What are the risks and recommendations for a patient taking anabolic steroids, prescription testosterone (testosterone), and Human Chorionic Gonadotropin (HCG)?

Risks and Recommendations for Patients Taking Anabolic Steroids, Prescription Testosterone, and HCG

Patients taking anabolic steroids, prescription testosterone, and HCG face significant health risks including cardiovascular complications, liver toxicity, reproductive dysfunction, and psychological effects, and should be advised to discontinue anabolic steroid use while considering legitimate testosterone replacement therapy only if clinically indicated by confirmed hypogonadism. 1, 2

Cardiovascular Risks

• Anabolic steroids and testosterone therapy may increase risk of cardiovascular events, particularly in high-risk populations 3, 2
• Testosterone therapy should not be initiated for 3-6 months after cardiovascular events 4
• Injectable testosterone formulations may be associated with greater cardiovascular risk than transdermal preparations due to fluctuating testosterone levels 3

Reproductive System Effects

• Combined use of anabolic steroids and testosterone causes profound suppression of the hypothalamic-pituitary-gonadal axis, leading to hypogonadism 5
• Significant reductions in luteinizing hormone, follicle-stimulating hormone, and endogenous testosterone occur during use 5
• Sperm production is severely impaired, potentially causing oligospermia or azoospermia and affecting fertility 4, 5
• Testicular volume reduction is common with prolonged use 5
• Recovery of the reproductive system may take months to years after discontinuation, with some effects potentially being irreversible 5

Liver Effects

• Anabolic steroids, particularly oral alkylated forms, can cause liver toxicity 4, 2
• Alkylated oral testosterone should never be prescribed due to risk of liver damage 4

Psychological and Behavioral Effects

• Anabolic steroid use may be associated with aggression, hostility, and psychological disturbances including affective and psychotic syndromes 2, 6
• Risk of aggressive behavior significantly increases when anabolic steroids are combined with alcohol 2
• Psychological dependence can develop with prolonged use 6

HCG-Specific Risks

• HCG may cause ovarian hyperstimulation syndrome when used for fertility purposes 7
• Anaphylaxis has been reported with urinary-derived HCG products 7
• HCG has been used to treat anabolic steroid-induced hypogonadism, but this is not an FDA-approved indication 8

Monitoring Recommendations

• For patients on legitimate testosterone therapy:
  • Measure testosterone levels 2-3 months after treatment initiation and after any dose change 3, 1
  • Monitor hematocrit regularly; consider phlebotomy if >54% 1
  • Monitor PSA in men at risk for prostate cancer 1
  • Assess for sleep apnea, especially in at-risk patients 4
  • Perform regular cardiovascular risk assessment 1

Treatment Recommendations

• Advise immediate discontinuation of non-prescribed anabolic steroids 2, 5
• For patients with hypogonadism requiring testosterone therapy:
  • Use only FDA-approved testosterone formulations rather than compounded products 4
  • Consider transdermal preparations for most patients as they produce more stable testosterone levels 3, 1
  • Target mid-normal testosterone range (500-600 ng/dL) 3
  • Be aware that transdermal preparations carry risk of transfer to women and children 4
  • Injectable testosterone may cause fluctuating levels but is less expensive 3

Recovery from Anabolic Steroid Use

• Gonadotropin levels may take 13-24 weeks to return to baseline after discontinuation 5
• Testosterone levels may remain suppressed for 16+ weeks after discontinuation 5
• In cases of prolonged hypogonadotropic hypogonadism due to anabolic steroid abuse, HCG therapy may be considered to restore testicular function, though evidence is limited 8

Key Pitfalls to Avoid

• Never use testosterone therapy in men without documented hypogonadism 1
• Do not use testosterone to enhance athletic performance or physical appearance 1, 9
• Do not overlook fertility concerns when managing patients of reproductive age 1
• Do not test testosterone levels during acute illness as they may be falsely low 1
• Be aware that most sports organizations ban anabolic steroids 9