Despite some heterogeneity, the majority of studies that investigated androgen levels in men with coronary disease, showed that testosterone levels were significantly lower in men with coronary disease than in matched controls. Multiple logistic regression analyses have shown that these differences are not explained by simple differences in coronary risk factor profiles.2 The relationship between male gender and the prevalence of coronary heart disease suggests a role for sex hormones in the aetiology of cardiovascular disease. We discuss the ‘cause' versus ‘effect' controversy, regarding low testosterone levels in men with coronary heart disease, as well as concerns over the use of testosterone replacement therapy in middle aged and elderly men. To the contrary, recent literature has raised concern for increased cardiovascular disease in certain groups of men receiving testosterone therapy. For men who clearly have testosterone deficiency, there is no apparent increased risk of heart attack or stroke or greater chance of developing a new prostate cancer from testosterone replacement therapy. Higher pre-natal testosterone indicated by a low digit ratio as well as adult testosterone levels increased risk of fouls or aggression among male players in a soccer game. As inflammation is a known risk factor for atherosclerosis and CVD, there has been interest in exploring the effects of testosterone on inflammation. Adiponectin is an adipocytokine of which the levels are inversely related to cardiovascular risk. Increased stimulation of leptin receptors on Leydig cells can attenuate LH stimulation and thus lower testosterone production.86 The use of aromatase inhibitors or DHT has resulted in the attenuation of the hormone's beneficial effects, indicating an important role of E2. Despite decades of research on the topic, clinical and preclinical data on the effects of exogenous and endogenous testosterone have produced contradictory and/or inconclusive results. Given the prevalence and morbidity of CVD, it is important to clarify potential risk factors, especially in men, as they face higher cardiovascular risk than women. However, it is important to further understand the interplay between the 2 variables in mediating risk and affecting the success of targeted interventions in men involving testosterone therapies and/or physical activity. Preclinical studies suggest that testosterone promotes the differentiation of pluripotent stem cells to the myogenic lineage and inhibits their commitment to the adipogenic lineage.83 At a later stage, testosterone may affect the Wnt-signalling pathway and β-catenin, inhibiting further differentiation of certain preadipocytes.84 Testosterone may also decrease abdominal fat through the stimulation of lipolysis and inhibition of adipogenesis.85 Clinical data have also indicated that Leydig cell response and LH production are lower in men with insulin resistance.82 These studies indicate that a more complex bidirectional relationship between diabetes and testosterone is perhaps more likely. Testosterone has been found to have prothrombotic effects, increasing the risk of myocardial infarction and stroke following atherosclerotic plaque rupture. Dyslipidemia, including elevated low-density lipoprotein and total cholesterol levels, is a major risk factor for atherosclerosis progression. The reflexive testosterone increases in male mice is related to the male's initial level of sexual arousal. Every mammalian species examined demonstrated a marked increase in a male's testosterone level upon encountering a novel female. When testosterone-deprived rats were given medium levels of testosterone, their sexual behaviours (copulation, partner preference, etc.) resumed, but not when given low amounts of the same hormone. In women, correlations may exist between positive orgasm experience and testosterone levels. Common side effects from testosterone medication include acne, swelling, and breast enlargement in males. Decline of testosterone production with age has led to interest in androgen replacement therapy. The Rancho Bernardo study also showed an inverse relationship between circulating T levels and plasma VLDL . Most of these studies have also demonstrated an inverse relationship between T levels and both plasma triglycerides 32–34,36 and total cholesterol 32,34. A positive correlation exists between HDL-c and circulating T concentrations, as seen in multiple studies including the San Antonito Heart study , the Tromso study , the Turku Male Aging study , the Rancho Bernardo study , MRFIT and a study from Ghent, Belgium . After adjustment for over 50 variables, those individuals who had received a prescription for T following coronary angiography had a higher incidence of CVD events compared with the group who had not received a T prescription over an average of 27.5 months of follow-up. Importantly, the interpretive value of these randomized controlled trials remains limited, as these studies were not powered to look at CVD events as an outcome. Studies of men who abuse anabolic steroids have clearly demonstrated higher risk of myocardial infarction and sudden cardiac death.10, 11, 12 In men, exogenous oestrogen therapy has also been trialled for secondary prevention of coronary disease, following acute myocardial infarction.13 This trial was terminated early due to a twofold increase in re-infarction and a significant increase in mortality. The article concludes with a discussion regarding the future direction for work in this interesting area, including the relative merits of screening for, and treating hypogonadism with testosterone replacement therapy in men with heart disease. Despite regional variations in the prevalence of coronary artery disease (CAD), men are consistently more at risk of developing and dying from CAD than women, and the gender-specific effects of sex hormones are implicated in this inequality. Although cross-sectional studies have demonstrated higher prevalence of CVD among men with low endogenous androgens, limited clinical data have not shown that testosterone replacement therapy (TRT) reduces CVD risk. Although the effect on high-density lipoprotein is unclear, it is hypothesized that prolonged testosterone administration may restabilize levels following cholesterol transport normalization.70 Because of the varying effects on lipoproteins, the overall effect of testosterone on lipid profile and cardiovascular risk is unknown. Valid concerns remain regarding the possibility of testosterone therapy increasing the risk of prostate cancer. Although all acknowledge the possible cardiovascular risks of testosterone therapy, there is disagreement on the minimum amount of time following a major cardiovascular event that an individual should receive testosterone therapy.35 As a result of these conflicting results, a recent meta-analysis found no significant association between testosterone therapy and cardiovascular events and mortality, and it reported low-quality evidence due to bias, inconsistencies, and imprecision.34 This disparity in results has led to inconsistencies among clinical practice guidelines. In contrast to these studies, others have reported a protective effect of testosterone therapy on cardiovascular health.