a paradox of manliness

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Anabolic steroid abuse: a paradox of manliness
The study by Rahnema et al. in this issue of the Journal has
highlighted a surprising issue in the understanding of anabolic
androgen steroid (AAS) use in that no quality studies on the
subject met inclusion criteria to perform a meta-analysis (1).
A systematic review of the literature over a 48-year period
from 1965 to 2013 and of expert opinion was performed.
This systematic review provided an educational insight into
the behavior of AAS abusers and the side effects, including
infertility, with subsequent management including the ironic
anabolic steroid–induced hypogonadism (ASIH). The dilemma
that always exists for providers is whether treating such pa-
tients, and the sudden or later hypogonadism, is feeding into
their abuse/dependent personality versus a liberal and
nonjudgmental belief that these men need help with their
physical symptoms and signs. Rahnema et al. proposed an
example of a ‘‘recovery’’ protocol for such men.
In a world where the lay press sensationalizes alleged and
actual AAS abuse by competitive athletes, Rahnema et al.
have highlighted the extent of the problem. The true illicit cul-
ture actually is more sinister and most likely underreported,
with 80% being for body enhancement by nonathletes. It is
hard to believe that the lifetime prevalence of AAS abuse is
as high as 4.2% and up to 30% among gym attendees. The
abuse has trickled down into high school sports and body im-
age, with a Centers for Disease Control study showing that
AAS use increased from 1991 to 2003 (2.7%–6.1%) but then
decreased from 2003 to 2011 (6.1%–3.6%), hopefully owing
to better education (2). It is interesting and distressing but
not surprising to note that much of the information that
men obtain on the subject of AAS comes through quasi scien-
tific literature, internet blogs, websites, and word of mouth
from one generation of abuser to the next. The facts that
20% of nutritional supplements have been reported to be
contaminated with AAS and that the global sales of these sup-
plements exceeded $32 billion dollars go to show the extent of
the potential public health problem. This has been further
exacerbated in recent years with the dramatic increase in
the use of medically prescribed testosterone (T), which is being
questioned as a possible source of additional overuse (3). The
desire to get the edge on life is a sign of the worsening
competitive nature of life itself—to be faster, stronger, better
looking, and able to work harder. What does that say about
our culture?
It is not surprising that male and female reproduction
specialists see such male patients in their practices with infer-
tility from the secondary hypogonadotropic hypogonadism or
the direct gonadotoxic effect of the anabolic steroids. The sys-
tematic review has gone on to suggest that in most cases,
azoospermia or severe oligiospermia is likely to resolve in
4–12 months after cessation of the anabolic steroid. The de-
layed or slow time line for recovery of spermatogenesis in
some cases of AAS use or past use may lead couples toward
the use of higher forms of assisted reproduction technologies
like IVF before full recovery has been given a chance to occur.
The role and benefit of recovery treatment and potentially
quicker sperm return with selective estrogen receptor modula-
tors, aromatase inhibitors, and/or hCG remains unclear (1, 4).
VOL. 101 NO. 5 / MAY 2014
The only analogous studies to investigate the recovery from
AAS are the trials that have used T as a male contraceptive
agent. The largest and longest study by Gu et al. in 2009
demonstrated that after a loading dose of 1,000 mg of T IM
and 500 mg once a month for 30 months, the median
recovery time for sperm production to the patient's baseline
after cessation of the treatment alone was 182 days (5). All
but two of 729 patients recovered spermatogenesis by 15
months (5). The largest difference between this
contraceptive study and the abuse of AAS is that
bodybuilders often ‘‘stack’’ multiple androgens and at much
higher doses of 500–1,500 mg/week for 4–12 weeks and
sometimes for years. With multiple different AAS regimens
being used and variable durations and cycles of treatment,
the exact recovery from AAS is not known. A prospective
study of different real world AAS regimens and recovery
would be difficult to conduct in a structured and ethical
manner since these are controlled drugs that are obtained
illicitly from a number of questionable sources of variable
quality and given in doses that are much higher than are
considered safe. Trials of different recovery medication
protocols and subsequent expert opinion may remain the
only methods to study the treatment of these men after
AAS abuse. How a medical provider feels about managing
these patients and the consequences of their abuse from
both a fertility and sexual standpoint is difficult to
ascertain because the ASIH might be lifelong. Management
should probably be a multidisciplinary and team approach
to address the physical and psychological issues.
Ajay K. Nangia, M.B.B.S.
Department of Urology, University of Kansas Medical Center,
Kansas City, Kansas
http://dx.doi.org/10.1016/j.fertnstert.2014.02.034
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manliness/
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REFERENCES
1. Rahnema CD, Lipshultz LI, Crosnoe LE, Kovac JR, Kim ED. Anabolic steroid–
inducedhypogonadism:diagnosis and treatment. Fertil Steril 2014;101:1271–9.
2. Eaton DK, Kann L, Kinchen S, Shanklin S, Flint KH, Hawkins J, et al. Centers for
Disease Control and Prevention. Youth Risk Behavior Surveillance—United
States, 2011. MMWR 2012;61:23.
3. Layton JB, Li D,Meier CR, Sharpless J, St€urmer T, Jick SS, et al. Testosterone lab
testing and initiation in the United Kingdom and the United States, 2000–
2011. J Clin Endocrinol Metab 2014 Jan 1:jc20133570. [Epub ahead of print].
4. Kim ED, Crosnoe L, Bar-Charma N, Khera M, Lipshultz LI. The treatment of
hypogonadism in men of reproductive age. Fertil Steril 2013;99:718–24.
5. Gu Y, Liang X,WuW, LiuM, Song S, Cheng L, et al. Multicenter contraceptive
efficacy trial of injectable testosterone undecanoate in Chinese men. J Clin
Endocrinol Metab 2009;94:1910–5.
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	Anabolic steroid abuse: a paradox of manliness
	References