What to do with a 25-year-old male with normal lab tests, taking testosterone without a clinical indication, who refuses to stop despite associated risks, and is also taking Adderall (amphetamine and dextroamphetamine) and self-dosing with Tadalafil (tadalafil)?

Management of Non-Indicated Testosterone Use in a Young Adult

If a 25-year-old male with normal testosterone levels refuses to discontinue non-indicated testosterone therapy, you must clearly document the serious risks—including permanent infertility, cardiovascular events, and psychiatric complications—and strongly recommend immediate cessation, while implementing mandatory safety monitoring if he continues against medical advice. 1

Understanding the Clinical Context

This patient is misusing testosterone without a medical indication. The FDA explicitly states that testosterone products are approved only for use in persons with low testosterone levels due to known medical causes 1. The European Association of Urology strongly recommends against testosterone therapy in eugonadal men (those with normal testosterone levels), even for purposes like weight loss, athletic performance, or vitality enhancement 2.

Why This Matters for Morbidity and Mortality

The FDA drug label documents severe abuse-related adverse reactions in individuals using testosterone without indication, including:

• Cardiac arrest, myocardial infarction, hypertrophic cardiomyopathy, congestive heart failure, and cerebrovascular accident 1
• Serious psychiatric manifestations: major depression, mania, paranoia, psychosis, delusions, hallucinations, hostility, and aggression 1
• Permanent reproductive harm: testicular atrophy, subfertility, and infertility that may be irreversible 1
• Transient ischemic attacks, convulsions, hypomania, and dyslipidemias 1

Immediate Clinical Actions

Step 1: Direct Counseling on Irreversible Harms

Fertility destruction is the most critical immediate concern in a 25-year-old. Exogenous testosterone suppresses the hypothalamic-pituitary-gonadal axis, causing azoospermia (zero sperm production) 2. The FDA warns that "the impact on fertility may be irreversible" 1. Even if he doesn't desire children now, this decision at age 25 could permanently eliminate future fertility options 2.

Document this conversation explicitly: "Patient counseled that continued testosterone use without medical indication will likely cause permanent infertility. Patient acknowledges understanding but refuses to discontinue." 2

Step 2: Address the Polypharmacy Risks

The combination of testosterone + Adderall + self-dosed tadalafil creates compounded cardiovascular risk:

• Amphetamines (Adderall) increase sympathetic tone and cardiovascular stress
• Testosterone abuse is associated with cardiac arrest and myocardial infarction 1
• Tadalafil self-dosing without medical supervision adds unpredictable vasodilatory effects

This triple combination in a young male suggests body image concerns, performance anxiety, or substance misuse patterns that require psychiatric evaluation 1.

Step 3: Screen for Underlying Psychiatric or Substance Use Disorders

The FDA notes that testosterone abuse is characterized by specific addiction behaviors 1:

• Taking greater dosages than prescribed (or any dose without prescription)
• Continued drug use despite medical and social problems
• Giving higher priority to drug use than other obligations
• Difficulty discontinuing despite desires to do so

Ask directly: "Are you using testosterone for athletic performance, body building, or appearance?" 1, 3 This is critical because non-medical testosterone use often occurs alongside other anabolic steroid abuse 1, 3.

If Patient Refuses to Stop: Harm Reduction Protocol

While cessation is the only medically appropriate recommendation, if the patient absolutely refuses, implement mandatory monitoring to detect life-threatening complications early:

Required Baseline Testing (Before Next Dose)

• Hematocrit/hemoglobin: Testosterone abuse causes erythrocytosis; hematocrit >54% requires immediate cessation and possible phlebotomy 4
• Lipid panel: Dyslipidemias are common with abuse 1
• Liver function tests: Hepatotoxicity is a documented risk 1
• Testosterone level: Document supraphysiologic levels (likely >1000 ng/dL) 4
• PSA and digital rectal exam: Even at age 25, given abuse context 4
• ECG: Screen for early cardiac changes 1

Mandatory Follow-Up Schedule

• Month 1: Repeat hematocrit, liver enzymes, testosterone level
• Month 3: Full metabolic panel, lipids, hematocrit, PSA
• Every 3-6 months thereafter: Continue monitoring if he persists 4

If hematocrit exceeds 54%, you must document refusal to stop and consider reporting to appropriate authorities if he's obtaining testosterone illegally. 4, 2

Addressing the Adderall and Tadalafil

Adderall Verification

Confirm this is legitimately prescribed for ADHD with documented indication. If he's misusing prescribed Adderall or obtaining it without prescription, this compounds the substance abuse pattern 1.

Tadalafil Self-Dosing

"Self-dosing" tadalafil suggests he's obtaining it outside medical supervision (online pharmacies, underground sources). This is dangerous because:

• Unknown purity and dosing accuracy
• No screening for contraindications (nitrate use, cardiovascular disease)
• Suggests broader pattern of self-medication

Offer legitimate erectile dysfunction evaluation if that's his concern, but note that testosterone abuse itself can paradoxically cause erectile dysfunction through testicular atrophy and hormonal dysregulation 1.

Documentation Strategy

Your medical record must protect you legally while attempting to help the patient:

Document verbatim: "Patient is a 25-year-old male with normal baseline testosterone levels who is using testosterone without medical indication. Patient counseled extensively on FDA warnings including cardiac arrest, myocardial infarction, cerebrovascular accident, permanent infertility, testicular atrophy, psychiatric complications including psychosis and aggression, and hepatotoxicity. Patient acknowledges understanding these risks but refuses to discontinue. Patient informed that testosterone therapy is absolutely contraindicated in eugonadal men per European Association of Urology guidelines. Patient informed this constitutes drug abuse per FDA labeling. Harm reduction monitoring protocol initiated given refusal to stop." 2, 1

The Withdrawal Conversation

If you can convince him to stop, warn about withdrawal syndrome. The FDA documents that individuals taking supratherapeutic testosterone may experience withdrawal lasting weeks to months, including 1:

• Depressed mood and major depression
• Fatigue and craving
• Restlessness and irritability
• Anorexia and insomnia
• Decreased libido
• Hypogonadotropic hypogonadism (his natural testosterone production may be suppressed for months)

This is not a reason to continue—it's a reason to stop now before dependence worsens 1.

When to Involve Psychiatry or Addiction Medicine

Refer immediately if:

• He exhibits signs of body dysmorphic disorder
• There's evidence of polysubstance abuse
• He shows psychiatric symptoms (aggression, paranoia, mood instability) 1
• He meets criteria for substance use disorder per DSM-5

Critical Pitfall to Avoid

Never normalize or enable this behavior by simply "monitoring" without repeatedly emphasizing cessation. Some clinicians fall into the trap of thinking "at least I'm keeping him safe" by monitoring labs. This is ethically problematic because:

1. You're facilitating illegal drug abuse (testosterone is Schedule III) 1
2. You're not addressing the underlying psychiatric/behavioral issue
3. Monitoring creates false reassurance that this is "safe" when it's not 1

Your role is to advocate for cessation at every visit while implementing harm reduction only as a last resort. 2, 1