Androgen therapy and musculoskeletal health in older adults: An umbrella review

Background Testosterone and androgen supplementation have been increasingly prescribed in older adults to counteract age-related declines in lean body mass and strength, however, there is uncertainty about their benefits. We synthesized the evidence concerning androgen therapy, particularly testosterone, on muscle-related outcomes in older adults. Methods Following prospective registration (OSF; osf.io/8wm3k), we conducted an umbrella review of systematic reviews (SRs) and meta-analyses of randomized clinical trials (RCTs) involving adults aged ≥60 years receiving androgen therapy. PubMed/MEDLINE, Scopus, and WOS were searched from inception to October 2025. Outcomes included lean body mass, muscle strength, and adverse events. Methodological quality was assessed with the AMSTAR-2 tool. The overlap of primary RCTs across reviews was assessed by calculating covered area (CCA). Pooled effect sizes with 95% confidence intervals (CIs) were summarized. Results There were 11 eligible SRs, comprising 121 unique RCTs, with 20,846 male participants, none were women (of whom 8447 received testosterone therapy). Methodological quality was rated in 3 SRs as high, in 5 SRs as moderate, and in 3 SRs as low or critically low. The overlap was moderate (CCA = 9.92%). Lean body mass changes in response to testosterone reported in 5 SRs of moderate to high quality ranged from 1.6 kg (95% CI 0.6–2.6; I 2 = 0.0%) to 3.59 kg (95% CI 2.38–4.81; I 2 = 98%). Muscle strength changes in response to testosterone reported in 6 SRs of moderate to low quality showed maximal lower-limb effect in leg press (91.23 Newtons; 95% CI 0.23–182.22; I 2 = 62%), and leg extension (144.10 Newtons; 95% CI 44.21–244.00; I 2 = 0%). There was no effect demonstrated on major cardiovascular events or all-cause mortality. Conclusion Testosterone therapy improved lean muscle mass and strength without adverse effect in older men. There is a need for well-designed trials, including both elderly men and women, to guide primary care and public health policy and practice in the future.