lowest quartile of the reference range for serum

testosterone and the remaining 13.3% were below

normal. While AAS type and duration were not

documented, after 1 or multiple cycles of solitary

combined

AAS

lower

baseline

testosterone

may possibly develop.

This could lead to testos-

terone above the threshold for symptoms but below

prior normal levels, ultimately resulting in these

men becoming symptomatic at an earlier than

expected age.

However, beyond these hypotheses lies the

question of how to evaluate and treat ASIH in

patients with prior AAS exposure. An example of

how identifying ASIH could change the evaluation

of young hypogonadal men relates to the indication

to perform pituitary magnetic resonance imaging in

the setting of profound hypogonadism. In our study

a pituitary adenoma was found in only 2% of men

with profound hypogonadism compared to 43% with

ASIH as the etiology.

In addition to evaluation, these ﬁndings suggest

a shift in the treatment paradigms of young hypo-

gonadal men. Because TRT negatively impacts

spermatogenesis and fertility, options that preserve

fertility should be discussed and preferentially

offered

young

men

with

hypogonadism.

Concomitant administration of low dose human

chorionic gonadotropin maintains spermatogenesis

in hypogonadal men who desire fertility preserva-

tion while receiving TRT.

Aside from TRT, other

options for hypogonadism treatment that preserve

fertility in men of reproductive age include off label

use of selective estrogen receptor modulators and

aromatase inhibitors.

23,25,26

This study has several limitations. The retro-

spective arm of the study had strict inclusion

criteria and the prospective arm more broadly

included all men who received TRT. This distinction

created a potential limitation in how ASIH may be

interpreted between these 2 cohorts. Also, to pre-

serve anonymity hormone proﬁles were not ob-

tained at the time of survey completion. Therefore,

our ability to correlate testosterone levels with the

duration of AAS exposure and compare the retro-

spective

and

prospective

cohorts

was

limited.

Because the survey relied on the honesty of patient

responses on a sensitive topic, data are subject

to recall bias as well as bias secondary to partici-

pant embarrassment or distrust, potentially under-

estimating the true prevalence of AAS use. The

study was performed at a single clinic in an urban

setting and results may not reﬂect the prevalence

of AAS use in rural, community or other urban

settings. Finally, we created the survey and no formal

validation was performed.

Nevertheless, our data highlight the signiﬁcance

of AAS use in men with profound hypogonadism and

in young hypogonadal men with its potential for

predisposing to hypogonadism at an earlier age. We

recommend that profoundly hypogonadal men and

young hypogonadal men be screened for prior AAS

use or TRT with a single question and that hypo-

gonadal treatment be administered in young men,

tailored to maximize fertility potential.

CONCLUSIONS

Prior AAS use is common in young men who seek

treatment

for

symptomatic

hypogonadism

and

ASIH is the most common etiology of profound

hypogonadism (testosterone 50 ng/dl or less). These

ﬁndings suggest a necessarily refocused approach

to the evaluation and treatment of young men

presenting with symptomatic hypogonadism. We

recommend that young hypogonadal men and

men who present with profound hypogonadism be

screened for prior AAS use or TRT. Hypogonadal

treatment in young men should be tailored to maxi-

mize fertility potential.

ACKNOWLEDGMENTS

Ross E. Krasnow, Michael L. Eisenberg and Rustin

C. Walters acquired preliminary data.

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