Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

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elite athlete: anabolic-androgenic steroid (AAS) use

1st line – provide evidence of approved use or discontinue AAS

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elite athlete: anabolic-androgenic steroid (AAS) use
1st line – 

provide evidence of approved use or discontinue AAS

Elite athletes may seek a therapeutic use exemption from the relevant antidoping agency for the use of an anabolic-androgenic steroid (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]​ 

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]

Consider – management of harms associated with chronic use

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elite athlete: anabolic-androgenic steroid (AAS) use
Consider – 

management of harms associated with chronic use

Treatment recommended for SOME patients in selected patient group

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).

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.

general population: anabolic-androgenic steroid (AAS) use

1st line – support AAS discontinuation

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general population: anabolic-androgenic steroid (AAS) use
1st line – 

support AAS discontinuation

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]

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 AAS 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]

Consider – management of harms associated with chronic use

Back
ONGOING
|
general population: anabolic-androgenic steroid (AAS) use
Consider – 

management of harms associated with chronic use

Treatment recommended for SOME patients in selected patient group

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.

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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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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