The Veterans Health Administration (VHA) is the largest single prescriber of testosterone therapy in the United States, and the veteran population faces unusually high rates of low testosterone due to factors like traumatic brain injury, chronic opioid use, and obesity. Whether you’re a veteran exploring treatment options or trying to understand what the VA offers, the landscape is more complex than a simple hormone prescription. The VA has specific diagnostic protocols, formulary preferences, and monitoring requirements that shape how testosterone therapy actually works within the system.
How Common Is Low Testosterone Among Veterans
Low testosterone is strikingly prevalent in the veteran population. A study of older male veterans found that about a third had total testosterone levels below 300 ng/dL, the conventional clinical cutoff. When researchers looked at biologically active testosterone, which accounts for proteins that bind testosterone and make it unavailable to tissues, the picture was far worse: roughly seven in ten participants fell below the clinical threshold.1PubMed Central. High Prevalence of Low Serum Biologically Active Testosterone in Older Male Veterans That gap between total and biologically active testosterone matters because standard blood tests often measure only total testosterone, potentially missing a large number of veterans who are functionally deficient.
Trend data from the VA system tells a similar story. Between the mid-2000s and early 2010s, the percentage of tested veterans with low testosterone levels climbed from 35% to over 47%.2PubMed Central. Recent trends in testosterone testing, low testosterone levels, and testosterone treatment among Veterans Some of that increase reflects more testing rather than an actual biological shift, but the raw numbers are still striking. A separate study of over 850 male veterans aged 40 and older found that about one in five had confirmed low levels on repeated testing, while another 28% fell into an equivocal range.3JAMA Internal Medicine. Low Serum Testosterone and Mortality in Male Veterans
Why Veterans Are at Higher Risk
Several factors common in the veteran population drive testosterone levels down. Traumatic brain injury is one of the most military-specific. The pituitary gland, which signals the testes to produce testosterone, sits at the base of the brain and is vulnerable to blast injuries, concussions, and blunt head trauma. Research on active-duty servicemembers with a history of TBI found their average testosterone levels were meaningfully lower than those of servicemembers without head injuries.4Journal of Military and Veterans’ Health. Testosterone and Vitamin D Status in Active Duty and Veteran Service Members with Traumatic Brain Injury This is not a temporary dip after injury; pituitary damage from TBI can cause a lasting reduction in hormone output.
Chronic opioid use is another major contributor. Veterans are prescribed opioids for pain at high rates, and opioids suppress the hormonal signals that drive testosterone production. The link is strong enough that researchers have given it a name: opioid-induced androgen deficiency.5PubMed Central. Opioid-Induced Androgen Deficiency in Veterans With Chronic Nonmalignant Pain A cross-sectional study of the VA system found that veterans taking high-dose opioids (the equivalent of more than 100 mg of oral morphine per day) were nearly six times more likely to be prescribed testosterone than veterans not on opioids.6SpringerLink / Journal of General Internal Medicine. Who Gets Testosterone? Patient Characteristics Associated with Testosterone Prescribing in the Veteran Affairs System: a Cross-Sectional Study Obesity plays a compounding role as well. Fat tissue converts testosterone into estrogen, and veterans with a BMI above 40 were about three times more likely to receive a testosterone prescription than those at a healthy weight.7SpringerLink / Journal of General Internal Medicine. Who Gets Testosterone? Patient Characteristics Associated with Testosterone Prescribing in the Veteran Affairs System: a Cross-Sectional Study
What makes this picture complicated is that only a small fraction of veterans getting testosterone through the VA have a classically diagnosed hormonal disorder. One large cross-sectional analysis found that just 6.3% of men receiving testosterone had a documented diagnosis involving the testes, pituitary, or hypothalamus.8SpringerLink / Journal of General Internal Medicine. Who Gets Testosterone? Patient Characteristics Associated with Testosterone Prescribing in the Veteran Affairs System: a Cross-Sectional Study The rest were being treated for low testosterone driven by opioids, obesity, aging, or combinations of all three. That does not mean the prescribing was inappropriate, but it does highlight that testosterone therapy in the VA often addresses secondary causes rather than primary glandular failure.
How the VA Diagnoses and Prescribes
Getting a testosterone prescription through the VA is not as simple as reporting fatigue and getting a blood draw. Clinical guidelines require at least two morning blood tests showing low testosterone levels, along with measurement of gonadotropins (the pituitary hormones that stimulate testosterone production), documentation of symptoms, and a conversation about risks and benefits. In practice, adherence to these steps has been inconsistent. Before the VA introduced standardized order templates at some facilities, only about 23% of veterans starting testosterone had the full recommended workup, including two confirmed low levels and gonadotropin testing.9PubMed Central. Preliminary Evaluation of an Order Template to Improve Diagnosis and Testosterone Therapy of Hypogonadism in Veterans
The VA has worked to close this gap. Facilities that adopted electronic order templates saw documentation of symptoms jump from 71% to 93%, and the rate of proper lab evaluation improved from 55% to 78%.10PubMed Central. Streamlined Testosterone Order Template to Improve the Diagnosis and Evaluation of Hypogonadism in Veterans Risk-and-benefit discussions were documented for 58% of veterans in the post-template period, up from 34% before. Those numbers still leave room for improvement, but the trend matters because a proper workup protects veterans from being started on lifelong therapy without adequate evidence that they need it.
One quirk of VA prescribing is the formulary. The VA pharmacy system has historically favored injectable testosterone (typically testosterone cypionate) over gels and patches, partly because injectables are far cheaper. This is different from the civilian healthcare landscape, where topical formulations are more commonly prescribed. The cost advantage is significant for a system serving millions of veterans, but it means veterans often need to either self-inject at home or come in for regular injections rather than simply applying a gel each morning. Despite large increases in testosterone testing during the late 2000s and early 2010s, the proportion of veterans with confirmed low testosterone who actually received treatment slightly decreased, dropping from 31% to 28%, a trend researchers attributed in part to VA formulary restrictions on transdermal options and the high burden of comorbidities among tested veterans.11PubMed Central. Recent trends in testosterone testing, low testosterone levels, and testosterone treatment among Veterans
Cardiovascular Safety and the VA Evidence
The cardiovascular safety of testosterone therapy has been one of the most debated questions in men’s health over the past decade, and much of the key evidence comes from VA populations. Early observational studies using VA data raised alarms about heart attacks and strokes, drawing FDA scrutiny and prompting new label warnings. But the picture has shifted considerably as more evidence has accumulated.
A comprehensive analysis found that testosterone therapy was not associated with the combined risk of heart attack, stroke, and sudden cardiac arrest, with an overall hazard ratio of 0.99, essentially no difference from untreated men. Looking at individual outcomes, testosterone users actually had a lower rate of stroke. However, venous thromboembolism, or blood clots in veins, was roughly 26% higher in testosterone users.12Oxford Academic. Effect of exogenous testosterone on cardiovascular, cerebrovascular, and thromboembolic adverse events: results of three complementary research designs A separate review of the available data reached a similar broad conclusion: the evidence does not support an increased cardiovascular risk from testosterone therapy.13PubMed Central. Testosterone treatment and cardiovascular and venous thromboembolism risk: what is ‘new’?
For veterans on chronic opioids, the cardiovascular picture is more encouraging. A study of long-term opioid users in the VA found that those who received testosterone had roughly half the rate of death from any cause and about 40% fewer major cardiovascular events compared to opioid users who did not receive testosterone.14JAMA Network Open. Health Outcomes Among Long-term Opioid Users With Testosterone Prescription in the Veterans Health Administration The same study found lower rates of hip fractures and anemia among the testosterone-treated group. These are observational findings, meaning the veterans who got testosterone may have been healthier in ways the study could not fully account for. But the magnitude of the differences is hard to dismiss entirely.
Bone Density, Fractures, and a Surprising Contradiction
One of the most intuitive expectations about testosterone therapy is that it should strengthen bones. Testosterone stimulates bone-forming cells, and low levels are associated with osteoporosis and fractures. A controlled trial in older men with low testosterone found that one year of treatment increased spine bone density by about 7.5% more than placebo and boosted estimated bone strength by roughly 10.8%, with similar improvements at the hip.15PubMed Central. Effect of Testosterone Treatment on Volumetric Bone Density and Strength in Older Men With Low Testosterone: A Controlled Clinical Trial
But bone density and actual fracture prevention are not the same thing, and this is where the evidence gets uncomfortable. A large randomized trial published in the New England Journal of Medicine followed men with hypogonadism for a median of about three years and found that testosterone-treated men had a higher rate of clinical fractures than men on placebo: 3.5% versus 2.5%, a statistically significant difference.16PubMed. Testosterone Treatment and Fractures in Men with Hypogonadism The finding was surprising and runs counter to the bone-density improvements seen in shorter trials. Researchers have proposed several explanations, including the possibility that testosterone increases physical activity and risk-taking, leading to more falls and injuries. The earlier, smaller trial had seen equal fracture numbers in both groups during the treatment year, so the larger trial’s finding was not necessarily foreshadowed.17PubMed Central. Effect of Testosterone Treatment on Volumetric Bone Density and Strength in Older Men With Low Testosterone: A Controlled Clinical Trial
For veterans, who may already face elevated fracture risk from mobility limitations, prior injuries, or medication side effects, this contradiction is practically important. Testosterone makes bones measurably denser and stronger by lab measures, yet the largest fracture trial showed it did not translate into fewer broken bones. This does not mean testosterone is bad for the skeleton, but it does mean fracture prevention alone is not a strong justification for starting therapy.
Prostate Cancer and Red Blood Cell Monitoring
Fear of prostate cancer has historically been one of the biggest reasons both doctors and patients hesitate about testosterone therapy. The concern made biological sense: prostate cancer cells feed on testosterone, so adding more seemed risky. But large-scale VA data has been reassuring. A study of veterans with low testosterone found that testosterone treatment was not associated with an increased risk of aggressive prostate cancer or prostate cancer overall.18PLOS ONE. Testosterone treatment and the risk of aggressive prostate cancer in men with low testosterone levels That said, the VA still screens for prostate cancer before and during therapy with regular PSA blood tests. A review of VA prescribing found that 1.4% of veterans who received testosterone already had prostate cancer at baseline, suggesting that screening protocols occasionally miss cases or that prescribing decisions sometimes outpace guideline recommendations.19Medical Care. Ascertainment of Testosterone Prescribing Practices in the VA
A more immediate monitoring concern is erythrocytosis, an excessive increase in red blood cells. Testosterone stimulates the bone marrow to produce more red cells, and when the blood becomes too thick it raises the risk of clots. The VA checks hematocrit (the percentage of blood volume occupied by red cells) before starting therapy and periodically afterward. About 3.5% of veterans prescribed testosterone already had elevated hematocrit at baseline.20Medical Care. Ascertainment of Testosterone Prescribing Practices in the VA The risk is compounded by certain medications. Veterans with type 2 diabetes who were taking both testosterone and an SGLT-2 inhibitor (a class of diabetes drug) had nearly four times the odds of developing erythrocytosis compared to those on the diabetes drug alone.21PubMed. Increased risk of erythrocytosis in men with type 2 diabetes treated with combined sodium-glucose cotransporter-2 inhibitor and testosterone replacement therapy If you’re on both medications, your VA provider should be checking your blood counts more frequently.
Sleep apnea is another condition the VA watches for. About 7.6% of veterans starting testosterone already had obstructive sleep apnea at baseline.22Medical Care. Ascertainment of Testosterone Prescribing Practices in the VA Testosterone can worsen sleep apnea, so veterans with untreated or poorly controlled apnea may need to address that before starting or continuing testosterone therapy.
What Opioid-Using Veterans Should Know
Veterans on chronic opioids occupy a unique space in the testosterone therapy conversation. Their low testosterone is largely drug-induced, which means it is potentially reversible if opioids are tapered or discontinued. But for many veterans managing chronic pain, opioid tapering is not realistic or safe, and in those cases testosterone replacement directly addresses the downstream hormonal deficit.
The outcomes data for this group is among the most encouraging in all of VA testosterone research. Among long-term opioid users, testosterone prescriptions were associated with roughly half the rate of death and significantly fewer hip fractures and cases of anemia over a follow-up of up to six years.23JAMA Network Open. Health Outcomes Among Long-term Opioid Users With Testosterone Prescription in the Veterans Health Administration These are large effect sizes for an observational study, and while confounding cannot be ruled out, the consistency of benefits across multiple outcomes is suggestive. If you’re a veteran on long-term opioid therapy and experiencing fatigue, low mood, decreased muscle mass, or sexual dysfunction, asking your VA provider to check testosterone levels is a reasonable step.
Gender-Affirming Testosterone Through the VA
The VA also prescribes testosterone as part of gender-affirming care for transmasculine veterans. The VHA has provided gender-affirming hormone therapy for over two decades, and research has examined patterns across more than 23 years of records. Younger veterans and those with higher disability ratings are more likely to fill gender-affirming prescriptions through the VA, with geographic variation as well: veterans in the western United States fill prescriptions at higher rates than those in the South.24PubMed Central. Treating Transgender and Gender-Diverse Veterans in the Veterans Health Administration: 23 Years of Findings
Metabolic monitoring is particularly relevant for transmasculine veterans on testosterone. A study of transgender veterans found that testosterone therapy was associated with the greatest increase in metabolic syndrome markers compared to other groups, including cisgender men on testosterone.25JAMA Network Open. Gender-Affirming Hormone Treatment and Metabolic Syndrome Among Transgender Veterans Metabolic syndrome involves a cluster of conditions, including elevated blood sugar, high blood pressure, excess abdominal fat, and abnormal cholesterol, that together raise the risk of heart disease and diabetes. The finding does not mean transmasculine veterans should avoid testosterone, but it underscores the need for regular metabolic screening including blood pressure, fasting glucose, and lipid panels. The VA generally includes this monitoring in follow-up care, though access and consistency vary by facility.
Navigating the VA System as a Veteran Seeking Treatment
If you suspect you have low testosterone and want to pursue testing through the VA, the process typically starts with your primary care provider. You’ll need to describe your symptoms, which often include persistent fatigue, decreased libido, erectile dysfunction, loss of muscle mass, depressed mood, and difficulty concentrating. Your provider will order a morning blood draw, since testosterone levels peak early in the day and afternoon samples can give misleadingly low readings. If the first result comes back low, a second confirmatory test is required before treatment can be considered.
Beyond the blood tests, your provider should check gonadotropins to determine whether the problem originates in the testes or in the brain’s signaling system. A complete blood count to assess hematocrit, a PSA test for prostate cancer screening, and evaluation for sleep apnea and other contraindications are also part of the standard workup. The VA’s introduction of electronic order templates has been specifically aimed at ensuring these steps are not skipped, and the templates have measurably improved adherence to guidelines at facilities that use them.26PubMed Central. Streamlined Testosterone Order Template to Improve the Diagnosis and Evaluation of Hypogonadism in Veterans
If you’re approved for treatment, the VA will most commonly prescribe injectable testosterone cypionate, typically administered every one to two weeks. Some veterans self-inject at home after training, while others come to a VA clinic. Topical gels and patches are available but may require additional authorization. Once on therapy, you’ll need follow-up blood work, usually at three to six months and then annually, to check testosterone levels, hematocrit, and PSA. If your hematocrit climbs too high, your provider may lower the dose, switch formulations, or recommend therapeutic blood donation.
Veterans who also carry a service-connected disability rating for conditions that contribute to low testosterone, such as TBI or chronic pain treated with opioids, may find the path smoother in terms of both clinical justification and any associated disability claims. While testosterone therapy itself is not a ratable disability condition, the underlying causes often are, and documenting the link between a service-connected condition and the resulting hormonal deficiency can be important for benefits purposes.
When Testosterone Therapy Might Not Be the Answer
Not every veteran with low testosterone needs replacement therapy. If the root cause is treatable, addressing it directly can sometimes restore testosterone levels without lifelong hormone replacement. Opioid tapering, weight loss, better sleep, and treating underlying pituitary conditions can all improve testosterone production. For veterans with obesity-driven low testosterone, even modest weight loss of 10-15% can produce clinically meaningful increases in testosterone levels.
There are also situations where testosterone therapy is actively risky. Men with untreated severe sleep apnea, very high hematocrit levels, uncontrolled heart failure, or a recent history of blood clots may need to delay or avoid treatment. The VA guidelines reflect these contraindications, though as prescribing practice data suggests, not every veteran receives a complete screening before starting therapy. If you feel like your workup has been rushed, asking your provider to walk through the checklist is your right and in your interest. Testosterone therapy is generally safe when properly monitored, but it is a commitment that suppresses your body’s own production and creates dependence on continued treatment. Understanding that tradeoff before starting is worth the extra appointment.