Steroid Abuse Withdrawal Symptoms Tied to Psychiatric Burden

Medscape

2 days ago

San Francisco — The sexual dysfunction and depression commonly seen in men following withdrawal from anabolic steroid abuse are more closely tied to psychiatric burden than to hormonal levels, new research suggests.
'Psychiatric burden was the only factor found to be independently associated with these symptoms, and no association with hormonal levels. This highlights the importance of psychological interventions in the management of men wishing to cease androgen abuse,' Bonnie Grant, MD, a clinical research fellow at Imperial College London, London, England, said at ENDO 2025: The Endocrine Society Annual Meeting.
Androgen abuse is 'a growing, global problem,' she said, noting that about 6.4% of men worldwide abuse anabolic steroids, increasing up to 20% in recreational gym users. The primary motivations are image and muscular enhancement. However, the practice confers a threefold higher mortality rate, predominantly from cardiac conditions such as cardiomyopathy, or from suicide.
Few studies have examined the effects of stopping steroid use, which precipitates a rapid drop in testosterone levels. 'We have noticed through our clinical experience that often these men, when they stop, report a lot of symptoms. They feel very depressed. They feel like they've lost their sexual function. We wanted to know what predicts that,' Grant told Medscape Medical News .
Psychiatric Comorbidity, Not Hormonal Levels, Linked to Steroid Withdrawal
In their cross-sectional, observational study, Grant and colleagues recruited men from four sites in the UK, where personal nonprescription use of anabolic steroids is legal. They were divided into three groups: 50 nonusers of anabolic steroids, 125 current users, and 90 who had stopped using within the past year. 'We focused on the first year, as this has been shown to be a time period with high rates of relapse, often due to the severity of withdrawal symptoms,' Grant explained.
The men had an average age of about 36.5 years. In the past user group, the average time since quitting was 4.5 months.
At a single study visit, the participants all completed several questionnaires: one on androgen use, the International Index Erectile Function-15 (IIEF-15) for sexual function, the Beck Depression Inventory-II (BDI-II) for depression, Generalized Anxiety Disorder-7 for anxiety, and Short-Form-36 for quality of life. They also underwent fasted, morning blood testing with urine toxicology to verify claims of noncurrent use.
Men in the current and past anabolic steroid use groups had significantly higher rates of psychiatric comorbidity, mainly depression and anxiety (27.2% of the current users and 24.4% of the past users vs 10.0% of the nonusers; P = .038). The use of illicit drugs, mainly cocaine and cannabis, was also greater in the current and past users (43.2% current and 47.7% past vs 22% nonusers; P = .007).
As expected, men with current use had significantly higher total testosterone levels, with a mean of 72.2 nmol/L compared with 14.3 nmol/L in the past users and 20.6 nmol/L in the nonusers ( P < .001). The latter two did not differ significantly. Levels of luteinizing hormone and follicle-stimulating hormone were fully suppressed in the current users but had recovered in the past use group ( P < .001 for both).
Men with past androgen abuse had significantly lower scores on the IIEF-15, indicating worse sexual function compared with the other two groups. Among past users, a total testosterone < 8 nmol/L had a positive predictive value (PPV) for sexual dysfunction of 73%, indicating that hypogonadism was relatively predictive of sexual dysfunction. However, the negative predictive value (NPV) was 48%, suggesting that a total testosterone level above this threshold does not reliably exclude sexual dysfunction, Grant said.
Looking at mood symptoms, the past use group had significantly higher scores on the BDI-II, indicating worse mood symptoms. Testosterone levels did not correlate with BDI scores. In the past users, total testosterone < 8 nmol/L poorly predicted moderate-to-severe depression (PPV, 20%), although the NPV was higher (81%).
In multivariate analysis, psychiatric comorbidity was the only independent predictor of symptoms among men who had quit abusing anabolic steroids in the past year ( P = .01 for sexual dysfunction; P < .0001 for mood disorders). Total testosterone levels were not independently associated with symptom scores.
'A Window of Opportunity'
Asked to comment, session moderator Shalender Bhasin, MD, director of the Research Program in Men's Health: Aging and Metabolism at Brigham and Women's Hospital, Boston, pointed out that in addition to depression and anxiety, these men will often have other psychiatric conditions, including body image disorder.
'Anabolic steroid use has not become a national priority, and I think it should be, because we have seen an underground, invisible epidemic of body image disorders and anabolic steroid use,' he told Medscape Medical News .
'People say, 'well, where are the dead bodies?' The thing is that these are gateway drugs, and we are seeing high rates of suicides, and other mental health problems in young men. The tragedy is that the [National Institutes of Health] and academia have done little to deal with this growing societal problem, mostly among young men. It is equally important to address the co-occurring psychopathology as it is to treat the withdrawal symptoms,' he said.
Bhasin, who is also professor of medicine at Harvard Medical School, Boston, added that when men try to quit anabolic steroid use, the severity of the withdrawal symptoms often leads to relapse, and a 'vicious cycle of [anabolic-androgenic steroid (AAS] use, withdrawal, and relapse. For this reason, AAS withdrawal hypogonadism needs to be managed carefully medically. This also offers a window of opportunity when the patients undergoing withdrawal may be amenable to getting off AAS use altogether.'
Grant received a speaker's honorarium from Besins Healthcare. Bhasin reported receiving research grant support from AbbVie and Metro International Biotech for investigator-initiated research, with the grants managed by Brigham and Women's Hospital. He had served as a consultant to Besins and Versanis and has an equity interest in XYone Therapeutics.