use. The present review focuses on the nonprescribed use of

AAS. At present, there is a lack of information in the peer-

reviewed literature describing the demographics, characteris-

tics, and psychologic make-up of AAS users. Furthermore,

there are no comprehensive management recommendations

available for the treatment of AAS-induced complications

such as infertility and ASIH. Understanding has been hindered

by a lack of publications, with only a few case series and very

few large-volume studies existing

—

making meta-analysis

impossible. Most physicians are uncomfortable addressing

AAS use and are hesitant to broach the topic with patients.

To effectively manage these patients, a basic understanding

of the AAS user's self-treatment strategy is required. With

the present review, we provide a summary of the pathophysi-

ology underlying AAS use and provide management recom-

mendations for symptomatic patients who have previous

used, or are currently using, AAS.

MATERIALS AND METHODS

A Pubmed literature search was conducted for the time period

of 1965

–

2013. There were insigni

cant published quality data

for meta-analysis, so a systematic review was performed. Key

terms included

‘‘

anabolic-androgenic steroids,

’’ ‘‘

androgens,

’’

‘‘

hypogonadotropic hypogonadism,

’’ ‘‘

gynecomastia,

’’ ‘‘

testic-

ularatrophy,

’’ ‘‘

erectile dysfunction,

’’ ‘‘

infertility,

’’ ‘‘

clomiphene

citrate,

’’ ‘‘

tamoxifen,

’’ ‘‘

human chorionic gonadotropin,

’’ ‘‘

se-

lective estrogen receptor modulators,

’’

and

‘‘

aromatase

inhibitors.

’’

Data collection for common treatment strategies was

based on in-depth unsolicited discussions with users who

had taken AAS for primarily bodybuilding purposes. Addi-

tionally, an Internet search strategy for AAS user blogs and

discussion sites was used to describe the demographics and

usage patterns of the modern AAS user

(17)

. The external

validity of these techniques is supported by earlier studies

that used similar methods of Internet data mining to report

consistent

ndings

(9, 18

–

26)

RESULTS

The Modern Anabolic Steroid User: An Evolving

Portrait

Since the early ergogenic use of AAS by Olympic athletes of

the 1950s and 60s, nonmedical use of AAS has evolved

from an ethical issue of fairness in sport to a very real public

health concern

(27, 28)

. The lifetime prevalence of AAS use

for men is estimated to be from 3.0% to 4.2%

(12)

and is

increasing

(29)

. Use among male gym attendees is estimated

to be as high as 15%

–

30%

(9, 19, 25)

. Furthermore, the

growing trend of androgen replacement in rejuvenation

clinics was recently acknowledged by Moss et al.

(6)

such, the prototype of an AAS user is rapidly shifting to

encompass a spectrum from the competitive body builder/

athlete to men seeking to optimize their physical appearance.

Historically, media coverage concerning AAS has focused

disproportionately on athletes (from elite professionals to

high school students) seeking a competitive edge. In reality,

at least four out of

ve AAS users are not competitive athletes

but rather men who desire what they perceive to be an

‘‘

enhanced

’’

appearance

(9, 17, 21, 25)

. Recently, however,

data from the

‘‘

Monitoring the Future

’’

study

(30)

found that

illicit

AAS

use

was

declining

among

adolescents

—

potentially due to the success of education and numerous

prevention campaigns targeting high school athletes

(31)

Consistent with these data, Cohen et al.

(17)

found that

94% of the 1,955 adult AAS users began after the age of

18 years with an overwhelming number being whites in their

late 20s

–

30s with a slightly above-average socioeconomic

status. These men were self-reported perfectionists and highly

goal-oriented. Data from a recent retrospective study found

that 20.9% of 382 hypogonadal patients seeking T replace-

ment therapy (TRT) had earlier AAS exposure

(16)

. Therefore,

physicians treating hypogonadism should be aware of poten-

tial etiologies such as ASIH and understand where AAS are

obtained, the regimens that users follow, and the adverse

events that should be monitored.

AAS Availability and Procurement

It has previously been suggested that the Internet is the most

common source for men to obtain AAS as well as ancillary

drugs

(9, 17, 21, 32, 33)

. Access to these suppliers can vary

from open access to special invitations offered by Internet

forum members or via word of mouth at local gymnasiums.

Internet suppliers offer bundled packages that commonly

include T and synthetic androgens as well as selective

estrogen receptor modulators (SERMs), aromatase inhibitors

(AIs),

human

chorionic

gonadotropin

(hCG),

and

phosphodiesterase-5 inhibitors (PDE5i)

(33

–

35)

. Beyond

nonphysician sources, nutritional supplements sold legally

online or in retail stores have been found to contain AAS or

other ancillary drugs that may or may not be listed as

ingredients on the product label

(33, 34, 36

–

41)

. Indeed,

20% of legally sold nutritional supplements have been

found to be contaminated with AAS

(39)

. With global sales

of nutritional supplements exceeding $32 billion in 2012

and

rapidly

rising,

this

ubiquitous

impurity

poses

signi

cant public health problems

(42)

. Therefore, when

counseling and developing a treatment plan for the

hypogonadal patient with ASIH, it is critical to have an

understanding of what supplements the patient is on and

where they were obtained.

Users' Sources of Information and Medical Advice

When developing a self-designed treatment plan, AAS users

spend considerable time researching and seeking advice

from more experienced associates

(43)

. Historically, AAS

use was developed by a gym subculture whereby novice body-

builders interested in performance-enhancing substance use

would obtain the drugs and information from more experi-

enced users at the gym, often establishing a mentor-mentee

relationship

(19, 25)

. Now the most easily accessible source

for information regarding the details of illicit AAS use is the

Internet

(9, 17, 44)

. Numerous blogs and forums exist (e.g.,

www.steroid.com

www.steroidology.com

) where AAS users

around the world can anonymously offer or request advice,

share drug sources, chronicle results, and collaborate on

dosing schedules. Another source of information involves

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VOL. 101 NO. 5 / MAY 2014

ORIGINAL ARTICLE: ANDROLOGY