A positive role for anabolic androgenic steroids:

preventing metabolic syndrome and type 2

diabetes mellitus

TO THE EDITOR:

We recently discussed the diagnosis and

treatment of anabolic steroid induced hypogonadism

(1)

subsequent commentary

(2)

detailed the dilemma of treating

patients after anabolic androgenic steroid (AAS) use.

Pervasive throughout the medical literature is the paradigm

that

‘‘

illicit

’’

AAS use is unsafe

(2)

and that it is used to satisfy

body-dysmorphic disorder

(3)

. But perhaps there is something

constructive to be learned from men who have used AAS at a

young age.

All types of T supplementation therapy (TST) are forms of

AAS. It is the most effective treatment for hypogonadism us-

ing legally approved and pharmaceutical-grade AAS (usually

T). The monitoring and management of known side effects

(i.e., infertility, erythrocytosis [1]) in a physician-controlled

environment has made TST more accepted. Given these

changing views, perhaps other beliefs regarding AAS, and

by de

nition TST, should be revisited.

Consider the following scenario: a young and obese,

currently overtly

‘‘

healthy,

’’

but unusually fatigued man be-

gins using AAS. In spite of the inherent risks, the young

man changes his diet, exercises, loses fat, and gains muscle

mass. We can then debate whether AAS has decreased the

likelihood of more signi

cant disease in this man as he

ages. If a physician were to evaluate this young man, identify

his hypogonadism and treat him with a T preparation (or

derivative), he could gain the bene

ts of TST while identifying

and treating side effects. In this context, it is tempting to spec-

ulate that the possible bene

ts of AAS/TST could potentially

mitigate other, more serious health conditions such as obesity

and metabolic syndrome (MetS), the precursor to type 2 dia-

betes mellitus.

This concept is particularly important given the stag-

gering increase of MetS. Current estimates note the preva-

lence of MetS in adults to be 39%, with approximately 7%

of the pediatric/adolescent population affected

(4)

. These sta-

tistics are critical because MetS increases a patient's risk for

developing type 2 diabetes mellitus

vefold and makes pa-

tients three times more likely to suffer a myocardial infarction

or stroke

—

underscoring the true nature of this health crisis

(4)

The current cornerstones of MetS treatment are diet, exercise,

and education. As such, an opportunity exists to enhance the

current intervention strategies with adjunct alternatives to

prevent MetS.

Treatment of MetS with TST has shown bene

ts with im-

provements in individual risk factors (i.e., abdominal obesity,

body mass index [BMI], blood pressure, and cholesterol), as

well as complete resolution of MetS in some individuals

(4)

Although TST is ef

cacious in both treating and reversing

MetS, perhaps it is time to consider TST as a preemptive treat-

ment strategy against MetS. Indeed, TST in combination with

weight loss, exercise, and a change in lifestyle may be suf

cient to ward off future negative health problems in

adulthood.

A well-designed, prospective randomized control trial

evaluating TST in young, obese men before the overt diag-

nosis of MetS/type 2 diabetes mellitus would be extremely

valuable. A study like this could determine whether TST

should be used as a preemptive medication in conjunction

with dietary modi

cation and exercise. It may even be that

early TST could become a signi

cant adjunct in preventing

MetS/type 2 diabetes mellitus in the at-risk patient.

Jason R. Kovac, M.D., Ph.D.

Jason Scovell, B.B.A.

Edward D. Kim, M.D.

Larry I. Lipshultz, M.D.

Urology of Indiana, Carmel, Indiana;

Scott Department of

Urology, Baylor College of Medicine, Houston, Texas; and

University of Tennessee Graduate School of Medicine,

Knoxville, Tennessee

April 29, 2014

http://dx.doi.org/10.1016/j.fertnstert.2014.05.010

REFERENCES

Rahnema CD, Lipshultz LI, Crosnoe LE, Kovac JR, Kim ED. Anabolic steroid-

induced hypogonadism: diagnosis and treatment. Fertil Steril 2014;101:

1271

–

Nangia AK. Anabolic steroid abuse: a paradox of manliness. Fertil Steril 2014;

101:1247

Pope HG Jr, Gruber AJ, Choi P, Olivardia R, Phillips KA. Muscle dysmorphia.

An underrecognized form of body dysmorphic disorder. Psychosomatics

1997;38:548

–

Kovac JR, Pastuszak AW, Lamb DJ, Lipshultz LI. Testosterone supplementation

therapy in the treatment of metabolic syndrome. Postgrad Med. In press.

VOL. 102 NO. 1 / JULY 2014

LETTER TO THE EDITOR