Does Testosterone Replacement Therapy Help with Fracture Recovery?
No, testosterone replacement therapy (TRT) should not be used as a primary treatment for fracture recovery, even in hypogonadal men, as the most recent high-quality evidence shows TRT actually increases fracture risk rather than reducing it. 1
Critical Evidence Against TRT for Fracture Recovery
The 2024 TRAVERSE trial—the largest and most rigorous study to date—definitively demonstrated that testosterone treatment in hypogonadal men resulted in a 43% higher fracture incidence compared to placebo (hazard ratio 1.43; 95% CI 1.04-1.97), with fractures occurring in 3.50% of testosterone-treated men versus 2.46% of placebo-treated men over a median 3.19-year follow-up. 1 This trial included 5,204 middle-aged and older men with confirmed hypogonadism and represents the highest quality evidence available on this question.
Recommended Treatment Algorithm for Fracture Recovery in Hypogonadal Men
First-Line Therapy
- Initiate oral bisphosphonates (alendronate or risedronate) as the primary anti-osteoporotic medication for men with fractures and testosterone deficiency. 2, 3
- Ensure adequate calcium intake (1,000-1,200 mg daily) and vitamin D supplementation (800-1,000 IU daily). 2, 3
Second-Line Therapy
- Use intravenous bisphosphonates or denosumab if oral bisphosphonates are not tolerated or contraindicated. 2
Role of TRT (If Any)
- TRT is not routinely indicated for orthopaedic surgery patients or fracture recovery. 4
- If TRT is considered for other symptomatic hypogonadism indications (libido, energy, mood), it should only be initiated concurrently with established anti-osteoporosis medications, never as monotherapy for bone health. 2, 5
- The decision must weigh the proven fracture risk increase against potential benefits for non-skeletal symptoms. 1
Why TRT Fails for Fracture Recovery Despite BMD Improvements
The BMD Paradox
While TRT does improve bone mineral density—with the T-trial showing a 7% increase in lumbar spine trabecular volumetric BMD after one year 6, 2 and 3% increases in cortical volumetric BMD after two years 6—these BMD improvements do not translate into fracture risk reduction. 1
Limited Evidence Base
- The American College of Physicians found that fractures occurred too rarely in testosterone trials to draw conclusions about treatment effects. 6
- There is consistently no controlled data on fracture incidence in response to testosterone therapy. 6
- A 2023 meta-analysis showed BMD benefits but could not demonstrate anti-fracture efficacy. 7
Diagnostic Requirements Before Any Treatment
Measure serum free or total testosterone levels as part of the osteoporosis work-up in men with fractures. 6, 2, 3 This identifies hypogonadism but does not automatically indicate TRT for fracture management.
Monitoring Protocol If TRT Is Used
- Measure bone turnover markers at baseline and 3 months to assess treatment response (looking for >38% reduction in P1NP or >56% reduction in CTX). 6, 2, 3
- Repeat BMD measurement after approximately 2 years. 2, 5, 3
- Monitor testosterone levels to ensure therapeutic range. 2, 3
Common Pitfalls to Avoid
Do not prescribe TRT based solely on BMD improvements seen in earlier studies, as the TRAVERSE trial's fracture data supersedes these surrogate endpoints. 1 The numerical increase in fractures across all fracture endpoints in testosterone-treated men represents a critical safety signal that cannot be ignored. 1
Do not delay bisphosphonate therapy while attempting TRT alone, as testosterone is insufficient to adequately reduce fracture risk in men with osteoporosis and hypogonadism. 2