Is TRT safe? Blood pressure, alcohol and sleep apnea, answered from the evidence

The questions change once a man is actually on testosterone. Before starting, it is “do I need this?” A few months in, it is a blood pressure reading that looks a little higher than last year, a partner who says the snoring got worse, or a weekend of drinks and the thought “is this a bad mix?” These are the practical safety questions, and most of them have better answers now than they did a few years ago, because in 2025 the FDA required class-wide changes to testosterone labeling after a large randomized trial and a set of blood pressure studies. This page answers each question from that labeling, from the two main clinical guidelines and from the trials behind them, and says how strong the evidence is for each. It does not cover doses; that belongs with your prescriber.

Is TRT safe?

For men with a confirmed diagnosis and monitoring, the best current evidence says TRT does not raise the risk of heart attack, stroke or cardiovascular death, but it is not risk-free. The TRAVERSE trial randomized 5,246 men aged 45 to 80 with low testosterone and existing or high cardiovascular risk to testosterone gel or placebo; major cardiac events occurred in 182 patients (7.0%) in the testosterone group and 190 (7.3%) on placebo, but the testosterone group had more atrial fibrillation, acute kidney injury and pulmonary embolism. On the strength of that trial, the FDA in February 2025 removed the cardiovascular-outcomes language from the boxed warning on all testosterone products while adding a blood pressure warning to every one of them. Evidence level in words: an approved drug with labeled use, backed by one large randomized safety trial, with blood pressure, sleep apnea and red blood cell count as the risks that need watching.

Does TRT raise blood pressure?

Yes, modestly, and the FDA now treats this as a class effect of all testosterone products. After premarket studies of an injectable and an oral product both showed rises, the agency required ambulatory blood pressure studies of every testosterone product, and it says those results confirmed an increase in blood pressure with use of all testosterone products, class-wide. The size of the rise is small on average. The Xyosted injection label reports an average increase of 3.9/1.5 mm Hg after 12 weeks, and in TRAVERSE, gel users’ systolic pressure rose 1.0 mm Hg over 36 months while placebo users’ fell 0.5, a 1.5 mm Hg gap. The label’s own framing is the useful one: a small rise that can increase cardiovascular risk over time, which is why it says to measure blood pressure periodically.

The figures below come from different products, designs and time points, so they show the range rather than a head-to-head ranking.

Blood pressure changes on testosterone in labeling and trial data. Sources are cited in the text.

Attribute	Xyosted injection label	Testosterone gel 1.62% ambulatory study	TRAVERSE gel trial
Design	One clinical study, 24-hour ambulatory monitoring, 62 men with usable recordings, compared with baseline	Single-arm study at 36 US sites, 246 men, 24-hour ambulatory monitoring	Randomized, placebo-controlled, 5,246 men with heart risk
Time point	12 weeks	16 weeks	36 months
Average systolic change	+3.9 mm Hg (diastolic +1.5)	+1.9 mm Hg, 24-hour average	+1.0 mm Hg vs -0.5 mm Hg on placebo (1.5 mm Hg difference)
Men already treated for hypertension	+3.9/1.3 mm Hg	A rise under 3 mm Hg could not be confirmed in men with hypertension or diabetes	Not reported separately on the label
Evidence level in words	Labeled drug data, no placebo arm in this measure	Single study without a control group	Large randomized trial, strongest of the three

Sources for the table: the Xyosted label (which also reports the TRAVERSE figures) and the gel ambulatory study by Weber and colleagues.

Can you take TRT if you have high blood pressure?

Controlled high blood pressure is not on the Endocrine Society’s list of reasons to avoid TRT, but the label says testosterone is not recommended when hypertension is uncontrolled, and men who already have it get the closest monitoring. The Xyosted label says to monitor blood pressure periodically, especially men with hypertension, and it reports that men already on blood pressure medication still saw an average rise of 3.9/1.3 mm Hg. In the gel ambulatory study, the overall rise was 1.9 mm Hg, and the researchers could rule out a meaningful effect in men without hypertension or diabetes but not in those with hypertension or diabetes. The label also warns that other medicines known to raise blood pressure may add to the increase when taken with testosterone, which is worth raising with the prescriber if you take one.

Does TRT cause sleep apnea or make it worse?

TRT can make existing sleep apnea worse in some men, and the effect in the best trial was mild and appeared early. The Xyosted testosterone label warns that treatment may potentiate sleep apnea in some patients, especially those with risk factors such as obesity or chronic lung disease. The clearest data comes from an 18-week randomized trial of 67 obese men with severe obstructive sleep apnea, all on a weight-loss diet: at 7 weeks, testosterone worsened the oxygen desaturation index by 10.3 events per hour compared with placebo, but by 18 weeks the difference was no longer statistically significant. The authors concluded that testosterone mildly worsens sleep-disordered breathing in a time-limited manner, and a follow-up analysis in 21 of the same men looked at changes in breathing control as one possible reason for the timing (Killick et al., J Sleep Res 2013). Evidence level in words: small randomized trials in a specific group (obese men with severe apnea, using an injected form), so the size of the effect in other men is less certain.

Can you start TRT if you have sleep apnea?

Untreated severe sleep apnea is one of the conditions the Endocrine Society lists as a reason not to start testosterone, so the usual order is to treat the apnea first. Its guideline recommends against starting testosterone in men with untreated severe obstructive sleep apnea, alongside elevated hematocrit, uncontrolled heart failure and a heart attack or stroke within the last 6 months. Sleep apnea also matters before treatment for a second reason: the American Urological Association names it as one of the explanations to look for when a man’s baseline hematocrit is above 50 percent, and says therapy should be held until that is explained (AUA guideline). Apnea can also produce symptoms that look like low testosterone, which our guide to low testosterone symptoms walks through.

Can you drink alcohol on TRT?

Alcohol is not listed as a drug interaction on the testosterone label we reviewed, so an occasional drink is not a known problem with the medication itself. The concern is that heavier drinking pushes on the same risks testosterone already carries. On blood pressure, a meta-analysis of 36 trials found that cutting back lowered blood pressure in people who drank more than two drinks a day, with the largest drop, 5.5 mm Hg systolic, in people who drank six or more a day and halved their intake; in people at two drinks a day or fewer, cutting back made no significant difference. On sleep apnea, a meta-analysis of 21 studies found that higher alcohol intake was linked to a 25 percent higher risk of sleep apnoea, though the authors also found signs of publication bias. Evidence level in words: randomized trials for the blood pressure effect, observational studies for the sleep apnea link, while the label and guidelines reviewed here do not address alcohol and TRT together.

Does heavy drinking work against TRT?

Heavy, long-term drinking is itself a cause of low testosterone, so it can work against the reason a man is on treatment. The Xyosted testosterone label lists toxic damage from alcohol among the causes of primary hypogonadism, meaning testicular failure. An NIAAA research review notes that chronic alcohol abuse produces sexual dysfunction and impairs sperm production in both humans and animals, and that animal studies consistently link both one-time and long-term drinking to low testosterone. Evidence level in words: well established for chronic heavy drinking, while most of the detail on mechanisms comes from animal studies.

Why does hematocrit keep coming up in TRT safety?

Hematocrit, the share of your blood made up of red cells, is the lab number most likely to force a change in TRT, and it ties the blood pressure, apnea and clotting questions together. The AUA calls for measuring hemoglobin and hematocrit before treatment and telling patients about the increased risk of polycythemia, and it says a hematocrit of 54 percent or higher on treatment warrants intervention. The Xyosted label says to check hematocrit approximately every 3 months, to stop the drug if it becomes elevated, and notes that a higher red cell mass may raise the risk of blood clots. What gets measured before the first prescription is covered in our guide to blood tests before starting TRT.

How do the main TRT safety risks compare?

The risks differ in how well they are measured and in what catches them, which is the more useful comparison than “safe or not.” Fertility belongs on this list too, and is covered in our page on whether TRT causes infertility.

Main TRT safety questions, the evidence behind each, and what monitoring looks for. Sources are cited in the text above.

Attribute	What the evidence shows	Evidence level in words	What monitoring looks for
Heart attack, stroke, cardiovascular death	No increase vs placebo in TRAVERSE (7.0% vs 7.3%)	Large randomized trial	Guideline screening; AUA says wait 3 to 6 months after a cardiovascular event
Blood pressure	Small average rise, about 1 to 4 mm Hg systolic, class-wide	Labeled ambulatory studies plus one randomized trial	Periodic blood pressure checks; not recommended with uncontrolled hypertension
Sleep apnea	Mild, early worsening in obese men with severe apnea	Small randomized trials	Guideline advice against starting with untreated severe apnea
Red blood cell count (hematocrit)	Rise is a labeled, common effect	Approved drug, labeled use	Baseline test, then roughly every 3 months on the label
Atrial fibrillation, kidney injury, pulmonary embolism	More frequent on testosterone in TRAVERSE	Large randomized trial (secondary findings)	Symptoms reported to the prescriber; clot warning on the label
Alcohol	Not a labeled interaction; heavy drinking raises blood pressure and apnea risk on its own	Randomized trials (blood pressure), observational studies (apnea)	Not addressed by the label or guidelines reviewed here

What does monitoring add to the cost of TRT?

Most of the safety work in this page is done by repeat blood pressure readings and blood tests, and those are part of what a TRT plan costs, not an extra. A plan that skips them is cheaper because it leaves out the checks the labels and guidelines call for. Our TRT cost breakdown shows what goes into the monthly figure, including lab work.

The bottom line

TRT is an approved treatment with a known, mostly manageable safety profile, and the 2025 labeling changes made that profile clearer: no added heart attack or stroke risk in the large safety trial, a small but real rise in blood pressure, a possible early worsening of sleep apnea, and a red blood cell count that needs watching. Alcohol is not a listed interaction, but heavy drinking pushes blood pressure and apnea risk the same way testosterone can and is itself a cause of low testosterone. The labels and guidelines put the weight on checking blood pressure, sleep and hematocrit. If you are still deciding whether your symptoms point to low testosterone at all, start with low testosterone symptoms and the baseline blood tests.