Approach

Anabolic-androgenic steroid (AAS) use can result in multiple medical and psychiatric problems for which users may seek treatment. AAS dependence is characterized by chronic AAS use despite adverse effects on physical, psychosocial, or occupational functioning.

Treatment focuses on supporting AAS discontinuation and managing the harms associated with chronic AAS use.[51]

Engaging with the patient

A nonjudgmental approach is required to help secure the patient’s trust, which is key to gain their future engagement with management. It is important to understand the patient’s:[6][52][53]

  • Motivation for AAS use

  • Level of AAS dependence: based on the presence of AAS-withdrawal symptoms when not using AAS (e.g., dysphoria, depression, fatigue, or body dysmorphia) and evidence of AAS-induced hypogonadism (loss of libido, erectile dysfunction, infertility)

  • Readiness to stop

  • Future goals for health and fertility.

AAS use creates an addictive state and dependency becomes a motivator for continued use.​[19]​​​ Understanding the mechanism of the dependence impacts its management and ideally will address: the underlying body image disorder; the androgen effects of AAS-induced hypogonadism and possible consequent major depression; and hedonic effects (similar to the mechanism of addiction for classical intoxicating drugs, particularly opioid brain reward mechanisms).[54]

Individuals who wish to stop may alleviate withdrawal symptoms by resuming AAS use, creating an abuse cycle that perpetuates the hypothalamic suppression and further delays ultimate recovery.[19]

Management should include:[54]

  • Therapies to build motivation to initiate and maintain abstinence from AAS use

  • Support during AAS withdrawal symptoms

  • Treatment of comorbid conditions, such as substance abuse and psychiatric disorders

  • Creating a supportive social network, finding mechanisms for coping with stress, and finding ways to balance fitness with other activities.

Elite athletes: evidence of approved use or discontinuation of AAS

Elite athletes may seek a therapeutic use exemption from the relevant antidoping agency for the use of an AAS for medical reasons (e.g., testosterone replacement therapy for treatment of hypogonadism resulting from Klinefelter syndrome).[1] World Anti-Doping Agency: therapeutic use exemptions Opens in new window​​

Endocrinologists may be asked to provide evidence of the medical indication for testosterone replacement therapy. Therapeutic use exemptions for the treatment of male hypogonadism are usually only granted for testosterone or gonadotropin therapy. Therapeutic use exemptions are not usually approved retrospectively or for non-testosterone AASs.

Retired elite male athletes may present with, or develop, secondary hypogonadism without an identifiable cause. They may be unwilling to divulge previous use of AASs because of concerns that information may be leaked into the public arena with associated reputational damage, loss of lucrative endorsements, and curtailed employment opportunities in their sport.[1]​ Endocrinologic input is important.

Athletes who are found guilty of the unapproved use of an AAS must discontinue the banned substance without the use of hormone therapy to mitigate against AAS withdrawal syndrome.[1]​ No tapering is required.[38]

Management of AAS use in the general population

There are no approved treatments of AAS withdrawal and clinical trials of medical therapy for AAS withdrawal are lacking.[1]​ Patient care is based on short-term aims, the possibility of AAS withdrawal symptoms, and a risk-benefit analysis of the treatment options compared with continued AAS use.[1]​

Users of AASs often study these drugs and their risks and benefits extensively and may believe themselves to be better educated on the subject matter than their clinician.[55]​ They are more likely to seek clinician advice for harm minimization than for stopping AAS use.[55]

Among those seeking help with AAS cessation, symptoms of AAS-induced hypogonadism (loss of libido, erectile dysfunction, infertility) are a common trigger for consultation with a clinician.[53]

All AAS users should be screened for neuropsychiatric disorders and alcohol and recreational drug use, and offered treatment as appropriate.

Ready to quit AAS use

In general, a supportive and educational approach is advised.[19][54]​ Strongly encourage cessation; no tapering is required.[38]

If complications such as suicidality or depression occur, antidepressant medications or admission to the hospital may be indicated.[33][54]​ Routine medical monitoring is not recommended (in the absence of medical problems); concerns exist that health checks that indicate no serious harm may precipitate continued AAS use.[11][19]​​

Collaboration with a psychiatrist for issues such as body-image disorders, major mood disorders, and substance use disorders is advised.[53]​ Counseling or psychotherapy may help to give people a more objective body image, to help them weigh risks and benefits of cessation, and to deal with the dysphoria that can accompany withdrawal from AASs.[54]

It is important to focus on alternatives to AAS for improving or maintaining muscle mass and performance. Alternatives include well-balanced nutrition and an appropriate training program.[56][57][58]​ Referrals to a sports dietitian and physical trainer are necessary for optimal alternative results. Use of some supplements may be beneficial, but others risk harm to the user’s health or performance. Use of supplements requires the input of a well-informed sports nutrition professional.[59]

Unwilling to stop AAS use

In cases of refusal to stop AAS use, the clinician should inform the patients about the known adverse effects with a focus on the cardiovascular system. The clinician should continue to encourage cessation of ASS use while monitoring for the development of complications. Addressing body dysmorphic disorder may improve the patient’s readiness to stop AAS use.

In some countries, an option to switch to prescription testosterone is considered to be a safer alternative to continued nonprescription AAS abuse, and facilitates tapering of testosterone over several months.[1]​ This approach may help to build a positive clinician-patient relationship, avoid AAS withdrawal symptoms, and prevent patients from using unregulated products bought online.[6]​ Note that prescribing testosterone or other androgens for people with AAS use disorder may be illegal or considered professional misconduct in some regions; check local guidance.[19]

For those patients who refuse to stop, harm reduction measures may still have benefits. The UK’s National Institute for Health and Care Excellence (NICE) recommends providing clean needles, syringes, and related equipment to adults who inject nonprescribed AASs.[60]

Management of harms associated with chronic AAS use

Warrants an interdisciplinary approach as chronic effects of AAS use, or discontinuation, may require review by a cardiologist (atherosclerosis, cardiomyopathy), endocrinologist (sexual dysfunction, infertility, other effects of hypogonadism), psychiatrist (mood disorders, body dysmorphia, depression), or addiction specialist (substance abuse).

After stopping use of AAS, changes in hormones, lipid and cholesterol metabolism, and salt and water balance typically resolve within weeks to months. Muscle tone will start to decrease even with continued bodybuilding exercise. Patients may also notice decreased stamina and decreased exercise tolerance.[61] ​Patients may have withdrawal-associated dysphoria, which could prompt a relapse.​​[19]​​​​

Patients should be reassured that many of the adverse effects associated with AAS use are reversible (e.g., acne, menstrual irregularities, dyslipidemia, elevated blood pressure, electrolyte abnormalities, needle marks) and will resolve within weeks to months of discontinuing the AAS.[38]​ Topical treatments may be used for acne.

Irreversible adverse effects

Some hormone-induced changes (including hair distribution/baldness, voice depth, hirsutism, gynecomastia, clitoral hypertrophy, infertility, testicular atrophy, short stature in adolescents) may be permanent.[19][20]​ 

Secondary hypogonadism can be confirmed with an early morning serum testosterone and gonadotropin levels. All other causes of secondary hypogonadism should be excluded. In men who have been on AAS for under a year, cessation of AAS use is likely to be sufficient to restore fertility. However, in men who have been on AAS for over a year and are infertile, recovery of the hypothalamic-pituitary-gonadal axis may take a long time.[1]

Surgical options may be considered for keloids and for irreversible gynecomastia. Cosmetic options (e.g., laser treatment) may be considered for hirsutism.

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