Testosterone & Bone Health

1) Evidence Summary 

• Low testosterone reduces bone density (BMD) and increases fracture risk as men age. 

• Testosterone converts to estradiol (E2), which helps maintain bone by reducing resorption. 

• TRT can increase spine BMD by ~3–4% over 12–24 months in hypogonadal men; hip gains are smaller. 

• No clear evidence that TRT prevents fractures. Muscle strength and falls remain key factors. 

2) When TRT is Appropriate 

Use TRT for symptomatic, biochemically low testosterone, not as a sole treatment for osteoporosis. Eligible men typically have: 

• Confirmed low morning testosterone (twice tested; check free T if SHBG abnormal), 

• Plus osteopenia/osteoporosis, sarcopenia, or other hypogonadal features. 

3) Levitas Clinics Pathway 

1. Assessment: Symptoms, falls history, labs (TT, SHBG, cFT, LH/FSH, prolactin, PSA, FBC, CMP, lipids, HbA1c, TSH, 25(OH)D), DXA, and FRAX. 

2. Treatment: 

3. TRT: gel, short-acting IM, or long-acting TU targeting mid-normal physiological range. 

4. Bone stack: vitamin D, calcium, protein, resistance/balance training, and bone medications if indicated. 

5. Monitoring: 6–8 weeks after starting, then 3–6 monthly in year 1; review testosterone, haematocrit, PSA, BP, weight; DXA at 12–24 months. 

4) Safety and Contraindications 

• Risks: erythrocytosis, prostate effects, OSA worsening, fluid retention. 

• Avoid in prostate/breast cancer, haematocrit >54%, uncontrolled heart failure, or severe OSA. 

5) Expected Outcomes 

• TRT improves symptoms and increases spine BMD when testosterone is low. 

• TRT alone has not been proven to reduce fractures—optimal results come with combined nutrition, exercise, and bone-specific therapy. 

Levitas Clinics provides: expert LOH assessment, tailored TRT regimens, integrated bone optimisation, and continuous safety monitoring. 

Key References 

1. Shigehara K, Izumi K, Kadono Y, Mizokami A. Testosterone and Bone Health in Men: A Narrative Review. Int J Mol Sci. 2021;22(3):1680. PMCID: PMC7867125. 

2. Isidori AM, Giannetta E, et al. Effects of testosterone on body composition and bone metabolism in middle-aged men: A meta-analysis. Clin Endocrinol (Oxf). 2005;63(3):280–293. 

3. Snyder PJ et al. Effects of Testosterone Treatment in Older Men. N Engl J Med. 2016;374(7):611–624. 

4. Fink HA et al. Association of testosterone and estradiol deficiency with osteoporosis and bone loss in older men. J Clin Endocrinol Metab. 2006;91(10):3908–3915. 

5. Tracz MJ et al. Testosterone use and its effects on bone health: A systematic review and meta-analysis. J Clin Endocrinol Metab. 2006;91(6):2011–2016.