Basics

Axis is key – exogenous steroids suppress anterior pituitary LH + FSH

• LH usually stimulates leydig cells to make testosterone
• FSH usually stimulates sertoli cells to make sperm

Reactivation of pituitary can take 6-18 months or longer after cessation of steroids

Concomitant PIEDs (performance and image enhacing drugs) is common

eg. HCG to increase testicular volume, tamoxifen to decrease gynaecomastia, growth hormone, diuretics

Also concomitant illicit drugs eg. stimulants, alcohol

Co-existing mental health common eg. depression, anxiety, body dysmorphic disorder

Can be taken orally (liver toxicity) and injectable (gluteal abscess)

Cycling and blast patterns of use

Illegal to possess or take non-prescribed anabolic steroids, but GP has no obligation to report

Insurance companies may request information but need patient consent

Presentations

Toned, muscular man – often not classical bodybuilder size – with low libido, infertility, mood problems

Toned, muscular female – irregular periods, androgenisation

Blood abnormalities – high Hb/hematocrit, abnormal LFT or renal function, high testosterone

Adverse effects/dependence

Adverse effects

Reversible, short term effects – acne, aggression/anxiety, scrotal pain, hypertension, oedema

Long term effects or irreversible – testicular atrophy, male pattern baldness, gynaecomastia, hirsutism, infertility, tendon rupture, hepatic Ca, cardiomegaly

Key points in history/exam

If not forthcoming, probe gently eg. ‘do you use any supplements for training?’

Duration of use, name of drug(s) used and method of admin

Reasons for taking (… motivational interviewing skills)

Illicit drug use

Mental health issues

BMI, BP, skin, testes

Investigations

Often more useful 3 months after cease use to assess recovery

Typical abnormalities during use:

FBC – high Hb, HCT

Testosterone – high (low post-cessation)

LH/FSH – low

Estradiol – high

LFT – high ALT, AST, ALP, GGT, LDH 

Creatinine – high (can be due to muscle bulk or kidney injury)

Lipids – high LDL, low HDL

Semen analysis – low count, low motility, abnormal forms

BBV screen – if needle use

ECG – LVH

Managing hypogonadism

Expect 6-18 months for recovery or longer and during this time, testosterone deficiency symptoms (lethargy, low libido, ED)

Symptomatic measures – sildenafil for ED, SSRI, psychology

Hormonal treatment – not licenced but include HCG, clomiphene for fertility, testosterone if not pursuing fertility – consider endocrinology referral