Testosterone replacement is possible for many men with cirrhosis, and recent evidence suggests it may actually improve outcomes rather than worsen liver disease. Roughly half of men with cirrhosis have low testosterone levels, a consequence of the liver damage itself. The question isn’t simply whether you can take it, but how it’s given, what form is used, and how closely you’re monitored.
Why Cirrhosis Lowers Testosterone
The liver plays a central role in hormone regulation. Cirrhosis disrupts testosterone production at multiple levels. The damaged liver overproduces a protein that binds to testosterone in the blood, effectively pulling it out of circulation and leaving less available for your body to use. At the same time, the signaling loop between your brain and testes becomes impaired, reducing testosterone production at the source. Alcohol-related liver disease can directly damage testicular tissue as well, compounding the problem.
The result is a cluster of symptoms that overlap with and worsen the effects of cirrhosis itself: muscle wasting, fatigue, anemia, low bone density, poor quality of life, and reduced sexual function. Because these symptoms mimic general liver disease progression, low testosterone in cirrhosis often goes undiagnosed and untreated.
What the Evidence Shows About Safety
A large target trial emulation published in 2025 followed 282 men with both cirrhosis and confirmed low testosterone who received replacement therapy, compared against a matched group who did not. Testosterone use was associated with an 8% lower risk of death and an 8% lower risk of new decompensation events. The benefits were especially strong for two feared complications of advanced liver disease: the risk of ascites requiring drainage dropped by 18%, and the risk of variceal bleeding dropped by 33%.
One persistent concern has been liver cancer. An older study found that men with naturally elevated testosterone levels had roughly four times the risk of hepatocellular carcinoma compared to men with lower levels. However, the 2025 trial found no statistically significant increase in liver cancer among men receiving testosterone replacement (the slight numerical increase fell well within the range of chance). A separate systematic review of testosterone therapy in men with fatty liver disease also reported zero cases of liver cancer or liver tumors in either treatment or placebo groups.
A randomized controlled trial specifically in men with cirrhosis and low testosterone found that therapy safely increased appendicular lean mass by 1.7 kg, total lean mass by nearly 5 kg, and reduced fat mass by over 4 kg. Bone mass and bone mineral density at the hip also improved significantly. Hemoglobin levels rose, addressing the anemia common in this population, and blood sugar control improved. No serious liver-related adverse events were reported.
Why the Form of Testosterone Matters
Not all testosterone formulations are equal when your liver is compromised. Oral testosterone and older oral anabolic steroids pass through the liver before reaching the rest of the body. This “first-pass” metabolism forces an already damaged liver to do extra processing work, and historically these oral forms have been linked to liver injury, cholestasis (bile flow obstruction), and rare liver tumors.
Topical testosterone gel bypasses the liver entirely. It absorbs through the skin directly into the bloodstream, avoiding first-pass metabolism altogether. Research in men with cirrhosis has found gel applications to be safe and well tolerated. Injectable testosterone similarly avoids the liver on its initial pass into circulation. For anyone with cirrhosis, these non-oral routes are strongly preferred.
Who May Not Be a Good Candidate
Cirrhosis alone does not rule out testosterone therapy, but certain conditions do. A hematocrit level above 54% (meaning your blood is already too thick with red blood cells) is a standard contraindication, because testosterone stimulates red blood cell production and could push you into dangerous territory for blood clots. Uncontrolled prostate concerns also need to be addressed first.
The severity of liver disease matters as well. The 2025 study noted substantial differences in treatment effect across patient subgroups, meaning the benefits were not uniform. Men with more advanced or decompensated cirrhosis (those already experiencing repeated episodes of fluid buildup, confusion from hepatic encephalopathy, or severe portal hypertension) present a more complex picture. Testosterone did not significantly reduce hospitalization for hepatic encephalopathy or fracture risk in the large cohort study, suggesting its benefits have limits in the most advanced stages.
What Treatment Looks Like in Practice
If you have cirrhosis and symptoms of low testosterone, the process typically starts with blood tests confirming low levels on at least two separate mornings (testosterone naturally peaks in the morning and declines throughout the day). Your doctor will also check your blood count, liver function markers, and screen for prostate issues.
Treatment usually means applying a testosterone gel daily or receiving injections every one to two weeks. Monitoring is more frequent than it would be for someone without liver disease. You can expect blood draws every few months initially to track your hematocrit, liver enzymes, and hormone levels. The goal is to restore testosterone to a normal range, not to push it above normal.
The muscle mass and body composition improvements seen in clinical trials took about 12 months to fully develop, so this is not a quick fix. Energy and mood improvements tend to come earlier, often within the first few weeks to months. Because cirrhosis itself is a progressive condition, testosterone replacement works best as part of a broader management plan that includes nutrition, physical activity when possible, and ongoing liver care.
The Bottom Line on Risk vs. Benefit
For years, doctors were cautious about prescribing testosterone to men with liver disease, largely because of concerns rooted in the era of oral anabolic steroids. The newer evidence paints a different picture. Non-oral testosterone replacement in men with confirmed low levels and cirrhosis appears to reduce mortality, lower the risk of major complications like ascites and variceal bleeding, and meaningfully improve muscle mass, bone density, and anemia. The liver cancer signal from older observational data has not held up in treatment trials. The key factors are using the right formulation, confirming the deficiency with proper testing, and maintaining close monitoring throughout treatment.