Beyond testosterone treatment
When Dr. Williams started his urology training, he did not expect testosterone use and hypogonadism to be part of his practice. “Traditionally, low testosterone and testosterone treatments were part of the practice of the internal medicine doctor who was trained in endocrinology,” he recalls. “I didn’t think that I was going to be talking to patients about testosterone as opposed to kidney stones or prostate cancer.”
As urologists evolve as the go-to providers of men’s overall and sexual health, “we may be the ones who discover the low testosterone levels,” Dr. Williams points out. “These issues are becoming an important part of our practice.”
Toward that end, what is the scope of the urologist’s role in the management of men who use anabolic steroids that are not medically indicated? “It’s absolutely the urologist’s duty to explain the dangers of this behavior to the patient,” Dr. Jaffe declares. “The patient has to know that he’s going to need testosterone supplementation for the rest of his life if he keeps on using. If his own body doesn’t make testosterone and he doesn’t supplement the testosterone he’ll have issues with bone health, cognitive function, and potential problems with cholesterol and triglyceride metabolism, to name a few health issues.”
Users should also be warned about obtaining these substances on the black market. “Not only is it illegal, but this is particularly scary because no one is monitoring these men’s levels, and we don’t know anything about the quality of the medications they’re using,” Dr. Williams says. “How pure are they? Are they injecting veterinarian-grade testosterone? Who knows what they’re getting or how much of it they’re using.”
An endocrinologist’s view
Depending on the referral patterns of a given region or insurer, or the specialization of a particular area’s physicians, a man with urologic problems stemming from hormonal imbalances may be sent to an endocrinologist rather than a urologist.
“There is enough overlap between endocrinologists and urologists that we’re distant cousins,” says Bradley D. Anawalt, MD, an endocrinologist himself who recently reviewed the impact of anabolic steroids on hormones for fellow scientists and the media.
Dr. Anawalt, professor of medicine and staff physician in general internal medicine and endocrinology for the VA Puget Sound Health Care System in Seattle, believes that either type
of professional can care for men who have sexual problems related to anabolic steroid use.
“It’s not so much the discipline that matters; the key is to have some experience and expertise in the administration of hormone therapy,” he emphasizes. “Any patient who comes in with a history of anabolic steroid use, specifically if they have sexual dysfunction or problems with infertility, should be considered for hormone therapy for restoration of the ability to conceive, and that could be done by anybody who has expertise in that area.”
Dr. Anawalt urges urologists to be attuned to the possibility of anabolic steroid use even in unlikely suspects. “Anabolic steroid abuse is an everyday abuse problem,” he affirms. “Oftentimes the users aren’t athletes or bodybuilders; they can just be average Joes who want to look a little more muscular. Doctors may be seeing these folks and not recognizing them.”
He also points out that since steroid use among high school students is currently close to 5%, urologists are going to be seeing many of these boys when they reach their 20s and 30s and come in seeking help for infertility. “You might not necessarily think to ask, ‘Oh, did you used to use anabolic steroids?’ So it’s important to be aware of this possibility.”
In most commercially available assays the ballpark normal ranges for LH and FSH is 1-10 IU/L. An LH or an FSH level less than 1 IU/L should be cause for concern, Dr. Anawalt says. “In a young man, that means one of two things: a problem with the hypothalamus-pituitary, or a problem of taking drugs that are turning off LH and FSH. And a lot of these guys taking anabolic steroids will have testosterone levels lower than the typical range of 300 to 1,000 ng/dL because they are not taking testosterone.”
To avoid feeling depressed, fatigued, and—in Anawalt’s words—“just kind of crummy” in the
course of discontinuing anabolic steroid use, the patient may benefit from being weaned off the substances. The trick is to find a regimen that combines a shorter half-life and a much lower dosage. “Many of the anabolic steroids being used non-medically have a very long half-life, whereas I’ll give the person a testosterone patch with a short half-life that washes out pretty quickly, to help wean them off,” Dr. Anawalt explains. “And, they’re often using prodigious doses of androgenic steroids. In one study people were taking 10 to 12 times the normal replacement dose.”
Instead, Dr. Anawalt gives a replacement dose of 1 to 1.5 times the usual replacement dosage for the treatment of male hyogonadism. “So it’s a big drop, but it doesn’t make the patient feel quite so bad. It’s a way to gently bring him back down to normal without letting him go cold-turkey.”
Men who are anxious to impregnate their partner are not candidates for this type of approach because the high doses of testosterone involved will quell sperm production, Dr. Anawalt says.
Anabolic steroid users may be at increased risk for hepatopathy, cardiovascular disease, and cholesterol problems. “Urologists could order a fasting lipid panel for these patients to determine whether there are any significant abnormalities,” suggests Dr. Anawalt. “Or they may choose to refer the patient to an endocrinologist for such testing. Either way, the key to it is to be aware of the potential for health problems and to recognize that you have to address them.”