Does intravenous (IV) testosterone replacement therapy increase the risk of deep vein thrombosis (DVT) in ambulatory surgery patients and how does it affect DVT prophylaxis risk assessment?

Testosterone Replacement Therapy and DVT Risk in Ambulatory Surgery Patients

Testosterone replacement therapy (TRT), regardless of route of administration including IV, does not increase the risk of DVT in post-surgical ambulatory patients and should not alter standard DVT prophylaxis risk assessment protocols.

Evidence on TRT and Thrombotic Risk

The most robust evidence comes from a 2024 systematic review and meta-analysis specifically examining TRT in hypogonadal men, which found no increased risk of venous thromboembolism based on randomized controlled trial data (OR = 1.42,95% CI: 0.22-9.03, P = 0.71) 1. This finding is supported by a large 2015 case-control study of 30,572 men that demonstrated no association between testosterone therapy and VTE risk across all routes of administration, including intramuscular (aOR, 1.15; 95% CI, 0.80-1.64) 2.

Route-Specific Considerations

While IV testosterone is not a standard formulation, the evidence for intramuscular administration—the closest parenteral comparator—shows no elevated DVT risk 2. A 2019 retrospective study of 1,180 hypogonadal men found an overall DVT rate of only 0.8%, with 70% of those cases having identifiable alternative etiologies beyond TRT 3.

Standard DVT Prophylaxis Assessment Remains Unchanged

TRT should be considered a neutral factor in DVT risk stratification for ambulatory surgery patients. The established risk assessment should focus on validated factors including 4:

• Patient-specific risks: Previous VTE history, age ≥60 years, obesity, restricted mobility, inherited thrombophilias
• Surgical factors: Major surgery (>45 minutes duration), anesthesia time >2 hours, perioperative bed rest ≥4 days, abdominal or pelvic procedures
• Comorbidities: Active malignancy, advanced-stage disease

Prophylaxis Recommendations for Ambulatory Surgery Patients

For ambulatory patients undergoing major surgery, pharmacological prophylaxis with LMWH or UFH is indicated based on standard risk factors, not TRT status 4. Extended prophylaxis up to 4 weeks post-surgery is recommended for high-risk patients (those with restricted mobility, obesity, or prior VTE history) undergoing major abdominal or pelvic surgery 4.

Important Caveats

Do not confuse TRT with other hormonal therapies that DO increase VTE risk. Estrogenic compounds (tamoxifen, raloxifene, oral contraceptives, hormone replacement therapy) and certain cancer treatments are clearly associated with increased thrombotic risk 4. The isolated case reports of thrombosis with supraphysiologic anabolic steroid abuse 5, 6 do not reflect therapeutic TRT dosing.

Polycythemia is not a relevant concern in the acute perioperative setting, as none of the DVT cases in the largest cohort study were polycythemic at diagnosis 3.

Clinical Algorithm

1. Assess standard VTE risk factors using validated tools (e.g., Caprini score) without adding points for TRT 4
2. Implement prophylaxis based on surgery type and patient risk profile, not TRT status 4
3. For major surgery: Begin LMWH or UFH preoperatively and continue 7-10 days minimum 4
4. For high-risk patients: Extend prophylaxis to 4 weeks post-operatively 4
5. If DVT occurs: Investigate standard risk factors (immobilization, surgery, malignancy, inherited thrombophilias) rather than attributing to TRT 3, 2