Deciding whether to continue or pause Testosterone Replacement Therapy (TRT) before major surgery, such as a knee replacement, requires careful medical balance. Patients must weigh the risks of maintaining elevated hormone levels during the perioperative period against the negative effects of suddenly halting treatment. This dilemma highlights the conflict between preparing the body for a safe surgical experience and preserving hormonal balance. This choice is a personalized strategy developed through consultation with the entire medical team, including the endocrinologist and the orthopedic surgeon.
How Testosterone Affects Surgical Risks
Testosterone’s primary concern during surgery is its effect on blood composition, specifically its tendency to increase hematocrit, the proportion of red blood cells in the blood volume. This rise in red blood cell count, known as erythrocytosis, effectively thickens the blood. Increased blood viscosity raises the risk of thromboembolic events, such as deep vein thrombosis (DVT) and pulmonary embolism (PE), risks already elevated following major orthopedic surgery.
The risk of developing a blood clot is particularly heightened during the first six months of initiating TRT. Injectable testosterone formulations, especially short-acting ones, are often associated with a greater incidence of erythrocytosis compared to transdermal gels or patches. Developing polycythemia (hematocrit above 52%) while on TRT is associated with a higher risk of venous thromboembolism in the first year.
Thicker blood can also alter the body’s response to general anesthesia and fluid management during the operation. The standard of care for major surgery is to mitigate all possible clotting risks, making testosterone management a key safety consideration when mobility is reduced post-surgery.
Consequences of Abruptly Discontinuing Testosterone
Stopping testosterone abruptly leads to a rapid drop in hormone levels and a return of the hypogonadal symptoms that TRT was intended to treat. This sudden decline causes significant physiological and psychological distress during the stressful period leading up to surgery. Patients may experience profound fatigue, reduced energy, and loss of muscle mass, which hinders pre-surgical conditioning and preparation.
The psychological impact is substantial, manifesting as mood swings, irritability, and depression. These emotional symptoms undermine a patient’s mental resilience and ability to cope with the procedure and recovery. Returning to a state of low testosterone can also negatively impact bone density and libido.
For individuals on TRT for an extended period, the body’s natural testosterone production is suppressed. A sudden cessation of therapy leaves the system temporarily depleted, unlike a medically supervised taper. Any decision to pause the therapy must be carefully managed to minimize these withdrawal effects.
Protocols for Hormone Management During Surgery and Recovery
The most prudent approach involves open communication among the patient, the endocrinologist, and the surgical team to create an individualized hormone management plan. This plan considers the patient’s baseline hematocrit, the type of testosterone formulation used, and individual risk factors for clotting. For many patients, a temporary pause in testosterone therapy is recommended, typically starting two to four weeks before the surgery.
The specific timing of the pause is determined by the half-life of the testosterone product. The goal is to allow hormone levels to fall safely before the operation without causing severe withdrawal symptoms. Injectable testosterone enanthate or cypionate has a half-life of approximately seven to nine days, meaning it takes several weeks for the drug to clear the system. Longer-acting formulations, like pellets, require a much longer lead time for a safe reduction in circulating testosterone.
Resuming therapy is timed to coincide with the post-operative period when the initial risk of DVT has decreased and the patient is mobilized. Testosterone’s anabolic effects promote muscle retention and protein synthesis, which are beneficial for post-surgical recovery and wound healing. The aim is to restart treatment as soon as it is medically safe, often within a few weeks post-surgery, to support muscle strength for physical therapy and accelerate the overall healing process.