Endocrine Abstracts

40year old bodybuilder was re-referred to clinic with low mood, reduced libido, poor morning erections and fatigue. His past medical history included hypogonadal hypogonadism secondary to anabolic androgen abuse, mental health disease and personality disorders. He had undergone breast reconstruction surgery for bilateral gynaecomastia secondary to anabolic steroid use despite taking precautionary tamoxifen injections as per peer groups’ advice. Previously, he was lost for clinic follow up after two months of treatment with testosterone enanthate injections after diagnosis in 2011. He continued on illegal testosterone supplements and had multiple hospital admissions later with cocaine induced cardiac vasospasm and seizures. His mental health worsened and was started on antipsychotics and subsequently, he discontinued anabolic steroids completely for last 2 years. Mood, libido, and energy levels did not recover and hence re-attended endocrine clinic after 11 years through GP referral.Investigations: HCt-0.463 LH-1 IU/l (1.5-9.3) FSH- 0.9 IU/l (1.4-18.4) Tetosterone-1.8 nmol/l(9-34.7) SHBG-9 nmol/l (17-66) Prolactin-1865 mIU/l (50-400) TSH-1.2 nmol/l (0.5-4.5) Cortisol- 467 PSA-0.17 mg/l Bone profie, U&E and LFT- Normal. Testogel was started on agreement of total avoidance of anabolic steroid use and regular monitoring for adverse effects.

Learning Points: 1. Anabolic abuse is now common among general population for physical aesthetic improvement with increased lean mass and reduced body fat. 2. Anabolic steroids induce feedback suppression of the hypothalamic-pituitary-gonadal axis resulting in inhibition of pulsatile gonadotropin-releasing hormone release and decrease in luteinizing hormone and follicle-stimulating hormone 3. Researchers has classified 4 types of anabolic steroid misusers: (1) the Expert type; (2) the YOLO (You Live Only Once) type; (3) the Athlete type; and (4) the Wellbeing type. 4. Knowledge on various regime of anabolic steroid use would help the endocrinologists to gain the trust and to improve the patient engagement in the treatment. 5. Information available on anabolic steroid users’ websites provides the users with advice on possible adverse effects and medications to minimize those. 6. Anabolic steroids cause testicular atrophy, infertility, gynaecomastia, and low endogenous testosterone which are self-managed by use of hCG, SERM and AI. 7. Aromatase inhibitors and SERMs potentiate pituitary gonadotropin secretion and therefore increases endogenous testosterone release by inhibiting oestrogenic negative feedback. 8. hCG binds to LH receptor resulting in increased endogenous testosterone production. 9. Topical testosterone should be preferred for initiation of treatment, whereas gonadotrophin therapy is only recommended when fertility is desired in men with secondary hypogonadism