Treatment and Post-Cycle Therapy for Low Sex Drive Following Anabolic Steroid Use
Men experiencing low sex drive after anabolic steroid cessation should first discontinue all exogenous androgens and undergo diagnostic testing to confirm hypogonadotropic hypogonadism, followed by human chorionic gonadotropin (hCG) plus FSH therapy if fertility is desired, or testosterone replacement therapy if fertility is not a concern. 1
Understanding Anabolic Steroid-Induced Hypogonadism
Anabolic-androgenic steroids suppress the hypothalamic-pituitary-gonadal (HPG) axis through negative feedback, causing hypogonadotropic hypogonadism characterized by low testosterone, low LH, and low FSH. 2, 3 This condition manifests with reduced libido, erectile dysfunction, testicular atrophy, fatigue, and mood disturbances. 3, 4 Recovery is highly variable—ranging from months to years—and depends on the duration and dose of steroid abuse, with some cases remaining irreversible. 3, 5, 6
Immediate Management: Cessation and Diagnostic Confirmation
Stop all anabolic steroids immediately. 3, 4 Continued use perpetuates HPG axis suppression and delays recovery.
Measure morning total testosterone (8-10 AM) on two separate occasions to confirm levels below 300 ng/dL. 2, 1 Single measurements are insufficient due to assay variability.
Measure LH and FSH levels to confirm hypogonadotropic hypogonadism (both will be low or low-normal with low testosterone). 1, 3 This distinguishes steroid-induced suppression from primary testicular failure.
Assess baseline hematocrit, PSA (if over 40 years), and perform testicular examination to evaluate testicular size and identify atrophy. 2, 1
Post-Cycle Therapy: Evidence-Based Approach
For Men Desiring Fertility Preservation
Gonadotropin therapy with hCG plus FSH is mandatory and represents the only evidence-based approach for restoring both testosterone production and spermatogenesis. 2, 1
Initiate recombinant hCG 1,000-2,500 IU subcutaneously 2-3 times per week. 1 This directly stimulates testicular Leydig cells to produce testosterone.
Add recombinant FSH 75-150 IU subcutaneously 2-3 times per week after 3-6 months if sperm counts remain low. 1 Combined hCG plus FSH provides optimal fertility outcomes compared to hCG monotherapy.
Monitor testosterone levels at 2-3 months, then every 6-12 months. 1 Target mid-normal testosterone levels (500-600 ng/dL).
Obtain semen analysis at 3-6 month intervals to assess spermatogenesis recovery. 2 Recovery from azoospermia to normal sperm counts typically requires 6-12 months but may take longer. 5, 6
Never use testosterone replacement therapy if fertility is desired, as exogenous testosterone immediately suppresses spermatogenesis and causes prolonged, potentially irreversible azoospermia. 2, 1
For Men NOT Desiring Fertility
Testosterone replacement therapy is the appropriate treatment once fertility is no longer a concern. 2, 1
Transdermal testosterone gel 1.62% at 40.5 mg daily is the preferred first-line formulation due to stable day-to-day testosterone levels and lower erythrocytosis risk compared to injectable preparations. 1
Alternative: Intramuscular testosterone cypionate or enanthate 100-200 mg every 2 weeks is more economical ($156 annually vs. $2,135 for transdermal) but carries higher erythrocytosis risk. 1
Monitor testosterone levels at 2-3 months after initiation, then every 6-12 months once stable. 2, 1 For injectable testosterone, measure levels midway between injections (days 5-7) targeting 500-600 ng/dL.
Monitor hematocrit at each visit—withhold treatment if >54% and consider phlebotomy in high-risk cases. 2, 1
Monitor PSA levels in men over 40 years with urologic referral if PSA increases >1.0 ng/mL in the first 6 months or >0.4 ng/mL per year thereafter. 2, 1
Alternative Approach: Selective Estrogen Receptor Modulators (Off-Label)
Clomiphene citrate 25-50 mg three times weekly can stimulate endogenous testosterone production in men with secondary hypogonadism who wish to avoid exogenous testosterone. 1, 7 This off-label approach preserves fertility by stimulating pituitary LH and FSH secretion. However, clomiphene is FDA-approved only for female ovulation induction, and its use in men represents off-label prescribing. 7
Expected Recovery Timeline and Outcomes
Natural Recovery Without Intervention
Testosterone levels typically recover to baseline over 3-12 months after steroid cessation, though some cases require years or remain permanently suppressed. 5, 6
Gonadotropin (LH/FSH) recovery occurs over 3-6 months in most cases. 6
Testicular volume recovery occurs over months to years, with near-complete recovery expected in most cases. 6
Spermatogenesis recovery ranges from 6 months to several years, with azoospermia potentially persisting for 10+ months. 5, 6
With Post-Cycle Therapy (hCG ± FSH)
Survey data suggest that post-cycle therapy reduces withdrawal symptoms by approximately 60%, including cravings to restart steroids, and reduces suicidal thoughts by 50%. 8 However, these are self-reported outcomes from uncontrolled surveys, and high-quality prospective data are lacking.
Management of Withdrawal Symptoms
The majority (95%) of men stopping anabolic steroids experience withdrawal symptoms, most commonly low mood (73%), tiredness (59%), and reduced libido (57%). 8
Symptomatic Treatment Options
For persistent low libido and erectile dysfunction despite testosterone recovery: Consider PDE5 inhibitors (sildenafil, tadalafil) as first-line adjunctive therapy. 1 These can be combined with testosterone therapy for optimal results.
For depressive symptoms: Selective serotonin reuptake inhibitors (SSRIs) may provide symptomatic relief during the withdrawal period. 4 However, depression may persist beyond hormonal recovery in some cases.
For muscle and joint pain: Nonsteroidal anti-inflammatory drugs (NSAIDs) can provide symptomatic relief. 4
For severe withdrawal symptoms including suicidal ideation: Immediate psychiatric evaluation and supportive therapy are mandatory. 4, 8
Expected Treatment Outcomes with Testosterone Therapy
Testosterone replacement therapy produces small but significant improvements in sexual function and libido (standardized mean difference 0.35), with modest quality of life improvements primarily in sexual function domains. 2, 1 However, testosterone therapy provides little to no benefit for physical functioning, energy, vitality, depressive symptoms, or cognition, even in confirmed hypogonadism. 2, 1
Critical Pitfalls to Avoid
Never restart anabolic steroids to treat withdrawal symptoms. This perpetuates the cycle of abuse and HPG axis suppression. 3, 4
Never initiate testosterone replacement therapy without first confirming the patient does not desire fertility. Exogenous testosterone causes prolonged, potentially irreversible azoospermia. 2, 1
Never diagnose hypogonadism based on symptoms alone or a single testosterone measurement. Always confirm with repeat morning testing and measure gonadotropins to distinguish primary from secondary hypogonadism. 2, 1
Never use testosterone therapy for weight loss, energy improvement, or athletic performance. These are not evidence-based indications, and the European Association of Urology explicitly recommends against testosterone therapy in eugonadal men for these purposes. 2, 1
Do not assume recovery will be rapid or complete. Some men experience persistent hypogonadism requiring long-term treatment, while others recover fully over months to years. 3, 5, 6
When to Reassess and Discontinue Treatment
If no improvement in sexual function occurs after 12 months of testosterone therapy, discontinue treatment to prevent unnecessary long-term exposure to potential risks without benefit. 1, 9 Testosterone levels return to baseline within 10-14 days after stopping injectable testosterone and within days of stopping transdermal preparations. 9