Harm reduction measures in a recreational gym user with anabolic androgenic steroid dependence: a case report in the context of current best clinical practice

Abstract

Introduction: The non-medical use of androgens among recreational gym users has become a global substance use concern. Complications from use particularly appear to affect the cardiovascular system, including the development of cardiovascular events, as well as anabolic steroid-induced cardiomyopathy (ASIC). Furthermore, the development of substance dependence with a specific withdrawal syndrome appears to be common and is contributed by the development of endocrine dysfunction related to anabolic steroid-induced hypogonadism. A 38-year-old male law enforcement officer and recreational bodybuilder presented with multiple health complaints following years of supraphysiologic androgen use and polypharmacy. Key symptoms included new-onset subacute dyspnea, dizziness, palpitations, headaches, and recurrent failed attempts at androgen cessation. Clinical findings showed abnormal blood pressure, testicular atrophy, plethoric appearance, and laboratory evidence of progressive polycythemia (hematocrit: 56.9%; normal < 49%), elevated testosterone, and suppressed luteinizing and follicle-stimulating hormones. He was at risk for muscle dysmorphia and met criteria for androgen dependence. Diagnosis confirmed ASIC. Treatment consisted of recurrent bloodletting for polycythemia, guideline-based cardiac management, and a structured endocrine regimen (tapered transdermal testosterone, oral Tamoxifen, subcutaneous human chorionic gonadotropin) to support androgen discontinuation and hormonal recovery. At 4 months, ASIC had normalized, and he was asymptomatic. However, after 6 months, he developed laboratory-confirmed idiopathic primary hypogonadism and began guideline-directed testosterone replacement. Despite more than a year of abstinence from non-medical androgen use and normalization of cardiac function, the patient died from a cardiovascular event, highlighting the possibly persistent risks of prior androgen use.

Conclusion: Non-medical androgen use is a growing global issue among recreational gym-goers. The intersection of severe health risks and substance dependence highlights the urgent need for an integrated, medical and harm-reduction approach-ideally delivered in specialized primary care settings. Early detection of cardiovascular risk factors is crucial for mitigating the often-overlooked yet potentially reversible complications. A reassessment of legal and clinical measures is warranted to optimize harm reduction and provision of care. Despite best practices and a year of abstinence from non-medical androgen use, the patient's fatal outcome underscores the critical need for further research, heightened awareness, and more robust prevention and harm reduction strategies for those affected by non-medical androgen use.

Keywords: Addiction; Anabolic androgenic steroids; Cardiomyopathy; Case report; Hypogonadism; Polycythemia; Substance use disorder.

Fig. 1

Results from 12-lead electrocardiogram and cardiac ultrasound on initial presentation and follow-up after androgen cessation and antihypertensive treatment. After 8 years of cyclic androgen use, the resting ECG demonstrated signs of left ventricular hypertrophy (LVH) (A), 4 months after stopping non-medical androgen use and antihypertensive treatment, no signs of LVH could be documented by ECG (B). Echocardiographic confirmation of LVH (concentric hypertrophic left ventricle with maximum septal thickness of 14 mm), normal pump function (LVEF 65%), but reduced longitudinal function (GLS -15%) as demonstrated in the parasternal longitudinal axis view (C) and 4-chamber view (E). Pleasant cardiological course 4 months after also by echocardiographic assessment with normalization of structural changes (max. septum thickness 10-11 mm, normal pump function, normalization of longitudinal deformation (GLS -17.5%) as demonstrated in the parasternal longitudinal axis view (D) and 4-chamber view (F)

Fig. 2

Course of testosterone recovery after androgen cessation. Course of testosterone recovery after cessation of non-medical androgen use. The patient received endocrine treatment for 4 months according to a tapering protocol by Rahnema and colleagues [14]. His endogenous testosterone did not recover over an observation period of 6 months, and he developed progressive symptoms consistent with ASIH