Testosterone replacement therapy (TRT) has become increasingly common in the United States over the past two decades. What many patients don’t realize is that testosterone therapy can carry important implications before surgery. Side effects of testosterone therapy can increase the risk of complications, repeat procedures, or cardiovascular events. That makes it an important topic to discuss with your doctor before scheduling surgery. In this post, we’ll review emerging research on testosterone therapy and surgical outcomes, along with practical steps patients should consider before undergoing shoulder surgery.

• Testosterone replacement therapy (TRT) used before surgery, such as rotator cuff repair, has been associated with higher odds of complications, including revision surgery, frozen shoulder, prolonged opioid use, and cardiovascular events.
• TRT may promote overgrowth of a skin bacterium called Cutibacterium acnes, which can increase the risk of serious shoulder infections after surgery.
• Disclosing TRT use, including pellets, injections, gels, or creams, to an experienced orthopedic surgeon before any shoulder procedure supports your safety.

Testosterone replacement therapy involves supplementing the body with exogenous, or externally supplied, testosterone. The FDA approves TRT for conditions such as clinically low testosterone levels. However, many men use it off-label for issues like fatigue, low sex drive, weight gain or depression.

TRT comes in many forms. Injections, gels, patches, pellets, and creams are all in common use. Some men report feeling younger, stronger, and more energetic on TRT. But the same hormonal forces that build muscle and boost energy can also create conditions inside the body and on the skin that may be problematic when surgery is on the table. This is precisely why understanding testosterone therapy side effects before surgery matters.

Testosterone does not act on just one system. It affects muscles, tendons, blood vessels, and even the skin. Each of these becomes relevant when a patient is preparing for shoulder surgery.

Let’s start with tendons. Testosterone promotes muscle growth by increasing muscle protein synthesis and activating satellite cells involved in muscle repair. In principle, that sounds beneficial. The issue is that surrounding tendons do not necessarily adapt proportionally. Increased muscle cross-sectional area can generate greater contractile forces across tendons, potentially placing additional stress on repaired tissue and increasing the risk of tendon failure after surgery.

Testosterone may also interfere with wound healing. Laboratory studies suggest testosterone can increase total wound healing time, promote pro-inflammatory cytokines, and inhibit collagen synthesis, which may work against the goal of surgically repaired tissue healing efficiently.

Then there is the cardiovascular system. Testosterone therapy has been linked in laboratory and epidemiologic studies to increased platelet aggregation and vascular smooth muscle proliferation, biological mechanisms that may contribute to heart attacks in some patients.

One of the lesser-known but particularly notable testosterone therapy side effects before surgery involves the skin and a bacterium that lives within it.

Cutibacterium acnes is a bacterium that resides in the dermis, the deeper layer of the skin, particularly around hair follicles and sebaceous glands. It cannot be fully eliminated from the skin surface, no matter how diligently a surgical site is prepared. In shoulder surgery, this matters enormously.

The shoulder is one of the most common anatomic sites for C. acnes infection after surgery. It is a slow-growing organism. It can seed a repaired tendon or a shoulder implant and cause an infection that may not become apparent for months or even years. Managing a C. acnes infection after shoulder surgery typically requires additional procedures, prolonged antibiotic courses, and sometimes implant removal.

Testosterone strongly stimulates sebaceous glands within the dermis, increasing oil production and creating an environment where C. acnes can thrive. When testosterone therapy increases this bacterial burden in the dermis around the shoulder, it may raise the risk that C. acnes contaminates the surgical field during shoulder procedures.

To minimize this risk, surgeons may use several strategies. These include instructing patients to wash the shoulder area with benzoyl peroxide for a week leading up to surgery. During the procedure itself, cauterization of the dermis during surgical exposure helps reduce the bacterial load in the tissue. Wound irrigation with agents such as saline with polymyxin, povidone-iodine, and 4% chlorhexidine is also employed. For patients with acne-prone skin, a preoperative course of doxycycline may be prescribed to further reduce the bacterial burden before the first incision is made.

Despite all of these precautions, fully eradicating C. acnes from the surgical field is not reliably achievable. Stopping TRT use before surgery may therefore be one of the most practical and impactful steps a patient can take.

In a large database study of men undergoing rotator cuff repair, patients who had taken testosterone within six months of surgery experienced worse outcomes than those who had stopped six to twelve months earlier. More recent TRT use was associated with higher rates of hospital readmission within 90 days, revision rotator cuff repair at two years, prolonged opioid use, and higher overall costs of care.

These findings suggest that the biological effects of testosterone on tissue healing and postoperative complications may be partially reversible over time. The body may benefit from a period of lower testosterone exposure before surgery. While more research is needed to determine the optimal cessation window, current data generally supports stopping TRT earlier rather than later when surgery is planned.

If you are on TRT and you are scheduled for shoulder surgery, several steps are worth discussing with your care team.

First and most important: disclose your testosterone use to your surgeon. Many patients do not include TRT when listing their medications, often because it does not feel like a traditional drug, particularly if it is delivered as a subcutaneous pellet, a topical gel, or a compounded cream. From a surgical standpoint, it counts. Tell your surgeon, regardless of the formulation.

Second, do not make changes to your TRT regimen without consulting both your prescribing physician and your surgeon first. Stopping testosterone abruptly can carry its own physiological consequences depending on your condition and how long you have been using it. Any decision to hold TRT before surgery should be made collaboratively, with full awareness of your individual health picture.

Third, take preoperative skin preparation protocols seriously. If your surgeon recommends benzoyl peroxide washes before surgery, follow through consistently. If doxycycline is prescribed due to acne-prone skin, complete the course as directed.

Testosterone replacement therapy is increasingly common among men in South Florida and across the United States. Many patients do not think of it as something their surgeon needs to know about. The evidence suggests that testosterone therapy side effects before surgery can include a meaningfully higher risk of revision procedures, frozen shoulder, prolonged opioid dependence, cardiovascular complications, and a greater skin bacterial burden that may predispose to surgical site infection.

The promising news is that some of this risk may be modifiable. Stopping TRT sufficiently in advance of surgery, following preoperative skin preparation protocols, and maintaining open communication with your surgical team can all contribute to a better outcome. If you are on TRT and planning shoulder surgery, bring it up.

Not necessarily. The research identifies a statistical association between preoperative TRT use and higher rates of certain complications, but individual outcomes vary considerably. Many factors influence surgical results, including the size and severity of the injury, overall health status, and adherence with postoperative restrictions. That said, the magnitude of the association in large-scale data is meaningful enough that disclosure and thoughtful planning are strongly advisable for any patient currently on TRT.

My current protocol is to hold testosterone therapy for at least six weeks before surgery and four weeks after surgery whenever medically appropriate. In my practice, I routinely screen patients for testosterone therapy before shoulder surgery. Because many individuals do not list TRT as a medication, it is important to ask specifically about injections, gels, creams, or pellet implants.

Cutibacterium acnes lives deep within the dermis and cannot be fully eradicated from the surgical field. Surgeons can work to reduce the bacterial burden through benzoyl peroxide washes, intraoperative irrigation with antiseptic agents, cauterization of the dermis, and in some cases, a preoperative antibiotic course, but complete elimination is not reliably achievable. Reducing TRT use before surgery may help lower the bacterial load in the skin and reduce, though not eliminate, infection risk.