Whether to continue testosterone use before knee surgery is a serious consideration that requires careful medical planning. This decision primarily affects individuals undergoing Testosterone Replacement Therapy (TRT) or those using supraphysiological doses of anabolic-androgenic steroids (AAS). Hormonal compounds can significantly influence the body’s physiological response to trauma and immobilization, making their use a factor in surgical risk assessment. The final, personalized instruction must come directly from the patient’s surgical team, which includes the orthopedic surgeon and the anesthesiologist.
Standard Guidelines for Pre-Surgical Testosterone Use
The medical community holds differing perspectives on the routine cessation of testosterone before elective surgery, leading to two main approaches. One perspective suggests that testosterone therapy should be continued without interruption, arguing that abrupt cessation can trigger undesirable symptoms of hypogonadism, such as mood changes and fatigue, which could complicate post-operative recovery. This approach relies on aggressive blood thinners (thromboprophylaxis) and early mobilization to mitigate the risk of clots.
The alternative, and often more conservative, guideline recommends a temporary “washout period” for patients undergoing procedures associated with a high risk of blood clots, such as total knee arthroplasty. This temporary pause aims to reduce the hormonal influence on blood components before the procedure begins. The decision to stop or continue is highly dependent on the type of testosterone used, the patient’s individual risk factors, and the nature of the knee surgery itself.
Transdermal formulations, like gels or patches, may sometimes be permitted closer to the surgery date or continued entirely, due to their steady absorption. Conversely, injectable forms, particularly long-acting esters, are often flagged for pre-surgical cessation because they generate higher peak concentrations linked to adverse hematological changes. These guidelines are not universally standardized, making direct consultation with the managing physicians necessary to establish a safe, individualized plan.
Specific Medical Complications During Surgery
The primary medical concern justifying the temporary cessation of testosterone before knee surgery is the elevated risk of Venous Thromboembolism (VTE), which encompasses both Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE). Orthopedic procedures involving the lower extremities, like knee surgery, inherently carry a high baseline risk for VTE due to trauma, inflammation, and necessary post-operative immobilization. When testosterone is added to this environment, the risk is compounded.
Testosterone stimulates erythropoiesis, the production of red blood cells, measured by an increase in the hematocrit level. Elevated hematocrit thickens the blood, a condition known as polycythemia, which increases blood viscosity and promotes sluggish flow (stasis). This thicker blood increases the likelihood of clot formation, particularly in the deep veins of the leg during periods of reduced mobility following the operation. Studies have suggested that testosterone therapy may double the short-term risk of VTE, particularly within the first six months of initiating therapy.
Testosterone also influences the clotting cascade by increasing the activity or concentration of certain clotting factors and enhancing platelet aggregation. These hematologic changes create a hypercoagulable state that directly contributes to the formation of a thrombus. High-dose or chronic testosterone use can also lead to subclinical cardiac remodeling or hypertension, which may increase cardiovascular strain under the stress of general anesthesia. Anesthesiologists must be aware of this potential strain when administering agents that affect blood pressure and heart rate.
Timelines for Stopping and Restarting Testosterone
If the surgical team determines that a period of testosterone cessation is necessary, the required duration, or “washout period,” is dictated by the specific formulation’s pharmacokinetic profile. Short-acting injectable testosterone esters, such as cypionate or enanthate, have a half-life of approximately seven to nine days. To ensure the medication is adequately cleared from the system and blood levels normalize, a cessation period of four to six weeks is often recommended before the scheduled procedure.
For ultra-long-acting injectables, like testosterone undecanoate (Nebido), which can have a half-life of 90 days, the cessation timeline must be significantly longer, potentially three to six months. Transdermal preparations, including gels and patches, have a much shorter half-life of hours and can often be stopped just a few days before surgery, or in some cases, continued with appropriate VTE prophylaxis. During this temporary cessation, patients may experience transient symptoms like hot flashes, reduced libido, and mood fluctuations.
Restarting therapy should not occur immediately post-operatively, but rather once the patient has been cleared from the period of high VTE risk. This typically means after the period of enforced immobilization has passed, and after primary wound healing is well-established. The surgical team will usually coordinate with the prescribing physician to schedule the resumption of testosterone, ensuring the patient is fully ambulatory and has completed the prescribed post-operative blood thinning regimen.
Essential Pre-Operative Communication Points
Open and honest communication with the entire surgical team is the most important step a patient can take to ensure a safe outcome. The patient must disclose all hormone use, including both prescribed Testosterone Replacement Therapy and any supraphysiological use of anabolic steroids. This disclosure must be detailed, covering the exact name of the compound being used, the precise dosage, the frequency, and the route of administration, such as intramuscular injection or transdermal application.
The date of the last dose must be accurately reported to allow the team to calculate the appropriate washout period and time the surgery safely. The patient should also ensure the surgical team has access to recent blood work, specifically focusing on the most recent hematocrit level, which is a direct measure of red blood cell concentration and blood viscosity. Failure to provide complete and accurate information compromises the surgical team’s ability to implement the correct VTE prevention protocol, which could include mechanical compression devices or prophylactic anticoagulation medications.