Does testosterone replacement therapy increase fracture risk for men with Hypogonadism?
Hypogonadism means the body does not make enough testosterone. Men with low testosterone tend to lose bone density, and low bone density is a known risk factor for broken bones. So a fair question is whether treating hypogonadism with testosterone replacement therapy (TRT) helps bone strength or, unexpectedly, raises fracture risk. The short answer from the newest evidence is mixed: one meta-analysis found a higher rate of clinical fractures with TRT than with placebo, but that result comes from just two trials and did not hold up when researchers looked only at the major osteoporotic fractures (hip, spine, wrist, arm) 5. Older reviews say there was simply not enough data on fractures to answer the question 911.
What the research says
The most direct evidence is a 2025 meta-analysis of randomized controlled trials in hypogonadal men. Pooling two trials with 2,711 men, it found TRT was associated with a higher risk of clinical fractures than placebo (relative risk 1.55, 95% CI 1.21 to 1.97) 5. That sounds alarming, but the same analysis found no difference between groups for major osteoporotic fractures (relative risk 0.62, 95% CI 0.12 to 3.35), and no difference for vertebral or hip fractures specifically 5. In plain terms, the signal is driven by a broad category of "clinical fractures" rather than by the breaks doctors worry about most, and the confidence intervals are wide.
What to ask your doctor
- Given my hypogonadism, what is my baseline bone density, and should I have a bone scan before or during TRT?
- How do you interpret the 2025 meta-analysis showing more clinical fractures with TRT but no difference in major osteoporotic fractures?
- What other fracture risk factors do I have (age, smoking, steroid use, family history), and how do they change the balance of starting or continuing TRT?
- Should my bone health be monitored over time while I am on TRT, and with what tests?
- Are there non-hormonal steps (calcium, vitamin D, weight-bearing exercise) you would recommend alongside or instead of TRT for bone protection?
This question is drawn from common patient questions about Rheumatology and answered using cited medical research. We do not provide individualized advice.