weight, alcohol, stress) is still the foundation—T isn’t a substitute for those.
