speci

‘‘

nutritionists

’’

who, for a fee, usually yearly, give

advice to these men about AAS, dietary supplements, and

nutritional plans.

The AAS user's rationale for choosing various drugs and

protocols is typically based on anecdotal evidence and inter-

pretations of quasiscienti

c literature propagated via Internet

forums. It is also apparent that some users achieve popular au-

thority within the Internet bodybuilding community and are

often consulted for medical advice via forums. Indeed, given

the minimal exposure that physicians have to AAS, coupled

with the fact that many

‘‘

expert

’’

users have experimented

with the majority of available AAS and their companion

medications, it is not too far-fetched to consider

rst-hand

experience of achievable gains, side effects, and

‘‘

optimal

’’

self-treatment regiments by seasoned AAS users to be of

perceived

‘‘

greater value

’’

than an average physician's recom-

mendation. Indeed, it is the general consensus within the

AAS community that experienced AAS users are more

educated than their physicians on AAS use, a sentiment that

may contribute to the AAS user's hesitancy to approach his

physician for advice when adverse symptoms occur

(17, 43)

Motivations for Use and Dependence: A Challenge

for Clinicians

Results from large surveys sampling AAS users on Internet

bodybuilding forums have reported that the most common

reason for beginning AAS use was to increase muscle mass

and decrease body fat

(9, 17)

. These users also reported

feeling compelled to continue their regimens for a fear of

the withdrawal that would result in excessive hypogonadal

symptoms and the loss of muscle mass

(6, 17)

When considering the concept of ASIH, the aggregate

AAS dose and duration likely portends the extent of the con-

dition; however, it must be recognized that there are substan-

tial variations in types and amounts of AAS used

(45)

subset of aggressive users may develop a dependence syn-

drome of combined physiologic and psychologic etiology,

subjecting themselves to long-term or permanent endocrine

dysfunction

(9, 12, 14, 15, 17, 31, 44

–

46)

. Given these case

reports as well as the known AAS side effects, one might

wonder whether AAS users experience regret over their

decision to use AAS. If these suspicions are correct, then

determining the reasons for regret would be a valuable tool

in educating current patients previously on AAS who are

seeking TRT for hypogonadism.

In stark contrast to the classic drug abusers, most AAS

users show considerable forethought in their illicit substance

use

(47)

. Users typically obtain all of the necessary medica-

tions before beginning their self-determined

‘‘

treatment

’’

cy-

cle and follow calculated dosing schedules

(9, 17, 25, 48, 49)

AAS users are often hesitant to stop their regimens and often

present to physicians with requests for diagnostics or

unwarranted therapies without the intent of stopping illicit

AAS use. It is also common for AAS users to want to cycle

off all TRT, feeling that this enhances their responsiveness

and improves safety. As such, the treatment of AAS users

poses a unique challenge for physicians. It may be helpful

to gauge the patient's knowledge of AAS-associated compli-

cations while working to address misconceptions that often

stem from Internet forum trends and popular anecdotal evi-

dence. Central to this is the need for physicians to become

more educated about the psychology and pathophysiology

underlying AAS use.

Pathophysiology

Feedback suppression.

Use of AAS results in hypogonado-

tropic hypogonadism by feedback suppression of the

hypothalamic-pituitary-gonadal (HPG) axis via inhibition of

pulsatile GnRH release and a subsequent decrease in LH and

FSH (

Fig. 1

). The duration of suppression and the resultant

symptomatic ASIH is highly variable and due to multiple fac-

tors, including differences in the choices of drugs, amounts

used, and durations of use. Based on our experience, there

may be differences between individual users regarding the

response kinetics of the HPG axis. Our experience and that of

other investigators suggests that younger men may have a

‘‘

elastic axis

’’

capable of recovering GnRH pulsation and

gonadotropin secretion faster and more completely than older

AAS users

(50)

. It is possible that shorter durations, lower doses,

youngerages,and higherT levelsatbaseline are associatedwith

a quicker recovery of HPG axis function after AAS use.

ASIH: a unique pathophysiology.

Considerable variation ex-

ists regarding drug combinations, dosing, and duration of use.

Up to 90% of AAS users combine or

‘‘

stack

’’

multiple andro-

gens, a practice that users believe provides the greatest results

while

minimizing

unwanted

side

effects

(19,

48)

Traditionally, a typical bodybuilding cycle includes a stack

of multiple AAS at a combined dose of 500

–

1,500 mg/wk

and lasts on average 4-12 weeks

(17, 19, 25, 32, 48, 51)

(

Table 1

). The most commonly used androgens reported by

multiple surveys are single-ester T, nandrolone, stanazolol,

metandienone, and trenbolone

(16, 17, 32)

. In contrast,

FIGURE 1

Illustrates the pathophysiology of anabolic-androgenic steroid (AAS)

–

induced hypogonadism (ASIH) and the mechanism of action of

selected treatment strategies. Recovery therapy focuses on estrogen

blockade at the level of the hypothalamus to encourage GnRH

pulsation and gonadotropin release to restart the hypothalamic-

pituitary-gonadal axis and increase testosterone production.

Rahnema. Anabolic steroid

–

induced hypogonadism. Fertil Steril 2014.

VOL. 101 NO. 5 / MAY 2014

1273

Fertility and Sterility®