Hip fractures in older women are not just orthopedic events. They trigger a cascade of metabolic damage that most patients never recover from. One of the least recognized consequences is a dangerous shift in body fat distribution: fat migrates from the limbs into the visceral compartment around the organs, where it drives inflammation, insulin resistance, and increased mortality risk.
A multi-site randomized controlled trial now shows that a simple topical testosterone gel can reverse that shift.
Key Takeaways
The STEP-HI trial randomized 66 women over age 65 recovering from hip fractures to exercise plus testosterone gel or exercise plus placebo for 6 months
Women receiving testosterone gel had a 10.6 percent reduction in relative visceral adiposity, while the placebo group gained 3.5 percent
The difference was statistically significant (p = 0.004 for relative visceral fat change)
Total body fat did not differ between groups -- testosterone selectively redistributed fat away from the viscera
This is the first RCT to show testosterone gel reduces visceral fat accumulation during hip fracture recovery
Published in Obesity Pillars (January 2026), conducted across 8 U.S. sites
Why Visceral Fat After Hip Fracture Matters
Hip fractures in women over 65 carry a one-year mortality rate between 14 and 36 percent. The injury itself is devastating, but the metabolic aftermath compounds the damage.
During recovery, immobility and hormonal changes cause fat to redistribute from the limbs (appendicular adipose tissue) into the abdominal cavity (visceral adipose tissue). This is not cosmetic -- it is a metabolic emergency in slow motion.
Visceral fat is biologically different from subcutaneous fat:
Releases inflammatory cytokines (IL-6, TNF-alpha) that drive systemic inflammation
Produces excess cortisol through local 11-beta-hydroxysteroid dehydrogenase activity
Worsens insulin resistance through direct portal vein delivery of free fatty acids to the liver
Increases cardiovascular risk independent of total body fat
Predicts reinjury -- women with higher visceral fat after hip fracture have worse functional outcomes and higher fall risk
In older women recovering from hip fractures, this visceral fat shift happens precisely when they can least afford it -- while their bodies are trying to heal bone, rebuild muscle, and restore mobility.
What the STEP-HI Trial Did
The Strategies to Enhance Physical Function and Prevent Hip Injury (STEP-HI) trial was a double-blind, placebo-controlled randomized clinical trial conducted across eight U.S. sites from December 2018 to August 2023.
Study Design
Parameter
Detail
Design
Double-blind, placebo-controlled RCT
Sites
8 U.S. medical centers (6 included in adipose analysis)
Population
Women 65 and older, within 22 weeks of hip fracture surgery
Testosterone group
35 women (mean age 79), received 1.0% topical testosterone gel
Placebo group
31 women (mean age 76), received identical placebo gel
Target testosterone levels
110 to 160 ng/dL (standard female range: 12 to 78 ng/dL)
Dose adjustment
Monthly, based on serum testosterone levels
Exercise program
All participants: supervised exercise 2 days per week plus home exercise 3 days per week
Duration
24 weeks (6 months)
Body composition assessment
DXA scans at baseline and 24 weeks
Clinical trial registration
NCT02938923
Publication
Obesity Pillars, January 2026
The exercise program was identical in both groups: progressive resistance training, functional movements, mobility work, and balance exercises. This controlled for the exercise variable -- any differences in fat distribution were attributable to the testosterone gel itself.
The headline result was not about total fat loss. Both groups had similar changes in total body fat. The difference was where the fat was stored.
Measure
Placebo + Exercise
Testosterone + Exercise
P-value
Total adipose tissue change
+298 g
+419 g
0.810
Appendicular adipose tissue change
+52 g
+39 g
0.960
Visceral adipose tissue change
+45 g
-44 g
0.073
Relative visceral adiposity (% of total)
+3.51%
-10.57%
0.004
The placebo group followed the expected trajectory: visceral fat increased during recovery. The testosterone group broke that pattern entirely. Their visceral fat decreased in both absolute and relative terms.
"This really bucked that trend and caused selective reduction of fat in that visceral compartment," said Jacob Earp, assistant professor of kinesiology at the University of Connecticut and lead author of the study.
Adjusted Analysis
After controlling for baseline covariates (age, BMI, baseline fat distribution), the multivariate analysis confirmed:
Relative visceral adiposity was 0.30 percentage points lower in the testosterone group (p = 0.029)
Absolute visceral adipose tissue was 59 grams lower in the testosterone group, though this did not reach statistical significance (p = 0.264)
The relative measure -- what proportion of total fat is stored as visceral fat -- is the more clinically meaningful metric. It reflects the body's fat distribution pattern rather than total fat quantity.
What This Means Physiologically
Testosterone did not make these women lose weight. It changed the architecture of their fat storage. Fat that would have accumulated around internal organs was either prevented from depositing there or redirected to subcutaneous compartments where it causes less metabolic harm.
This aligns with known mechanisms. Testosterone:
Inhibits visceral preadipocyte differentiation (prevents new visceral fat cells from maturing)
Enhances lipolysis selectively in visceral fat through androgen receptor density differences
The immediate clinical application is narrow: older women recovering from hip fractures. But the implications extend further.
For Postmenopausal Women Generally
Visceral fat accumulation accelerates after menopause as testosterone and estrogen decline. The STEP-HI data adds to growing evidence that testosterone therapy can selectively target visceral fat in postmenopausal women, a finding consistent with broader research on testosterone and weight management in women.
For the Testosterone-in-Women Evidence Base
No testosterone product is currently FDA-approved for women. Every prescription is off-label. The STEP-HI trial adds another piece of randomized trial evidence showing measurable benefits of testosterone therapy in women -- data that clinicians and regulators need to move toward formal approval pathways.
Both groups exercised. Only the testosterone group saw visceral fat reduction. This reinforces that exercise alone may not be sufficient to counteract the metabolic consequences of hormonal decline and injury in older women. The combination of exercise with hormonal support produced outcomes that neither intervention achieves alone.
Limitations Worth Knowing
This is a small study with important constraints. Understanding them is essential for interpreting the results correctly.
Sample size is small -- 66 women total (35 testosterone, 31 placebo). Statistical power is limited, which is why the absolute visceral fat change (p = 0.073) did not reach significance while the relative measure (p = 0.004) did.
DXA, not CT or MRI -- DXA scanning estimates visceral fat less precisely than CT or MRI, the gold-standard imaging methods. Two different DXA systems were used across sites (Hologic and Lunar GE).
No pre-injury baseline -- researchers could not measure body composition before the hip fracture occurred, so they could not quantify total change from pre-injury status.
Narrow population -- women over 65 recovering from hip fractures. Direct extrapolation to younger women, healthy older women, or men is not supported.
Six months may be too short -- longer follow-up would clarify whether the visceral fat redistribution persists and whether it translates to reduced cardiovascular events or mortality.
Clinical significance is uncertain -- the magnitude of visceral fat change, while statistically significant, has not been linked to hard clinical endpoints in this population. Whether a 10 percent reduction in relative visceral adiposity prevents heart attacks, diabetes, or rehospitalization remains unknown.
How to Access Testosterone Therapy for Women
If you or a family member is recovering from a hip fracture and interested in whether testosterone therapy might help, here is the practical path forward.
Step 1: Get Bloodwork
Ask the treating physician to check total testosterone, free testosterone, and SHBG. Most women recovering from hip fractures will have low levels, but establishing a baseline is essential before treatment.
Step 2: Find a Knowledgeable Provider
Most orthopedic surgeons and rehabilitation physicians do not prescribe testosterone for women. You need an endocrinologist, gynecologist, or menopause specialist experienced in hormone therapy. For women not in acute post-fracture care, online clinics that serve women offer testosterone prescriptions through telehealth, though post-fracture patients may need in-person coordination.
Step 3: Understand the Formulation
The STEP-HI study used generic 1.0 percent topical testosterone gel. In clinical practice, women's testosterone is typically prescribed as:
Doses are individually titrated based on blood levels and symptom response. The target range used in STEP-HI (110 to 160 ng/dL) is higher than some clinical protocols use for symptom management, so monitoring is important.
Step 4: Combine With Exercise
The STEP-HI protocol included structured exercise: supervised sessions twice weekly plus home exercises three times weekly. Testosterone without exercise did not produce the observed effects -- the combination is what worked. Post-fracture rehabilitation programs should incorporate progressive resistance training alongside any hormonal intervention.
The Bigger Picture
This study fills a specific gap: what happens to body fat distribution when you add testosterone to exercise rehabilitation after hip fracture in older women. The answer -- visceral fat goes down while total fat stays the same -- is both surprising and mechanistically logical.
For the roughly 300,000 Americans over 65 who suffer hip fractures annually (the majority of them women), this could represent a meaningful addition to rehabilitation protocols. Visceral fat accumulation during recovery contributes to the cascade of complications -- insulin resistance, inflammation, cardiovascular risk, functional decline -- that makes hip fractures so deadly in older adults.
Testosterone gel is inexpensive, easy to administer, and well-tolerated in this study. What it lacks is regulatory approval for women and large-scale outcome data. Both are necessary before this becomes standard care, but the STEP-HI trial makes a compelling case for the next step: a larger trial powered for clinical endpoints like rehospitalization, cardiovascular events, and mortality.
Earp JE, Zhao S, Xu F, et al. Testosterone Therapy Effects Adipose Distribution in Older Females Post Hip-Fracture: The STEP-HI Study. Obesity Pillars. 2026;17:100247. doi:10.1016/j.obpill.2026.100247
Maggi M, Buvat J, Corona G, et al. Hormonal Causes of Male Sexual Dysfunctions and Their Management. Journal of Sexual Medicine. 2013;10(3):661-677.
Sattler FR, Castaneda-Sceppa C, Binder EF, et al. Testosterone and growth hormone improve body composition and muscle performance in older men. Journal of Clinical Endocrinology and Metabolism. 2009;94(6):1991-2001.
Davis SR, Baber R, Panay N, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. Journal of Clinical Endocrinology and Metabolism. 2019;104(10):4660-4666.
Cauley JA, Thompson DE, Ensrud KC, et al. Risk of mortality following clinical fractures. Osteoporosis International. 2000;11(7):556-561.
This content is for informational purposes only and is not medical advice. Consult a qualified healthcare provider before starting any treatment.
Frequently Asked Questions
Does testosterone gel reduce belly fat in women?
The STEP-HI trial found that topical testosterone gel combined with exercise reduced relative visceral adiposity by 10.6 percent over six months in older women recovering from hip fractures. The gel did not reduce total body fat but selectively shifted fat distribution away from the dangerous visceral compartment. This is the first randomized controlled trial to demonstrate this effect in post-fracture women.
What testosterone dose was used in the STEP-HI study?
The study used generic 1.0 percent topical testosterone gel, with doses adjusted monthly to achieve serum testosterone levels between 110 and 160 ng/dL. This is above the standard female reference range of 12 to 78 ng/dL but within the range used in clinical testosterone therapy for women. The dose was individually titrated based on blood work.
Is visceral fat more dangerous than other body fat?
Yes. Visceral fat surrounds the internal organs and is metabolically active, releasing inflammatory cytokines that increase the risk of heart disease, type 2 diabetes, and insulin resistance. Unlike subcutaneous fat under the skin, visceral fat cannot be removed by liposuction and is strongly linked to chronic disease risk. Older women recovering from injuries are especially vulnerable to visceral fat accumulation.
Can younger women use testosterone gel for fat loss?
The STEP-HI study specifically examined women over 65 recovering from hip fractures. Results cannot be directly applied to younger, healthy women. However, other research shows testosterone therapy improves body composition in postmenopausal women generally. Any use of testosterone therapy requires a prescription and medical supervision. Discuss options with a provider experienced in hormone therapy for women.
Does testosterone therapy for women affect total body weight?
In the STEP-HI trial, total body fat remained similar between the testosterone and placebo groups. Testosterone did not cause weight loss on the scale. Instead, it selectively reduced the proportion of fat stored as visceral fat while preserving lean tissue. This pattern is consistent with other testosterone studies in women, where the primary benefit is body composition improvement rather than scale weight change.
Is testosterone gel FDA-approved for women?
No testosterone product is currently FDA-approved for use in women. Clinicians prescribe testosterone off-label for women using compounded creams, gels, or pellets. The FDA provided guidance in January 2026 on a development pathway for a women-specific testosterone therapy (AVA-291), but approval is years away. Off-label prescribing is legal and common, but it means insurance coverage is inconsistent.
