Can testosterone or anabolic steroids enlarge the heart even when blood pressure and bloodwork look normal?

Yes, a normal blood test does not exclude an enlarged or impaired heart. Bloodwork measures circulating markers; it does not measure ventricular wall thickness, chamber size or pumping function. In the prospective HAARLEM echocardiography study, anabolic steroid exposure was accompanied by increased left-ventricular mass and impaired systolic and diastolic function. These are different questions from whether cholesterol or hematocrit happens to fall within a laboratory range. A normal office blood-pressure reading also cannot reconstruct blood-pressure exposure throughout a cycle.[1]

The HAARLEM participants who completed follow-up showed recovery after stopping, but that does not guarantee reversibility after years of use. A larger observational cohort linked AAS exposure to increased cardiovascular disease risk over longer follow-up. These findings should not be treated as an exact risk estimate for medically supervised replacement testosterone, which involves different exposure and patient selection. For someone with substantial AAS exposure, cardiac symptoms and exposure history can justify assessment beyond routine bloodwork. Improving cholesterol alone does not establish that heart structure is normal.[1][2]