What is the appropriate documentation and management for a 25-year-old male patient taking testosterone (without medical indication) unnecessarily?

Documentation and Management of Non-Indicated Testosterone Use in a 25-Year-Old

Document clearly that the patient is using testosterone without medical indication, counsel on serious risks including irreversible infertility and cardiovascular complications, and implement harm reduction monitoring if the patient refuses to discontinue.

Immediate Documentation Requirements

Your medical record must protect you legally while attempting to help this patient. Document the following:

• Explicitly state that testosterone therapy is not medically indicated because the patient lacks both biochemical hypogonadism (testosterone <300 ng/dL on two separate morning measurements) and clinical symptoms of hypogonadism 1, 2
• Record that the European Association of Urology strongly recommends against testosterone therapy in eugonadal men, even for purposes like weight loss, athletic performance, or vitality enhancement 3, 4
• Document FDA warnings that testosterone abuse has been associated with cardiac arrest, myocardial infarction, hypertrophic cardiomyopathy, congestive heart failure, cerebrovascular accident, hepatotoxicity, and serious psychiatric manifestations including major depression, mania, paranoia, and psychosis 5
• Note that approximately 25% of men receiving testosterone in the United States do not meet diagnostic criteria, representing widespread inappropriate prescribing 1

Critical Counseling on Irreversible Harms

The most important conversation focuses on fertility destruction, which may be permanent:

• Exogenous testosterone suppresses the hypothalamic-pituitary-gonadal axis, causing azoospermia (zero sperm count), and this impact on fertility may be irreversible even after discontinuation 1, 4
• Recovery of spermatogenesis after stopping testosterone is unpredictable, with some men experiencing prolonged azoospermia lasting months to years 1
• At age 25, this patient is in his peak reproductive years, and testosterone abuse now could eliminate his ability to father children naturally in the future 4

Additional Serious Risks to Document

• Cardiovascular risks are compounded if the patient is using other substances—the combination of testosterone + stimulants (like Adderall) + self-dosed tadalafil creates multiplicative cardiovascular stress 4
• Erythrocytosis occurs in up to 43.8% of men on injectable testosterone, with hematocrit >54% requiring immediate discontinuation due to thrombotic risk 2, 4
• Testicular atrophy and subfertility are common adverse reactions in men who abuse testosterone 5
• Psychiatric manifestations including major depression, mania, paranoia, and aggression have been reported with testosterone abuse 5

Mandatory Harm Reduction Monitoring Protocol

If the patient refuses to stop testosterone, implement intensive monitoring to detect life-threatening complications early:

Monthly Monitoring (First 3 Months)

• Hematocrit/hemoglobin - withhold testosterone immediately if hematocrit >54% and document patient refusal if he continues 2, 4
• Blood pressure and cardiovascular symptom assessment - chest pain, shortness of breath, dizziness require emergency evaluation 1, 4

Quarterly Monitoring (Ongoing)

• Complete blood count with attention to erythrocytosis 4
• Comprehensive metabolic panel including liver function tests to detect hepatotoxicity 4, 5
• Lipid panel - testosterone abuse causes dyslipidemias 5
• Testosterone level - document supraphysiologic levels as evidence of abuse 4
• PSA and digital rectal exam starting at age 40 or earlier if family history of prostate cancer 4

Document Patient Refusal

• If hematocrit exceeds 54%, document that the patient was informed to stop immediately and record his refusal in detail 4
• Consider reporting to appropriate authorities if the patient is obtaining testosterone illegally through non-prescription sources 4

Screen for Underlying Psychiatric and Substance Use Disorders

Testosterone abuse rarely occurs in isolation and often signals deeper problems:

• Screen for body dysmorphic disorder - does the patient have distorted perception of his physique despite normal or above-average muscle mass? 4
• Assess for polysubstance abuse - is he using anabolic steroids, stimulants, erectile dysfunction medications, or other performance-enhancing drugs? 4, 5
• Evaluate for addiction behaviors per DSM-5 criteria: taking greater dosages than intended, continued use despite medical/social problems, spending significant time obtaining the drug, giving higher priority to drug use than other obligations, difficulty discontinuing despite desires to do so 5
• Refer immediately to psychiatry or addiction medicine if the patient meets criteria for substance use disorder 4

Address Polypharmacy Risks

Document the dangerous drug interactions if the patient is using multiple substances:

• Amphetamines (like Adderall) increase sympathetic tone and cardiovascular stress, which is compounded by testosterone's effects on hematocrit and blood pressure 4
• Self-dosed tadalafil adds unpredictable vasodilatory effects and may mask cardiovascular symptoms 4
• The combination creates compounded cardiovascular risk far exceeding any single agent 4

Counsel on Withdrawal Syndrome

If the patient agrees to stop testosterone, warn about withdrawal:

• Withdrawal symptoms may last weeks to months and include depressed mood, major depression, fatigue, craving, restlessness, irritability, anorexia, insomnia, decreased libido, and hypogonadotropic hypogonadism 5
• The patient may require temporary medical support during withdrawal, potentially including clomiphene citrate or hCG to restart endogenous testosterone production 1
• Close psychiatric follow-up is essential as major depression during withdrawal can be severe 5

Alternative Interventions to Offer

Rather than testosterone, address the underlying reasons the patient sought it:

• If concerned about body composition: recommend evidence-based resistance training programs and nutritional counseling 1
• If experiencing fatigue or low energy: evaluate for obesity, metabolic syndrome, depression, anxiety disorders, sleep disorders, chronic medical conditions, and medication side effects 2
• If concerned about sexual function: assess for relationship or psychological factors, and consider PDE5 inhibitors if erectile dysfunction is present 3
• If seeking athletic performance enhancement: counsel that testosterone provides no benefit in eugonadal men and creates only risks 3

Legal and Ethical Documentation

Your documentation must clearly establish that:

• The patient does not meet diagnostic criteria for hypogonadism requiring treatment 1, 2
• You counseled extensively on risks including irreversible infertility, cardiovascular complications, and psychiatric effects 2, 4, 5
• You offered appropriate alternatives and referrals to psychiatry/addiction medicine 4
• If the patient continues testosterone against medical advice, you implemented harm reduction monitoring and documented his informed refusal 4
• You are not prescribing or endorsing the testosterone use, but are providing medical monitoring to prevent death or serious injury 4

This approach balances your duty to counsel against harmful behavior with the reality that some patients will continue regardless, requiring harm reduction strategies to prevent the worst outcomes.