Stopping the use of hormonal drugs is not the final point, but the beginning of a period during which the body returns to its own regulation. This process can take months, and in some people it takes years. Control tests allow you to see how the recovery is going and to notice problems that need treatment in time. The editors explain which indicators are important, why they change at different speeds and when to consult a doctor.
What happens after cessation
Exogenous androgens suppress the secretion of gonadoliberin in the hypothalamus and LH and FSH in the pituitary gland through a negative feedback mechanism. As a result, the testicles almost stop their own production of testosterone and spermatogenesis. While the drug works, a person does not feel it: the level of androgens is provided from the outside.
After stopping the concentration of the exogenous hormone gradually falls, and the own system has not yet had time to "wake up". A condition called anabolic steroid-induced hypogonadism (ASIH) occurs. It is characterized by low testosterone, low or "normal" LH and FSH, and clinically by fatigue, depressed mood, decreased libido and erectile dysfunction, and loss of muscle mass.
The duration of this period is very individual. It depends on which substances and how long they were used, on the duration of their action in the body, on age and the initial state of the hormonal system. The review by Rahnema and co-authors emphasizes that some people take months to recover, and some do not fully recover.
Simultaneously with the hormonal axis, other systems changed by the drugs gradually return to their original state: hematopoiesis, lipid metabolism, liver. But the speed of these processes is different, and that is why one control analysis is not enough.
Hormonal axis: the main issue of recovery
Key indicators for assessing recovery are total testosterone, LH, and FSH, as well as SHBG, estradiol, and prolactin as indicated. As during the initial diagnosis, blood for testosterone is taken in the morning, on an empty stomach, and conclusions are drawn based on repeated measurements.
Interpretation depends on time. If the test is done early, while the exogenous hormone is still circulating, high testosterone against low LH and FSH reflects the residual effect of the drug, not recovery. If enough time has passed since cessation, low testosterone, along with low or "normal" LH and FSH, indicates long-term suppression of the axis.
| Laboratory pattern | Possible interpretation |
|---|---|
| Testosterone is high, LH and FSH are suppressed | The drug is still effective; it is too early to assess the recovery |
| Low testosterone, low LH and FSH | Axis still suppressed; observation is required, for a long-term condition - a doctor |
| Testosterone is low, LH and FSH are elevated | Possible damage to the testicles themselves; an andrologist's consultation is required |
| Testosterone, LH and FSH are normal | Suggests axis recovery; confirmation may be needed |
Studies show that the problem does not always go away quickly. Kanayama et al. described long-term hypogonadism after withdrawal in former users of anabolic steroids. A Danish study by Rasmussen et al found former users had lower testosterone levels and hypogonadism symptoms years after quitting compared to controls. The Dutch prospective HAARLEM study found that hormone levels returned to baseline levels in most participants over time, but not in all.
Therefore, persistently low testosterone with corresponding symptoms a few months after stopping is a reason to consult an endocrinologist or andrologist, and not try to "speed up" the system yourself. The doctor will assess the cause and decide if treatment is needed. The editors do not provide any schemes of "restorative" therapy: they should be prescribed individually.
Blood, lipids, liver, kidneys
Hematocrit and hemoglobin. Androgens stimulate erythropoiesis, and during their administration, the hematocrit often increases. After cessation, it decreases, but gradually - in accordance with the life span of erythrocytes. Control of the complete blood count allows you to make sure that the indicators return to normal, and to exclude other causes of erythrocytosis.
Lipid profile. It is especially noticeable when taking anabolic steroids, in particular oral steroids, that HDL decreases, and LDL often increases. After discontinuation, these changes are usually gradually reversible, but monitoring the lipid profile after several months ensures that the profile has normalized and not remained atherogenic.
Liver. Oral 17-alpha-alkylated steroids are associated with cholestasis, elevated liver enzymes, and, less commonly, liver tumors. Monitoring of ALT, AST, GGT, and bilirubin after discontinuation indicates whether injury markers and bile-flow abnormalities have resolved. We will remind you that after intensive training, ALT and AST can increase due to muscles, so it is useful to look at them together with CK.
Kidneys. Creatinine, GFR, urea, and a general urinalysis help assess the condition of the kidneys, which can be affected by high blood pressure, a very high-protein diet, dehydration, and some medications. With large muscle mass, cystatin C may be needed for a more accurate assessment.
- complete blood count with hematocrit;
- lipid panel (total cholesterol, LDL, HDL, triglycerides);
- ALT, AST, GGT, bilirubin, if necessary, CK;
- creatinine and GFR, urea, general urinalysis;
- fasting glucose, HbA1c.
Heart, psyche, fertility
The cardiovascular system requires special attention. A review by Baggish et al. describes anabolic steroid-related decreases in myocardial contractile function, hypertrophy, accelerated atherosclerosis, and arrhythmias. Some of these changes may diminish after withdrawal, but not all are completely reversible. Regular blood-pressure monitoring, and according to the indications of ECG and echocardiography, allow to assess the condition of the heart and compare it with the original.
Mental state is another important component. The post-cessation period is often accompanied by low mood, anxiety, loss of motivation, and in some people, depression. The Endocrine Society's scientific statement also draws attention to the risk of developing anabolic steroid addiction. If the depressed mood is persistent or thoughts of self-harm appear, you should immediately seek professional help.
Fertility. Suppression of LH and FSH stops spermatogenesis, and its recovery takes at least several months - if only because the full cycle of sperm maturation lasts about 70-75 days. For men who plan to have children, a semen analysis after cessation is an important control study, and in the case of prolonged azoospermia, it is a reason for consultation with a reproductive specialist.
Finally, gynecomastia and other changes associated with an imbalance of estrogens and androgens should be monitored. New lumps in the mammary gland, pain, discharge are reasons to consult a doctor.
When to take tests: approximate chronology
There is no one-size-fits-all schedule: the time depends on what and how long it was used, and how long the drug remains in the body. Therefore, the exact terms are determined by the doctor. However, the control logic is general and it is useful to understand it.
Assessment may be needed immediately at cessation or earlier if symptoms or abnormal results occur; do not wait for drug clearance to investigate a safety problem. Later tests, after most pharmacological effects have waned, help interpret residual axis suppression and recovery. The clinician selects blood count, metabolic, liver, kidney and hormone tests as indicated.
The second stage is about a few months later. This is the main control point: re-estimation of testosterone, LH and FSH, lipid panel, hematocrit, and, if necessary, a semen analysis. Comparison with baseline tests taken before any intervention is particularly valuable here.
The third stage is long-term observation, if not all indicators have returned to normal in the second stage, or if there are symptoms. In such cases, the doctor may prescribe an in-depth examination of the pituitary gland, a consultation with a cardiologist or reproductive specialist.
For athletes participating in competitions, it is worth remembering: anabolic agents are on the WADA Prohibited List, and some metabolites are detected long after cessation. Health control tests have nothing to do with anti-doping testing and cannot be used to predict its results.
Editorial conclusions
After stopping hormonal drugs, different systems recover at different speeds: lipids, hematocrit, and liver enzymes — relatively quickly, the hormonal axis and spermatogenesis — more slowly, and in some people recovery takes years.
Hormonal recovery tests depend on timing and comparison with baseline values. Early tests may reflect residual drug effects, but can still be necessary for clinical safety and must not be delayed when concerning symptoms occur.
Persistent hypogonadism, changes in the heart, problems with fertility and mental health are grounds for consulting a specialized doctor, not for self-medication.
We also advise you to read the editorial materials on tests before starting the use of hormonal drugs, on lipoprotein(a) and cardiovascular risk, and on CK and liver enzymes in athletes.
References
- Rahnema CD, Lipshultz LI, Crosnoe LE, et al. Anabolic steroid-induced hypogonadism: diagnosis and treatment. Fertil Steril. 2014;101(5):1271–1279.
- Kanayama G, Hudson JI, DeLuca J, et al. Prolonged hypogonadism in males following withdrawal from anabolic-androgenic steroids: an under-recognized problem. Addiction. 2015;110(5):823–831.
- Rasmussen JJ, Selmer C, Østergren PB, et al. Former abusers of anabolic androgenic steroids exhibit decreased testosterone levels and hypogonadal symptoms years after cessation: a case-control study. PLoS One. 2016;11(8):e0161208.
- Smit DL, Buijs MM, de Hon O, den Heijer M, de Ronde W. Positive and negative side effects of androgen abuse. The HAARLEM study: a one-year prospective cohort study in 136 men. Scand J Med Sci Sports. 2021;31(2):427–438.
- Baggish AL, Weiner RB, Kanayama G, et al. Cardiovascular toxicity of illicit anabolic-androgenic steroid use. Circulation. 2017;135(21):1991–2002.
- Pope HG Jr, Wood RI, Rogol A, et al. Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement. Endocr Rev. 2014;35(3):341–375.
- Bhasin S, Brito JP, Cunningham GR, et al. Testosterone therapy in men with hypogonadism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2018;103(5):1715–1744.
