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

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.