Perioperative Management of Testosterone Therapy for Shoulder Arthroscopy
Continue testosterone injections through the perioperative period for right shoulder arthroscopy, as there is no evidence-based indication to discontinue hormone replacement therapy for this procedure. 1
Rationale and Evidence Analysis
The available evidence does not support routine discontinuation of testosterone therapy for shoulder arthroscopy. While recent observational studies have identified associations between testosterone use and complications after shoulder surgery, these findings must be interpreted carefully:
Key Evidence Considerations
Guideline-based approach: The most recent perioperative guideline for gender-affirming hormone therapy explicitly states that hormone therapy should be continued throughout the perioperative period unless there are specific contraindications 1. This represents current best practice for testosterone management in surgical patients.
Conflicting research evidence: Several database studies have reported associations between preoperative testosterone use and complications:
- Increased revision rates after rotator cuff repair 2 and total shoulder arthroplasty 3
- Higher periprosthetic infection risk after total shoulder arthroplasty 4, 5
- However, one systematic review found testosterone supplementation improved outcomes including functional scores, body composition, and bone mineral density 6
Critical Limitations of Observational Data
These database studies have significant methodological limitations that prevent definitive causal conclusions:
- Confounding by indication: Patients on testosterone therapy have underlying hypogonadism, which itself may independently affect surgical outcomes 7
- Heterogeneous populations: Studies mixed rotator cuff repairs with total shoulder arthroplasty—very different procedures with different risk profiles
- Lack of causality: Associations do not establish that testosterone directly causes complications
- No randomized trials: No controlled studies have evaluated testosterone discontinuation vs. continuation for shoulder surgery
Practical Management Algorithm
Preoperative Assessment
- Verify testosterone regimen: Document formulation (enanthate, cypionate, gel, patch), dose, and frequency 8, 9
- Check baseline hematocrit: If >54%, address before surgery as this represents a relative contraindication to continued therapy 9
- Assess for sleep apnea: Particularly if elevated hematocrit, as this may require optimization 9
Perioperative Continuation
- Maintain usual testosterone schedule through surgery 1
- For injectable testosterone (enanthate/cypionate): Continue regular dosing schedule; no need to adjust timing relative to surgery 10
- For transdermal formulations: Continue daily application 8
Postoperative Monitoring
- Standard wound surveillance: Monitor for infection as with any patient—testosterone status does not change basic surgical principles
- Resume normal dosing immediately postoperatively 1
- Monitor hematocrit at 3-6 months if on long-term therapy 9
Important Caveats
Absolute contraindications to continuing testosterone:
- Hematocrit >54% (stop until <54%, then may resume at reduced dose) 9
- Active prostate cancer or male breast cancer 11, 12
Relative contraindications requiring individualized assessment:
- Severe untreated sleep apnea 9
- Recent thromboembolic event (though arthroscopy is low VTE risk) 13
- Uncontrolled polycythemia 11
Clinical Pitfalls to Avoid
- Do not reflexively discontinue testosterone based on observational database studies showing associations—these do not establish causation and may reflect confounding
- Do not confuse testosterone therapy with estrogen-based HRT—the VTE risk profile differs substantially 13
- Do not assume testosterone increases infection risk in a clinically meaningful way for arthroscopy—the absolute risk differences in database studies were small and may reflect unmeasured confounding
- Do not delay surgery to discontinue testosterone—there is no evidence this improves outcomes
The evidence strongly favors continuation of testosterone therapy for shoulder arthroscopy, with standard perioperative monitoring and attention to the specific contraindications outlined above.