Testosterone Enanthate Pre-Surgery Hold Window: Clinical Guide

At a glance

• Product / Testosterone enanthate intramuscular injection
• Label dosing / 50 to 400 mg every 2 to 4 weeks [1]
• Label VTE warning / DVT and PE reported; discontinue if suspected [1]
• Label blood pressure warning / Can raise blood pressure; monitor periodically; not recommended in uncontrolled hypertension [1]
• Hematocrit / Polycythemia listed; guideline advises against starting with elevated hematocrit [1][2]
• Surgical VTE guidance / ASH 2019 addresses prevention in surgical patients generally [3]
• Controlled substance / Schedule III [1]

What the Label Says

The label gives 50 to 400 mg intramuscularly every 2 to 4 weeks and says injections more often than every 2 weeks are rarely indicated [1]. It warns about VTE, blood pressure and edema; polycythemia is listed under adverse reactions [1].

What the Label Warns About VTE and Blood Pressure

The label says postmarketing reports include DVT and PE in patients using testosterone products such as testosterone enanthate injection. It says to evaluate leg pain, swelling, warmth or redness for DVT and acute shortness of breath for PE; if a VTE is suspected, testosterone enanthate should be discontinued and workup started [1]. The label also says testosterone can increase blood pressure, which can increase cardiovascular risk over time. It says to monitor blood pressure periodically, especially in men with hypertension, and that testosterone products are not recommended in men with uncontrolled hypertension [1].

What Studies Add

A UK population-based case-control study included 19,215 patients with confirmed VTE and 909,530 age-matched controls. The adjusted rate ratio for VTE was 1.25 (95% CI 0.94 to 1.66) with current testosterone treatment versus no treatment; it was 1.63 (1.12 to 2.37) in the first six months and 1.00 (0.68 to 1.47) after more than six months [4]. That study was not a surgical trial and did not test a hold period.

A network meta-analysis of 29 placebo-controlled randomized trials with 3,393 men found intramuscular testosterone enanthate or cypionate raised mean hematocrit by 4.0% (95% CI 2.9 to 5.1) compared with placebo [5].

Why Surgery Raises the Question

Surgery is itself a VTE risk. The American Society of Hematology 2019 guideline makes recommendations for VTE prevention in surgical hospitalized patients, including mechanical and drug prophylaxis depending on the procedure [3]. It is not specific to testosterone enanthate.

What to Check

The label says to monitor blood pressure periodically and lists VTE symptoms that call for evaluation [1]. The 2018 Endocrine Society guideline recommends against starting testosterone in men with elevated hematocrit and recommends monitoring hematocrit in the first year of therapy [2].

Bottom Line

Neither the label nor the guidelines cited here set a hold window for testosterone enanthate before surgery. What they do cover is VTE symptoms, blood pressure and hematocrit [1][2], and surgical VTE prevention in general [3].

Frequently asked questions

›How long before surgery should I stop testosterone enanthate?

The testosterone enanthate label gives no week-based pre-surgery hold period [1]. It does warn about VTE, blood pressure and polycythemia [1].

›Does testosterone enanthate increase blood clot risk?

The label says DVT and PE have been reported with testosterone products such as testosterone enanthate injection [1]. A UK case-control study found higher VTE rates in the first six months of testosterone treatment, with an adjusted rate ratio of 1.63 (95% CI 1.12 to 2.37) [4].

›Does the label require blood pressure monitoring?

The label says testosterone can increase blood pressure and to monitor blood pressure periodically, especially in men with hypertension; it is not recommended in uncontrolled hypertension [1].

›What does the label say about hematocrit?

Polycythemia is listed under hematologic adverse reactions [1]. The 2018 Endocrine Society guideline recommends against starting testosterone in men with elevated hematocrit and recommends monitoring hematocrit in the first year of therapy [2].

References

1. U.S. National Library of Medicine, DailyMed. Testosterone enanthate injection USP intramuscular, Hikma prescribing information. Testosterone enanthate injection USP intramuscular, Hikma label
2. Bhasin S, Brito JP, Cunningham GR, Hayes FJ, Hodis HN, Matsumoto AM, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018;103(5):1715-1744. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline
3. Anderson DR, Morgano GP, Bennett C, Dentali F, Francis CW, Garcia DA, et al. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Adv. 2019;3(23):3898-3944. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients
4. Martinez C, Suissa S, Rietbrock S, Katholing A, Freedman B, Cohen AT, et al. Testosterone treatment and risk of venous thromboembolism: population based case-control study. BMJ. 2016;355:i5968. Testosterone treatment and risk of venous thromboembolism: population based case-control study
5. Nackeeran S, Kohn T, Gonzalez D, White J, Ory J, Ramasamy R. The Effect of Route of Testosterone on Changes in Hematocrit: A Systematic Review and Bayesian Network Meta-Analysis of Randomized Trials. J Urol. 2022;207(1):44-51. The Effect of Route of Testosterone on Changes in Hematocrit: A Systematic Review and Bayesian Network Meta-Analysis of Randomized Trials