03-2013 Case of the Month

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What would you do in this this case?

A 35-year-old very muscular man presents with low libido and fatigue. He is a former competitive bodybuilder, but claims to have been “all natural” throughout his career. His total and free testosterone levels are very low. You decide to further investigate his hormonal balance by checking gonadotropin levels. Which combination of gonadotropins is most consistent with current anabolic steroid use? 

Choose your answer:  

A. Elevated FSH and normal LH
B. Elevated FSH and low LH
C. Elevated FSH and elevated LH
D. Low FSH and low LH 

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Answer A is incorrect: Elevated FSH and normal LH
Rationale: This pattern is characteristic of a primary testis failure due to impaired sperm production.

Answer B is incorrect: Elevated FSH and low LH
Rationale: If either LH or FSH is elevated, then hypogonadotropic hypogonadism is not classically present. This pattern is indicative of primary testis failure with impaired spermatogenesis.

Answer C is incorrect: Elevated FSH and elevated LH
Rationale: This pattern of hormones is called hypergonadotropic hypogonadism, also termed primary bicompartmental testis failure. It represents an end-organ problem of the testis and is not typical of anabolic steroid use.

Answer D is correct: Low FSH and low LH
Rationale: Anabolic steroids cause hypogonadotropic hypogonadism which is precisely the pattern here. Through negative feedback inhibition characteristic of the pituitary-gonadal axis, exogenous androgens inhibit LH and FSH production by the anterior pituitary. Lack of these gonadotropins causes sperm production to stop, resulting in azoospermia.
 

Learn more about this topic while earning CME at ASRM eLearn®.  

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