Anabolic steroid induced hypogonadism Diagnosis and treatment

A profile of the user with anabolic steroid–induced hypogonadism is provided, and management strategies are proposed.

Cyrus Rahnema, B.S., Larry Lipshultz, M.D., Lindsey Crosnoe, B.S., Jason Kovac, M.D., Ph.D., Edward Kim, M.D.

Volume 101, Issue 5, Pages 1271–1279


To develop an understanding of hypogonadal men with a history of anabolic-androgenic steroid (AAS) use and to outline recommendations for management.

Review of published literature and expert opinions. Intended as a meta-analysis, but no quality studies met the inclusion criteria.

Not applicable.

Men seeking treatment for symptomatic hypogonadism who have used nonprescribed AAS.

History and physical examination followed by medical intervention if necessary.

Main Outcome Measures(s):
Serum testosterone and gonadotropin levels, symptoms, and fertility restoration.

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.

Although complications of AAS use are variable and patient specific, they can be successfully managed. Treatment of ASIH depends on the type and duration of AAS use. Specific details regarding a patient’s AAS cycle are important in medical management.

  • Michael Scally

    I wish to thank the authors for raising the awareness of ASIH. Not only is this a concern for nonprescription AAS, but is an increasing problem among TRT users wishing to stop for a number of reasons.

    I have written on ASIH almost 15 years ago. This is discussed in Chapter 11 of the following book. The abstracts are listed following. [The book and abstracts are available free from]

    Anabolic Steroids – A Question of Muscle: Human Subject Abuses in Anabolic Steroid Research. .

    Street C, Scally MC. Pharmaceutical Intervention of Anabolic Steroid Induced Hypogonadism – Our Success at Restoration of the HPG Axis. Medicine and Science in Sports and Exercise 2000 Suppl;32(5).

    Scally MC, Street C, Hodge A. Androgen Induced Hypogonadotropic Hypogonadism: Treatment Protocol Involving Combined Drug Therapy. The Endocrine Society 2001 Abstract.

    Vergel N, Hodge AL, Scally MC. 2002 HPGA Normalization Protocol After Androgen Treatment. 4th International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV. Antiviral Therapy 2002; 7:L53.

    Scally MC, Kovacs JA, Gathe JC, and Hodge AL Uncontrolled Case Study of Medical Treatment for Elimination of Hypogonadism After Androgen Cessation in an HIV+ Male with Secondary Polycythemia treated 2 years Continuously with Testosterone. Endocrine Practice Vol.9 (Suppl 1), March/April 2003.

  • A growing problem that all fertility specialists need to be familiar with. Men with history of AAS often presents with hypogonadotropic hypogonadism on initial evaluation. I often struggle with proper evaluation and the role of pituitary MRI in this setting. I wonder what is the practice pattern among my fellow colleagues…

  • This informative article highlights the importance of increased knowledge about and screening for prescribed and nonprescribed use of AAS. I have made it a habit to ask every male partner of a couple presenting for infertility evaluation about AAS use. Prescribed and nonprescribed use has become so widespread, with little awareness amongst patients and even primary care physicians about the negative consequences on health and fertility. I have met more than one couple where AAS use was only disclosed by the male partner just before the start of an IVF/ICSI cycle (she being unaware of his AAS use and he being unaware of the effect on his SA). The article mentions that AAS-induced oligospermia or azoospermia can resolve spontaneously 4-12 months after AAS discontinuation. Makes me wonder how many thousands of IVF/ICSI or IUI cycles would be obsolete with proper awareness and screening.

  • Carlos Balmori

    Excellent review. Although the oral PDFE5i therapies are useful for erectil
    dysfunction, we must not forget that in these patients time to recover can be
    prolonged. It is necessary to work on the psychological aspects, explaining
    carefully how the treatment and the recovery expectations will be.

    • Jason Kovac

      Thank you for your kind words. Another consideration is that anecdotally, many men report improved erectile function, along with desire, following commencement of testosterone supplementation (TST). Further to this, several men in our practice have been able to stop using PDE5i’s after starting TST. No studies exist to document these observations but they are known to occur.

  • Excellent review on a very prevalent topic. Given the pressures to maintain youth or to augment appearances or performance, testosterone has become the cure all marketed to men of all ages. Although most men are being treated to maintain physiologic levels, those that are above and beyond from self dose adjustments are the ones at risk for developing the side effects outlined in this article. Unfortunately, the available information online for dosing regimens are all based on anectdotal evidence at best from the bodybuilding world and lack oversight. Because of this, we as physicians have to address the misinformation and treat the sequelae of therapy. It is reassuring that the complications can be successfully managed.

    • Jason Kovac

      Thank you. As an adjunct to your comments about self-dosing…. one of our earlier studies on ASIH in Journal of Urology found that 21.5% of AAS users increased their prescribed dose of testosterone without consulting a physician. While this has never been looked at in patients not on AAS, it is quite possible that such a trend would hold true in that population as well. Proper questioning and management of complications is critical.

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