The diagnosis of hypogonadism and its treatment
with TRT has shown significant growth in recent
years with testosterone prescriptions increasing
more than 170% since 2007
and 500% since
The characterization of hypogonadal men
treated with TRT provides an improved under-
standing of the role of testosterone in aging males
but far less is understood about hypogonadal men
with a history of AAS use.
The initial objective of the current study was to
identify causes of profound hypogonadism (total
testosterone 50 ng/dl or less) in our entire popula-
tion. After a retrospective review of 6,033 patients
we found that 43% of those with profound hypo-
gonadism reported prior AAS exposure. Because
only profoundly hypogonadal men were assessed,
the percent with prior AAS exposure could over-
estimate the prevalence in the general hypogonadal
population. Also, profound hypogonadism could
have resulted from recent discontinuation or from
active AAS use, of which neither could be discerned
retrospectively. Therefore, we performed a prospec-
tive survey of men currently receiving TRT to
determine whether prior AAS use was as common in
hypogonadal men in general as it was in those pre-
senting with profound hypogonadism in particular.
Previous groups noted escalating trends of AAS
use. In 1973 a study at 5 American universities
showed a 1.5% prevalence of AAS use.
In a 1988
survey of 3,402 twelfth grade males 6.6% reported
current or previous AAS use.
A study in 2002
showed that 5.4% of 4,746 middle and high school
students had prior AAS exposure.
Given its subculture use, it has been difficult to
obtain reliable information on the demographics of
AAS users. Contrary to the common public percep-
tion that AAS is used primarily by professional
athletes or those in a small sector of society, we
found instead that AASs are much more common-
place. Compared to men without prior AAS expo-
sure, hypogonadal men with a history of AAS use
were more likely to be younger and less educated,
and have fewer children. Despite these correlations
most AAS users are heterosexual (98.7%) and
married (53.7%) (table 2), and 38.7% have at least 1
child (data not shown). These demographics clearly
reflect AAS use among mainstream society.
In regard to specific AAS use patterns we iden-
tified the most common AASs used as nandrolone
decanoate (Deca-Durabolin
, 75% prevalence), sta-
nozolol (Winstrol
, 56.3%) and methandrostenolone
, 48.8%) (table 3). In a 1992 study 300
subjects from private gymnasiums around the
United Kingdom reported a preference similar to
the types of AAS used (59.5%, 30.6% and 69.4%,
The side effect profile that we identified included
fluid retention in 45% of cases and testicular atro-
phy in 41% as the top reported adverse events.
These rates were similar to data from a survey of
500 AAS users in which 63.6% reported testicular
atrophy and 52% reported fluid retention.
can also have adverse effects on the heart and liver.
Cardiovascular toxicity can include atherosclerosis
secondary to dyslipidemia, and platelet dysfunction,
hypertension and cardiomyopathy.
is relatively common
and it was reported by 8.8%
of our cohort. While AAS is also associated with
increased liver transaminases, hepatic neoplasms,
jaundice and cholestasis,
none was observed in the
current study.
Partially due to a lack of research in the field,
prior AAS use is a rarely considered etiology of
hypogonadism. The diagnosis requires a trusting
patient-physician relationship, which may be diffi-
cult to achieve during an initial visit. Obtaining an
AAS use history can be uncomfortable for patients
and physicians. Also, physicians may believe that a
history of AAS use is not clinically useful after it is
identified. In contrast, we propose that a history of
AAS use is a possible risk factor for early hypo-
gonadism in young men.
The existence of ASIH was directly identified in
1990 by Jarow and Lipshultz when blunted gonad-
otropin levels were found 1 to 3 years after the last
documented AAS use.
The finding that younger
hypogonadal men are more likely to have used AAS
hints at the possibility that hypogonadal symptoms
may have developed at a younger age in these men
(see figure). The degree of suppression and ability to
recover largely depends on the particular AAS used,
and its duration and cumulative dose.
Most men
return to baseline testosterone within 1 to 2 years
after AAS exposure
but some may never fully
Therefore, in the current study it is
possible that some patients initially presented with
symptomatic hypogonadism warranting TRT while
gonadotropins were still actively recovering.
In 2003 a group retrospectively examined the
long-term effects of AAS in 32 males.
Mean time
after AAS discontinuation was 43 months (range
1 to 10 years). Of the patients 86.7% were in the
Table 4.
Self-reported side effects of AAS use in 80 patients
No. Pts (%)*
Fluid retention
Decreased testicular size
33 (41.3)
40 (37.5)
Aggressiveness/behavior change
13 (16.3)
Infertility/low sperm count
9 (11.3)
High cholesterol
7 (8.8)
Increased hematocrit
6 (7.5)
*No patient had liver problems or lower urinary tract symptoms.