The endocrinologist's guide to managing self-treating patients

[Re-Ride]

Male Central Hypogonadism Secondary to Exogenous Androgens

Clin Endocrinol. 2015;82(5):624-632.

In this paper a group of clinicians acknowledges that practitioners are encountering an increasing number of patients seeking help with recovery from self-administered anabolic steroids.

[ "Clinicians are increasingly encountering demanding, well-informed men affected by ASIH, yet lacking authoritative information on the subject may struggle to project a credible message" ]

How men learn about, acquire and use hCG, SERMS, AI's from internet sources is discussed along with a survey of information they receive on the web.

While the focus of this paper is on helping clinicians understand miss-use rather than legitimate HRT, it is an excellent resource for both the newly diagnosed hypogonadic patient and the treatment experienced. I find it well written and easy to read.

[ "mainstream academic endocrinology rather lost credibility with the 'performance-enhancement community' in the 1980s and 1990s, by persisting overlong in (a) doubting whether further enhancement of athletic performance could be achieved through raising serum T levels above the physiological reference range and (b) questioning whether any therapeutic separation of androgenic and anabolic actions was achievable, due to the single androgen receptor." ]

Please refer to the link Nelson posted in his reply.
Male Central Hypogonadism Secondary to Exogenous Androgens

 

[Nelson Vergel]

Great post. Thanks!

Here is the PDF

 

[CoastWatcher]

Excellent material.

 

[Re-Ride]

Being in the lower 20% of "normal range" is fine with these guys.

Under the heading "Effective Treatment of steroid abuse related Hypogonadism" they agree that hCG has a legitimate use in treating secondary hypogonadism:

[" Clinical indications for hCG use in men are for the treatment of T deficiency and/or induction of
spermatogenesis in gonadotrophindeficient
adults (typically with concomitant FSH therapy in the latter role) "] , but

["we found that AAS users misused hCG by men (for) sustained suppression of their hypothalamus–pituitary–testicular axis from prolonged use of high dose AAS use, in an attempt to increase endogenous testicular T secretion"] [ "In reality, this merely prolongs suppression of the hypothalamus–pituitary–testicular axis, which is the root cause of the reduction in testicular size and serum T levels."]

They don't seem to acknowledge that hCG use is legitimate for PCT. As far as Excel-Mates are concerned that's fine. We are not engaged in post cycle therapy.

["In a small case series of 13 azoospermic men with acquired gonadotrophin deficiency ( from juicing?), hCG in combination with FSH was successful in stimulating and maintaining spermatogenesis in hypogonadotrophic, hypogonadal men.
[45] Lowdose hCG with testosterone supplementation has also been shown to be effective in maintaining
spermatogenesis, although whether this can translate to successful pregnancies is uncertain.[46] In the context of
AAS use, hCG has been shown to be effective in accelerating testicular production of testosterone and reversing
azoospermia, but evidence is only available from case reports."]

In understanding the frustration we often encounter in seeking legitimate HRT we can look to the authors' conclusions which are mixed.

[" The treatment of ASIH and subsequent subfertility remains inadequately studied, and many clinicians have
limited experience with regard to managing men with Anabolic Steroid-Induce Hypogonadism. AAS users appear to be well aware of this and may thus tend to give less weighting to clinician recommendations than those of 'online expert users'."]

Wait and see approach:

[" hCG, SERMs and AIs are amongst the drugs commonly used to counteract the side effects of ASIH. Although
some of these are certainly effective in the context of congenital (or pituitary lesionrelated) hypogonadotrophic
hypogonadism,[74] the extent to which data from medical treatments can be compared and extrapolated to ASIH
is uncertain. This is because the pathophysiology of ASIH may be more complex, representing a combination of
the endocrine disruption and direct testicular toxicity related to the supraphysiological doses or multiple drug
combinations used by users.[75]

We recommend that, based on currently available evidence, if fertility is desired, the logical first-line
management is to cease using AAS along with any other potentially 'culprit' agents (e.g. marijuana, opioids,
methamphetamine, cocaine), with serial semen analysis."]

[" However, what if the period of biochemical recovery from ASIH is prolonged and associated with relationship endangering
features, and/or the partner's age militates against a prolonged watch-and-wait
strategy in respect of fertility? A judgmental approach imputing patient 'fault' may not be hugely effective, whereas involvement of community based addiction teams can be invaluable. "]

O.K. well maybe we were a bit hasty above:

[" If spontaneous reversal of hypogonadism does not occur with expectant management within a reasonable
time frame as discussed above, then use of hCG ± hMG, SERMs or AIs is potentially effective alternatives.[75]

My conclusion: It's easy to see why clinicians are reluctant to offer HRT patients the best available protocol. We are most likely illicit drug addicts. Clinicians are still lacking clear guidelines for testing and treating non-steroid abusing hypogonatic males.

Excelmale sends a clear and consistent message: "HRT is a last resort and a life-long commitment. Make lifestyle changes first. Get labs and understand them. Track your progress and have clear serum goals. Rely on how you feel in setting those goals rather than be obsessed with numbers. If you do need HRT, by all means get it under qualified medical supervision, don't suffer."

 

[Nelson Vergel]

Re-Ride: I would not have said it better:

"Excelmale sends a clear and consistent message: "HRT is a last resort and a life-long commitment. Make lifestyle changes first. Get labs and understand them. Track your progress and have clear serum goals. Rely on how you feel in setting those goals rather than be obsessed with numbers. If you do need HRT, by all means get it under qualified medical supervision, don't suffer."