Are testosterone injections safe to continue after a total hip replacement surgery?

Testosterone Injections After Hip Replacement: Proceed with Caution and Enhanced Monitoring

Testosterone injections can be continued after total hip replacement, but patients require heightened surveillance for venous thromboembolism (VTE) and infection, with consideration for temporary discontinuation in the immediate perioperative period.

Key Safety Concerns

The most recent and highest-quality evidence reveals significant risks:

Thromboembolism Risk

Testosterone replacement therapy (TRT) is associated with increased pulmonary embolism risk after total knee arthroplasty 1. While the 2025 national registry study of 640,219 patients found no statistically significant VTE increase after hip replacement specifically (PE: OR 1.35, p=0.166; DVT: OR 1.26, p=0.192), the trend toward increased risk combined with testosterone's known prothrombotic effects warrants caution 1.

Infection Risk

Multiple 2025-2026 studies demonstrate concerning infection patterns:

• 3.4% periprosthetic joint infection rate in TRT patients vs 0.3% in controls after hip replacement 2
• TRT within one year of hip surgery increases reoperation due to infection (OR 1.8) 3
• Untreated testosterone deficiency paradoxically shows lower infection risk than TRT use 4

Clinical Management Algorithm

Preoperative Assessment

1. Document TRT regimen: Injectable testosterone (enanthate, cypionate, or undecanoate) carries different pharmacokinetics than transdermal preparations 55
2. Measure baseline hematocrit: Values >54% require therapy cessation until normalization 67
3. Assess VTE risk factors: Chronic conditions, immobility history, prior thrombosis
4. Check testosterone levels: Confirm therapeutic necessity (total testosterone <300 ng/dL with symptoms) 8

Perioperative Decision Framework

For patients on injectable testosterone:

• Consider 2-4 week discontinuation before surgery based on the 8-day half-life of testosterone cypionate 5 and evidence that cessation 6-12 months preoperatively reduces complications compared to <6 months 9
• Balance against hypogonadal symptom recurrence
• Document shared decision-making discussion

For patients requiring continuation:

• Implement aggressive VTE prophylaxis per standard hip replacement protocols (LMWH or adjusted-dose warfarin for 10-14 days minimum, consider extending to 35 days) 1010
• Monitor hematocrit at 3-6 months postoperatively 67
• Heightened infection surveillance through 2 years 3

Postoperative Monitoring

First 90 days (critical window):

• Weekly assessment for DVT/PE symptoms
• Monitor surgical site for infection signs
• Check hematocrit if not done preoperatively 11

3-6 months:

• Resume standard testosterone monitoring: measure levels midway between injections, targeting 500-600 ng/dL 1212
• Hematocrit verification (stop if >54%) 67
• Assess wound healing completion

Long-term (2+ years):

• Standard testosterone therapy monitoring every 6-12 months 67
• Remain vigilant for late infections (increased risk persists through 2 years) 3

Important Caveats

Contradictory Evidence

While recent arthroplasty-specific studies show increased complications 123, a 2025 systematic review of heterogeneous studies suggested perioperative testosterone may improve functional outcomes and bone mineral density in hip fracture patients 13. However, these were primarily hip fracture fixation studies, not elective arthroplasty, representing a different patient population and surgical context.

Injectable vs Transdermal Formulations

Injectable testosterone shows higher erythrocytosis rates (43.8%) compared to transdermal preparations (15.4%) 11, and some evidence suggests greater cardiovascular risk with injections 1212. If continuing therapy perioperatively, consider switching to transdermal formulations to minimize fluctuating supraphysiologic levels 1212.

Untreated Testosterone Deficiency

Paradoxically, untreated testosterone deficiency (<300 ng/dL without TRT) also increases DVT, PE, and revision risk after hip replacement 4. This suggests the relationship is complex—neither untreated deficiency nor aggressive replacement is optimal; physiologic replacement with careful monitoring represents the middle ground.

Common Pitfalls to Avoid

1. Assuming all testosterone formulations carry equal risk: Injectable preparations have more pronounced effects on hematocrit and potentially VTE 1112
2. Neglecting extended VTE prophylaxis: Hip replacement patients have DVT risk persisting up to 2 months; standard 7-14 day prophylaxis may be insufficient in TRT patients 1010
3. Failing to document timing: Recent TRT use (<6 months preoperatively) carries higher complication rates than remote use 9
4. Overlooking infection surveillance: Increased infection risk extends through 2 years, not just the immediate postoperative period 3

The decision to continue testosterone injections after hip replacement requires explicit discussion of increased VTE and infection risks, implementation of enhanced prophylaxis and monitoring protocols, and consideration of temporary discontinuation or formulation change in the perioperative period 67123.