Testosterone replacement therapy does not appear to protect men from bone fractures, and the largest randomized trial to test the question found the opposite: men on TRT fractured more often than men on placebo, even though testosterone measurably increased their bone density. Researchers call this a paradox because the biology says TRT should help bones, while the outcomes data says otherwise. Men considering TRT, especially those with osteoporosis risk factors, should understand this gap before starting treatment.
What Did the TRAVERSE Trial Find About Fractures?
TRAVERSE was a large, randomized, placebo-controlled trial built primarily to test testosterone's cardiovascular safety, but a prespecified substudy also tracked fractures in 5,204 men aged 45 to 80 with hypogonadism and existing cardiovascular disease or risk factors. Over a median follow-up of 3.19 years, 3.50 percent of men on testosterone gel had a clinical fracture compared with 2.46 percent of men on placebo gel, a statistically significant increase (hazard ratio 1.43, 95% CI 1.04 to 1.97) (Snyder et al., New England Journal of Medicine, 2024). By the third year of the study, cumulative fracture incidence had climbed to 3.8 percent in the testosterone group versus 2.8 percent in the placebo group.
The most common fracture sites were the ribs, wrist, and ankle, and more than 80 percent of the fractures involved trauma, mostly falls. Testosterone was linked to a higher rate across essentially every fracture category the researchers tracked, not just one isolated type (Cleveland Clinic, 2024).
Why Would TRT Increase Fractures If It Improves Bone Density?
This is the part researchers are still trying to explain. Testosterone directly stimulates osteoblasts, the cells that build bone, and indirectly suppresses the signaling that drives bone breakdown, an effect that reliably raises bone mineral density in clinical trials, particularly at the spine (Corona et al., Journal of Endocrinological Investigation, 2022). On paper, denser bone should mean fewer fractures, not more.
Steven Nissen, MD, the TRAVERSE study chair at Cleveland Clinic, has pushed back on the theory that testosterone simply makes men more physically active and therefore more prone to accidents. "The data do not support that," he said, noting that the rise in nonimpact fractures tracked closely with the rise in fractures overall, and that testosterone's measured effects on strength and function in the trial were too modest to explain a sudden jump in risky activity (Cleveland Clinic, 2024). A more recent review describes testosterone's relationship with male bone health as "a puzzle of interactions" that isn't fully resolved by bone density data alone (Tenuta et al., Journal of Clinical Endocrinology & Metabolism, 2025).
What Does Real-World Data Show Outside of TRAVERSE?
A separate retrospective analysis of more than 150,000 patients in the PearlDiver insurance claims database, matched 1:1 by age, sex, and comorbidities, found that men and women on TRT had a 2-year vertebral fracture rate of 0.31 percent compared with 0.04 percent among matched controls. After adjusting for other risk factors, TRT was associated with roughly 7.7 times higher odds of a vertebral fracture (95% CI 5.1 to 11.7) (Singh et al., Journal of the American Academy of Orthopaedic Surgeons Global Research & Reviews, 2025). The effect was strongest in men, and the rate climbed with age in both sexes. Because this was a retrospective claims analysis rather than a randomized trial, it cannot prove TRT caused the fractures, but it points in the same direction as TRAVERSE using an entirely different data source and fracture type. A separate 2026 review of hypogonadal men likewise concluded that TRT may raise the risk of non-major osteoporotic fractures even as it improves bone density readings (Anagnostis et al., Maturitas, 2026).
Does This Mean TRT Is Unsafe for Bones?
Not necessarily for every man, but it does mean TRT is not a fracture-prevention treatment and should not be started with that goal in mind. Dr. Nissen's guidance to clinicians has been direct: men with a history of osteoporosis, or those who regularly engage in activities with meaningful fall or impact risk, should be cautious about starting testosterone, and should not expect it to lower their fracture risk (Cleveland Clinic, 2024). For most men without preexisting bone disease, TRAVERSE's absolute fracture numbers were still low in both arms, so the finding is a reason for informed monitoring rather than automatic disqualification from treatment. If you're also managing other cardiovascular risk factors on TRT, our guide to TRT and blood pressure covers a related monitoring conversation worth having with your prescriber.
