The GP’s role
General practitioners have a role in identifying androgen use as a performance and/or image-enhancing drug (PIED), in the management of (potential) adverse effects of this practice, and its cessation, usually under the guidance of an experienced endocrinologist.
Overview
The extent of the use of androgens as PIEDs is unknown; however, it is estimated that lifetime use in the general population is probably 1-5% globally, with prevalence at least 50-times higher in men than women.
Two percent of Australian secondary-school students report using androgens as PIEDs.
Use of androgens as PIEDs can involve large doses and multiple drugs taken simultaneously that may provide a vastly higher level of androgen action than required for physiological replacement in legitimate androgen deficiency.
Commonly used non-prescribed androgenic substances
| Substance | Common or brand name | Route |
|---|---|---|
| Boldenone undecylenate | Equipoise, Parenabol | IM |
| Clostebol acetate | Steranabol | IM |
| Chlorodyhydromethyltestosterone | CDMT | Oral* |
| Dihydrotestosterone | Oral*, transdermal, IM | |
| Drostanelone propionate | Dromostanalone, Masteron | IM |
| Fluoxymesterone | Halotestin, Ultandren | Oral* |
| Formebolone | Esiclene | Oral* |
| Mesterolone | Proviron | Oral* |
| Metandienone | Methandorosteneolone, Dianabol | Oral* |
| Methenolone acetate | Primabolon | IM |
| Methyltestosterone | Android, Metandren, Testred | Oral* |
| 19-Nortestosterone | Nandrolone, Deca-Durabolin | IM |
| Oxandrolone | Anavar | Oral* |
| Oxymetholone | Anadrol | Oral* |
| Stanozolol | Winstrol | Oral* |
| Testosterone | Sustanon, Testo depot, Nebido | IM |
| Tetrahydrogestinone | THG, The Clear | Oral* |
| Trenbolone ethanate | Trenabol, Parabolan | IM |
Legitimate androgen uses
Off-label androgen use
Non-prescribed androgen use
Compounds commonly used in combination with androgens
Use of androgens as PIEDs often involves administration of multiple substances (“stacking”) and various dosing regimens.
Cycles of use, lasting for several weeks or months (interspersed with periods of abstinence or lower dosing, for ‘recovery’) are usual, with an entrenched but incorrect belief that it is possible to maximise anabolic effect while minimising androgenic impact; this is biologically implausible given the action of androgens through a single type of androgen receptor. However, different androgenic substances are likely to produce a different range of adverse effects.
Antiestrogens (clomiphene, tamoxifen) and aromatase inhibitors (letrozole, anastrozole, exemestane) are used in attempt treat or to reduce the risk of developing adverse effects (e.g. gynaecomastia) but this is often unsuccessful, and these drugs have inherent adverse effects such as bone loss and increased thromboembolic risk. These drugs, together with injectable hCG, are also used as “post-cycle therapy” in attempt to reverse the androgen-induced suppression of sperm and testosterone production. However, there is no evidence that these regimens are effective in the way they are used as part of this practice.
In reality, cessation of androgen use is the only current effective approach to restoring the reproductive axis, which may take up to 6-18 months and clearly requires a doctor’s support, as for other behavioural disorders.
The list below, of medications commonly used in combination with androgens is for information only, not as an endorsement of clinical use.
| Substance | Details |
|---|---|
| Clenbuterol | a veterinary β2-adrenergic receptor agonist, used to increase muscle mass and reduce body fat |
| Ephedrine, Synepherine | used to reduce body fat |
| Growth hormone | used for its anabolic and lipolytic properties, and its potential to reduce muscle and tendon rupture |
| Growth hormone releasing hormones/peptides (e.g. Modified GRF(1—29), Sermorelin, Ipomorelin, GHRP-2), HGH analogues (e.g. HGH Fragment 176-191) | falsely claimed to increase muscle mass and do not increase GH levels |
| Recombinant human luteinising hormone (rLH) | may be promoted for stimulation of the testes but it is difficult to manufacture and exceedingly expensive, so marketed preparations are likely to be fake |
| Clomiphene citrate and aromatase inhibitors | used to prevent gynecomastia, promote testis growth and/or hasten recovery of the suppressed HPT axis |
| Prohormones (e.g., androstenedione, dihydroepiandrostenedione) | used as substrate for androgen production |
| Prescription drugs (e.g., sedatives, analgesics, anti-inflammatories, PDE5 inhibitors, antidepressants, diuretics) | used to treat unwanted side-effects of androgen abuse |
The internet is a common source of androgens and other drugs used in combination, but there is concern about the actual content, purity and safety of any agents obtained online. People who use non-prescribed androgens may attempt to obtain prescriptions from doctors, whose compliance would constitute professional misconduct.
Dietary supplements
Contamination of protein supplements with biologically active androgens can result in an identical clinical and biochemical picture to androgen abuse. Close examination of products acquired through gyms or online is required.
The Australian Institute of Sport classifies dietary supplements according to scientific and practical considerations related to safety, efficacy and permissibility, and provides guidance for choosing safe products.
Patients should be advised to eat healthy food rather than use supplements. Supplements do not contain all the nutrients contained in whole foods and cannot compensate for a poor diet.
Diagnosis of use of androgens as PIEDs
An effective means of knowing if a patient is using non-prescribed androgens is to ask them, after establishment of a trusting, non-judgemental relationship.
This may be done by asking about any supplements that a person may take to assist with their workouts and explaining that the reason for asking is for appropriate health monitoring.
For patients suspected of non-prescribed androgen use, or who seek treatment for non-prescribed androgen use or its side-effects, an appropriate medical history, physical examination and laboratory tests should be undertaken.
There is a wide variety of motivations and methods of androgen use for performance and image enhancements. Whilst the traditional image of a muscular body-builder may illicit suspicion, many PIEDs users may not appear, or aspire to be, particularly large. It is therefore useful to have awareness of this practice and ask appropriate questions where there may be warning signs.
The regimens used can also vary greatly — from use of low-to-moderate doses of testosterone, to high doses and multiple androgens, with or without other chemicals.
Typically, serum LH, FSH and SHBG will be supressed. Serum testosterone levels will vary. High levels will be obtained if testosterone administration is recent.
Low testosterone levels will occur if synthetic androgens, which are not detected by testosterone immunoassays, are used, or during the withdrawal phase when hypogonadotrophic hypogonadism is induced.
Medical history
Clinical features of non-prescribed androgen use
Psychological signs of non-prescribed androgen use
Adverse effects of non-prescribed androgen use
Management of non-prescribed androgen use
There are no clinical trials of managing patients from the public who use non-prescribed androgens, so information to guide practice is limited to that from observational studies.
Treatment usually requires a multidisciplinary approach involving the combined efforts of the general practitioner, endocrinologist and psychologist.
A formal care plan could facilitate this approach and would also facilitate patient education for long term behaviour change. The focus of care should be for the expeditious and permanent cessation of this potentially dangerous behaviour.
A supportive approach that is analogous to that used for other licit and illicit social drugs (e.g., alcohol, caffeine, cocaine) and behavioural disorders (e.g. anorexia nervosa, muscle dysmorphia) is the best option. Encouragement and advice that reproductive function will recover with time, and that patience is necessary, may be helpful.
Referral for psychological assessment and possible therapy may benefit patients who use non-prescribed androgens because of body image issues.
Patients who are unwilling to cease non-prescribed androgen use should be advised of the adverse effects of continued use, focusing on the potential consequences for their fertility and long-term cardiovascular health.
They should be counselled about the health risks associated with the use of potentially unknown substances and self-injecting.
Medical practitioners should not allow themselves to become resources for ongoing drug supply, including medications used in this subculture (e.g., anti-oestrogens, hCG), or to facilitate continuation of androgen use. However, harm reduction measures are encouraged and treatment of adverse effects (e.g. infections, hypertension, cardiac disease) should be offered.
The development of a trusting clinician-patient relationship may facilitate discontinuation of non-prescribed androgen use. A care plan should be established, aimed at cessation, ideally performed by a supportive team with endocrine and psychological expertise.
Discontinuing androgen use
People who use androgens can develop psychological and physical dependence and be defined as having a substance use disorder. Withdrawal symptoms from discontinuation of androgen use include decreased sexual drive and a flu-like syndrome consisting of fatigue, headache, musculoskeletal pain and insomnia, followed by depression. Like other substance use disorders, relapse can be common.
These features are like those from withdrawal from caffeine or benzodiazepines, and less severe than those from withdrawal from nicotine.
There is no legal pathway for the prescription of testosterone or synthetic androgens without a legitimate medical indication. In fact, consistent prescriptions for androgens for use as PIEDs constitutes professional misconduct.
Therefore, general practitioners should offer supportive care and health monitoring aimed at cessation of non-prescribed androgen use, in the context of an agreed and active understanding of the goals of treatment within the limits of medical services for the patient. Referral to an experienced endocrinologist is advised.
Fertility recovery
Many men who use non-prescribed androgens seek assistance with discontinuation because of infertility. Cessation of androgen use often allows recovery of fertility within 6-18 months.
Recovery of endogenous gonadotrophins, testosterone and spermatogenesis, may take many months, with the duration of recovery depending mainly on the time since cessation. The outlook for recovery of fertility and testosterone production is generally very good but prolonged.
Ad hoc treatment with anti-estrogens, aromatase inhibitors or hCG lacks any sound evidence basis for safety and efficacy.
If there is claimed urgency for restoration of spermatogenesis (e.g. restoration of fertility for a man with a female partner of advanced age), consultation with an experienced endocrinologist is essential because potential treatment may be subject to restrictions based on ‘off label’ uses and/or uncertain safety considerations.
This resource was produced in response to requests from Australian General Practitioners, for information to help them respond to use of non-prescribed androgens for performance and image enhancement.
Clinical review
Dr Beng Eu, Prahran Market Clinic
