Could testosterone therapy in hypogonadal men ameliorate anemia, a cardiovascular risk factor?

July 2017

Could Testosterone Therapy in Hypogonadal Men Ameliorate Anemia, a Cardiovascular Risk Factor? An Observational, 54-Week Cumulative Registry Study. Zhang LT, Shin YS, Kim JY, Park JK. J Urol. 2016;195(4 Pt 1):1057-1064.

Anemia is a common concern among the elderly; after the age of 50 years, anemia prevalence increases rapidly, especially in men.1-4 In community studies, the prevalence of anemia in older men has been reported to range from 11%1 to 28%.3,5 The decline of hemoglobin and development of anemia with age is not part of "normal aging"; it is a sign of health deterioration and disease.3,6

Several studies have suggested that anemia is an independent risk factor for mortality.3,5,7,8 Men with anemia may be at higher mortality risk than women; in a large-scale investigation of 6880 elderly patients seen in primary care clinics, and even mild anemia without severe comorbidities was associated with nearly double the risk for all-cause mortality in men, but not in women.4 Anemia also has been shown to pose a greater risk in men with myocardial infarction than in women.9 Therefore, laboratory investigation of anemia in men older than 50 years is warranted. It is alarming that anemia is rarely acknowledged and investigated among patients.10

Here we summarize the results of a registry study, published in the Journal of Urology, which investigated if testosterone undecanoate treatment of hypogonadal men reduces the prevalence of anemia.11


  • Anemia is a common concern among the elderly; after the age of 50 years, anemia prevalence increases rapidly, especially in men, in parallel with reductions in testosterone levels.
  • Testosterone treatment reduces prevalence of anemia in hypogonadal men, regardless whether the anemia is caused by established causes (such as iron and/or vitamin B12 deficiencies, chronic inflammation) or unexplained.
  • The initial increases in hematocrit, whole blood viscosity and white blood cell count tend to stabilize with continuing testosterone treatment. In this study, stabilization occurred after 18 weeks.

What is known

The WHO (World Health Organization) defines anemia as hemoglobin levels less than 13 g/dL in men and less than 12 g/dL in women.12 The reference range for hemoglobin levels in men is 14-17.5 g/dL (reference ranges may vary depending on laboratory, instruments, and methods).13

Anemia has numerous health consequences – summarized in table 1 - which historically have not been acknowledged among health care professionals. In the ARIC (Atherosclerosis Risk in Communities) study, which included 14,410 subjects (6,267 men and 8,143 women), nearly 10% were found to have low hemoglobin.14 During a follow-up of 6.1 years, 3.8% of the subjects had cardiovascular disease events and it was concluded that anemia is an independent risk factor for cardiovascular disease outcomes.14

In the CADILLAC study (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications), 12.8% of 2082 patients of any age with acute myocardial infarction had anemia, which was strongly associated with adverse outcomes and increased mortality.15

In a study of 1410 consecutive patients with acute coronary syndromes (ACS), anemia was detected in 27% of the CAS patients.16 Anemia was found to be an independent predictive factor of mortality and had incremental predictive value to the GRACE risk score for early clinical outcomes (the GRACE score stratifies risk in patients with diagnosed ACS to estimate their in-hospital and 6-month to 3-year mortality17).16

An analysis of 422,855 patients with ACS showed that 28% of patients presenting with ACS are anemic and that these patients are older, have a greater prevalence of renal disease, peripheral vascular disease, diabetes mellitus, and previous acute myocardial infarction, and are less likely to receive evidence-based therapies shown to improve clinical outcomes.18 It was also found that anemia is independently associated with 30-day and 1-year mortality.18 It was concluded that the prevalence of anemia in a national UK ACS cohort is clinically significant. Patients with anemia are older and multi-morbid and less likely to receive evidence-based therapies shown to improve clinical outcomes, with the presence of anemia independently associated with mortality outcomes.18

Table 1. Summary of adverse outcomes observed in elderly with anemia.6

Worse quality of life

  • Fatigue, weakness, and dyspnea
  • Increased frailty
  • Higher rates of disabilities
  • Lower muscular strength and physical performance
  • Lower cognitive function, dementia, and depression

Increased healthcare utilization

  • Higher hospitalization rates
  • Longer lengths of stay
  • Higher readmission rates

Increased fracture risk independent of bone mineral density19

Increased morbidity

  • Increased odds of developing cardiovascular disease
  • Worse outcomes in cardiovascular conditions such as myocardial infarction and heart failure
  • Worse outcomes in other diseases such as cancer and renal failure

Increased morbidity

  • Double the mortality risk even with mild anemia (hemoglobin >10 g/dL)
  • High mortality rates in nursing home residents

Table adapted from Halawi R, Moukhadder H, Taher A. Anemia in the elderly: a consequence of aging? Expert review of hematology. 2017;10(4):327−335

Often, there is an underlying etiology for the anemia.6 Several causes of anemia in the elderly are recognized, including iron and vitamin B12 deficiencies, chronic inflammation and disease, chronic renal insufficiency, and the myelodysplastic syndromes.6 However, in approximately one-third of older adults with anemia no recognized cause can be found.1,20-22 No treatment has been shown to ameliorate this unexplained anemia.

One possible cause of unexplained anemia in older men is testosterone deficiency, because testosterone levels decline as men age23,24, in parallel with declining hemoglobin levels1-4, and testosterone treatment of men with low testosterone increases hemoglobin levels.25,26 Further support for this comes from population studies showing that low testosterone levels are significantly associated with unexplained anemia.27,28

What this study adds

The registry study reported here investigated if testosterone undecanoate attenuates anemia and the risk of cardiovascular disease in patients with hypogonadism.11 58 hypogonadal patients, age 18 to 80 years (mean age 57), BMI 18 to 40 kg/m2 (mean 25) and total testosterone levels of less than 8.1 nmol/L (235 ng/dL) and at least mild symptoms of testosterone deficiency were included in the analysis.

All patients received an injection of 1,000 mg testosterone undecanoate at the initial visit, followed by injections at 6, 18, 30, 42 and 54 weeks. Serum hormones, hemoglobin, hematocrit, anemia prevalence, lipid profiles, whole blood viscosity and anthropometry were measured.

After 1 year of treatment with testosterone undecanoate, total testosterone increased from 6.5 to 19.1 (190 to 550 ng/dL) and free testosterone from 3.0 to 7.2 pg/mL. Hemoglobin and hematocrit significantly increased after testosterone undecanoate therapy by an average of 2.5 g/dL and 3%, respectively. There was also an increase in white blood cell count. The prevalence of anemia was reduced from 30% to 10% and patients with anemia had an increase in erythropoietin after testosterone undecanoate therapy. Total cholesterol was reduced from 166 to 154 mg/dL. All changes were significant. The increases in hematocrit, whole blood viscosity and white blood cell count stabilized after 18 weeks.

It was concluded that 1 year treatment with testosterone undecanoate significantly decreases the prevalence of anemia and components of the metabolic syndrome.


This registry study did not report on possible causes of anemia, likely because anemia is rarely acknowledged and investigated among patients in clinical practice (and this was a registry of patients in clinical practice).10 Despite varying underlying causes of anemia, and possibly also existing unexplained anemia, it was demonstrated that testosterone undecanoate treatment significantly reduces prevalence of anemia by two thirds (from 30% to 10%).

The results from this registry study are supported by The Anemia Trial of the Testosterone Trials, which found that testosterone treatment reduces prevalence of anemia in hypogonadal men, regardless of underlying cause of anemia, known or unexplained.29 This is notable considering that there is no established treatment of unexplained anemia.

The improvement in hemoglobin levels by testosterone treatment in men who have unexplained anemia supports the suggestion that testosterone deficiency may contribute to the development of anemia, even in the absence of other causes.25-28 The improvement in hemoglobin levels by testosterone treatment in men who have anemia of known cause suggests that this anemia is due to both the known cause (such as iron and/or vitamin B12 deficiencies, chronic inflammation) as well as to low testosterone levels.29 Therefore, evaluation of unexplained anemia in older men with symptoms consistent with hypogonadism should include measurement of testosterone levels.

In line with the adverse outcomes observed in elderly men with anemia (table 1)6, increases in hemoglobin levels with testosterone treatment were associated with improvement in walking and vitality, as well as with men’s impression of change in overall health and energy.29 This suggests that the increase in hemoglobin levels and amelioration of anemia with testosterone treatment is clinically meaningful.


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