What can be prescribed for a male patient post anabolic steroid use to restore natural testosterone production?

Treatment Options for Post-Anabolic Steroid Use in Males

Human chorionic gonadotropin (hCG) is the first-line treatment for males after anabolic steroid use to restore natural testosterone production, with a recommended dosage of 500-1,000 USP units three times weekly for 6-12 weeks. 1, 2

Pathophysiology and Impact of Anabolic Steroid Use

• Anabolic steroid use causes suppression of the hypothalamic-pituitary-gonadal axis, resulting in decreased endogenous testosterone production and potentially impaired spermatogenesis 3
• Exogenous testosterone administration provides negative feedback to the hypothalamus and pituitary gland, inhibiting gonadotropin secretion and potentially causing oligospermia or azoospermia 2
• Recovery of natural testosterone production after anabolic steroid cessation can be prolonged, taking months or rarely years without intervention 2

First-Line Treatment Options

Human Chorionic Gonadotropin (hCG)

• FDA-approved for hypogonadotropic hypogonadism in males 1
• Recommended dosing regimens:
  • 500 to 1,000 USP units three times weekly for three weeks, followed by the same dose twice weekly for three weeks 1
  • 4,000 USP units three times weekly for six to nine months, followed by reduced dosage of 2,000 USP units three times weekly for an additional three months 1
• hCG directly stimulates testicular Leydig cells to produce testosterone, bypassing the suppressed hypothalamic-pituitary axis 2
• The only FDA-approved agent among fertility-preserving options for males with testosterone deficiency 2

Alternative and Adjunctive Treatments

Selective Estrogen Receptor Modulators (SERMs)

• Clomiphene citrate is commonly used off-label for post-anabolic recovery 4, 5
• Mechanism: Blocks estrogen receptors in the hypothalamus, increasing gonadotropin release and stimulating testicular testosterone production 5
• Benefits include:
  • Preservation of fertility potential 6
  • Fewer side effects compared to exogenous testosterone 5
  • Effective in increasing both total and free testosterone levels 5

Aromatase Inhibitors

• May be used as part of combination therapy for post-cycle recovery 3, 7
• Mechanism: Reduces conversion of testosterone to estradiol, thereby decreasing negative feedback on the hypothalamic-pituitary axis 2

Combination Therapy Approach

• A combination of hCG, SERMs, and aromatase inhibitors may be more effective than monotherapy for recovery of spermatogenesis and testosterone production 3, 4
• Survey data suggests that post-cycle therapy (PCT) with these agents reduces withdrawal symptoms by approximately 60% and suicidal thoughts by 50% in men discontinuing anabolic steroids 4

Monitoring and Follow-up

• Measure initial follow-up total testosterone level after an appropriate interval to ensure target levels are achieved 2
• Continue monitoring testosterone levels every 6-12 months while on therapy 2
• Assess for symptom improvement (energy, libido, mood) as well as biochemical parameters 2, 5

Important Considerations and Cautions

• Avoid prescribing exogenous testosterone therapy in men desiring future fertility, as it can further suppress the hypothalamic-pituitary-gonadal axis 2
• Commercially manufactured products should be prescribed rather than compounded formulations when possible 2
• Alkylated oral testosterone should not be prescribed due to risk of liver toxicity 2
• Treatment should be discontinued if target testosterone levels are achieved but symptoms do not improve after 3-6 months 2

Predictors of Treatment Response

• Lower normal range LH levels before treatment may predict better response to SERMs like clomiphene citrate 5
• Testicular size prior to treatment correlates with response to hCG therapy 2