In men with hypogonadism due to diseases of the hypothalamus, pituitary, or testis, testosterone therapy is generally safe and has been shown to induce beneficial effects. Conversely, in men with age-related low testosterone levels, the significance of this change and the effects of testosterone therapy are debatable. Studies have linked low testosterone levels with increased cardiovascular morbidity and mortality, with testosterone therapy being reported to improve cardiovascular risk profiles. However, two recent retrospective studies have fueled the controversy on testosterone therapy by reporting increased cardiovascular events. Because placebo-controlled, randomized clinical trials on testosterone therapy in older men with age-related decline in testosterone levels are lacking, long-term cardiovascular health following testosterone therapy in this patient population remains unclear. Therefore, a careful approach should be adopted when considering therapy of hypogonadism and coexisting cardiovascular disease in older men. Adequately powered, long-term prospective randomized trials on testosterone in older men are urgently needed.