Management of Non-Medical Testosterone Use in a Young Male with Normal Levels
You should not prescribe testosterone to this patient, as he does not meet diagnostic criteria for hypogonadism and testosterone therapy is explicitly contraindicated in eugonadal men. 1, 2
Diagnostic Requirements Not Met
This patient fails to meet the established criteria for testosterone replacement therapy on multiple fronts:
FDA-approved indications require documented hypogonadism from primary testicular failure or hypogonadotropic hypogonadism due to hypothalamic-pituitary dysfunction—not normal testosterone levels with subjective symptoms. 2
The European Association of Urology explicitly recommends against testosterone therapy in eugonadal men, even when patients report symptoms of low energy, decreased muscle mass, or other complaints. 1
Diagnosis requires both biochemical confirmation AND symptoms: Two separate morning total testosterone measurements below 300 ng/dL (8-10 AM) are mandatory, along with consistent clinical symptoms. 1, 3, 4 This patient's normal levels disqualify him regardless of reported symptoms.
Approximately 20-30% of men receiving testosterone in the United States do not have documented low testosterone levels before treatment initiation—a practice pattern that violates evidence-based guidelines. 5
Critical Distinction: Enhancement vs. Medical Treatment
The patient's history reveals non-medical use (bodybuilding/muscle enhancement) rather than legitimate hypogonadism:
Testosterone misuse is defined as systematic over-prescribing for unproven medical indications, including use for muscle building in men without confirmed androgen deficiency. 6
His prior use has likely suppressed his hypothalamic-pituitary-gonadal axis, making current symptom assessment unreliable while exogenous testosterone remains in his system. 1
To properly evaluate for true hypogonadism, he must discontinue all testosterone use and undergo a washout period of 2-4 weeks before diagnostic testing can accurately differentiate primary from secondary hypogonadism. 1
What Testosterone Therapy Actually Does (and Doesn't Do)
Even if this patient had confirmed hypogonadism, the evidence shows limited benefits:
Small improvements in sexual function only: Testosterone therapy produces modest improvements in libido and sexual function (standardized mean difference 0.35) but little to no effect on physical functioning, energy, vitality, or cognition. 5, 1
No benefit for muscle building in eugonadal men: The primary indication is sexual dysfunction in biochemically confirmed hypogonadism—not athletic performance or body composition. 5, 1
Quality of life improvements are minimal: Effect sizes are small even in men with documented low testosterone. 5
Serious Risks of Inappropriate Prescribing
Prescribing testosterone to this patient exposes him to significant harms without medical benefit:
Erythrocytosis risk: Up to 44% of men on injectable testosterone develop elevated hematocrit, particularly with the supraphysiologic dosing patterns common in non-medical use. 1, 7
Cardiovascular events: Observational data suggest increased cardiovascular risk (Peto odds ratio 1.22). 1
Permanent fertility compromise: Exogenous testosterone suppresses spermatogenesis and can cause prolonged or permanent azoospermia—absolutely contraindicated in men of reproductive age who may desire future fertility. 1, 4
Testicular atrophy: Chronic suppression of the hypothalamic-pituitary-gonadal axis leads to testicular shrinkage. 1
Appropriate Clinical Response
Your management should focus on education, harm reduction, and addressing underlying issues:
Explain that his symptoms are likely withdrawal effects from chronic exogenous testosterone use suppressing his natural production, not true hypogonadism. 1
Offer a proper diagnostic workup after complete washout: If he discontinues testosterone for 2-4 weeks, you can then measure morning total testosterone on two separate occasions, along with LH and FSH, to determine if true hypogonadism exists. 1, 3, 4
Screen for underlying causes of his symptoms: Evaluate for obesity, sleep disorders, thyroid dysfunction, anemia, vitamin D deficiency, metabolic syndrome, and cardiovascular risk factors—all of which can cause fatigue and decreased energy. 1
Recommend lifestyle interventions: Weight loss through low-calorie diets and regular exercise can improve testosterone levels in men with obesity-associated secondary hypogonadism. 1
Document your refusal clearly: Note that the patient does not meet FDA-approved indications for testosterone therapy and that prescribing would constitute off-label use for bodybuilding purposes. 2
Common Pitfalls to Avoid
Do not diagnose hypogonadism based on symptoms alone—screening questionnaires lack specificity and approximately 20-30% of older men have low-normal testosterone without disease requiring treatment. 1, 3
Do not attempt to measure LH/FSH while the patient is on testosterone—results will be misleadingly suppressed and cannot differentiate primary from secondary hypogonadism. 1
Do not prescribe "just to see if it helps"—this perpetuates the cycle of dependence and exposes the patient to serious risks including permanent infertility. 1, 4
Do not assume his symptoms will resolve immediately after stopping—recovery of the hypothalamic-pituitary-gonadal axis can take months, and he may benefit from referral to endocrinology for management of withdrawal symptoms. 1
If He Refuses to Discontinue Use
Counsel on harm reduction: If he continues non-medical use despite your recommendation, discuss monitoring hematocrit (withhold if >54%), PSA in men over 40, and fertility preservation options. 1
Refer to addiction medicine or psychiatry: Body dysmorphia and anabolic steroid dependence may require specialized treatment. 6, 8
Document extensively: Clearly note that you advised against continued use, explained the risks, and offered appropriate alternatives. 2