Anabolic steroid
–
induced
hypogonadism: diagnosis
and treatment
Cyrus D. Rahnema, B.S.,
a
Larry I. Lipshultz, M.D.,
b
Lindsey E. Crosnoe, B.S.,
a
Jason R. Kovac, M.D., Ph.D.,
b
and Edward D. Kim, M.D.
a
a
University of Tennessee Graduate School of Medicine, Knoxville, Tennessee; and
b
Scott Department of Urology, Baylor
College of Medicine, Houston, Texas
Objective:
To develop an understanding of hypogonadal men with a history of anabolic-androgenic steroid (AAS) use and to outline
recommendations for management.
Design:
Review of published literature and expert opinions. Intended as a meta-analysis, but no quality studies met the inclusion
criteria.
Setting:
Not applicable.
Patient(s):
Men seeking treatment for symptomatic hypogonadism who have used nonprescribed AAS.
Intervention(s):
History and physical examination followed by medical intervention if necessary.
Main Outcome Measures(s):
Serum testosterone and gonadotropin levels, symptoms, and fertility restoration.
Result(s):
Symptomatic hypogonadism is a potential consequence of AAS use and may depend on dose, duration, and type of AAS
used. Complete endocrine and metabolic assessment should be conducted. Management strategies for anabolic steroid
–
associated
hypogonadism (ASIH) include judicious use of testosterone replacement therapy, hCG, and selective estrogen receptor modulators.
Conclusion(s):
Although complications of AAS use are variable and patient speci
f
c, they can be successfully managed. Treatment of
ASIH depends on the type and duration of AAS use. Speci
f
c details regarding a patient's AAS cycle are important in medical manage-
ment. (Fertil Steril
Ò
2014;101:1271
–
9.
Ó
2014 by American Society for Reproductive Medicine.)
Key Words:
Anabolic-androgenic steroids, androgens, hypogonadotropic hypogonadism,
gynecomastia, testicular atrophy, erectile dysfunction, clomiphene citrate, tamoxifen, human
chorionic gonadotropin
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A
nabolic-androgenic
steroid
(AAS) users have come a long
way since the end of the 19th
century, when an aging Dr. Brown-
S
±
equard eagerly reported
‘‘
a decided
gain in strength
’’
after injecting himself
with the
‘‘
orchitic
fl
uid
’’
of laboratory
animals. This discovery created enthu-
siasm and controversy alike while
laying the foundation for the
f
eld of
andrology
(1
–
3)
. Synthetic androgens
were born in the 1930s when Foss
f
rst
described the medical use of orally
bioavailable methyltestosterone
(4, 5)
.
Since that time, androgens have been
approved for the treatment of a variety
of conditions, including testosterone
(T) de
f
ciency, osteoporosis, cachexia,
delayed puberty, and breast cancer
(6)
.
Derivatives of T have varying degrees
of relative anabolic and androgenic
activity
—
exerting their ergogenic and
cosmetic
effects
by
targeting
the
androgen receptor to increase lean
muscle mass, burn fat, and boost
athletic performance
(7
–
10)
.
Unfortunately the use of androgens
is not without signi
f
cant side effects,
including hepatotoxicity, cardiotoxic-
ity, polycythemia, dyslipidemia, hyper-
tension,
depression,
gynecomastia,
testicular atrophy, and infertility
—
all
well described but poorly understood
sequelae
(7, 11
–
14)
. Additionally, for
men who have previously used AAS, a
unique condition known as anabolic
steroid
–
induced hypogonadism (ASIH)
becomes
a
real
concern.
Clearly
described in 1990 by Jarow and
Lipshultz
(15)
, ASIH has recently been
identi
f
ed as a potentially under-
recognized cause of hypogonadism in
young men
(16)
. Demographics and
usage patterns vary among AAS users,
who report different motivations for
Received December 11, 2013; revised January 26, 2014; accepted February 4, 2014; published online
March 14, 2014.
C.D.R. has nothing to disclose. L.I.L. has nothing to disclose. L.E.C. has nothing to disclose. J.R.K. has
nothing to disclose. E.D.K. has nothing to disclose.
Reprint requests: Edward D. Kim, M.D., Division of Urology, Department of Surgery, University of Ten-
nessee Graduate School of Medicine, 1928 Alcoa Highway, Suite 222, Knoxville, Tennessee 37920
(E-mail:
ekim@utmck.edu
).
Fertility and Sterility® Vol. 101, No. 5, May 2014 0015-0282/$36.00
Copyright ©2014 American Society for Reproductive Medicine, Published by Elsevier Inc.
VOL. 101 NO. 5 / MAY 2014
1271