Iron Game
Veteran
Anabolic Steroids: What Urologists Should Know
In 1994, the Substance Abuse and Mental Health Services Administration's National Household Survey on Drug Abuse revealed that nearly 1.1 million Americans—0.5% of the adult population—said they had used anabolic steroids. The youngest users are largely found in middle schools and high schools nationwide. Urologic problems can begin after just one cycle of use, eventually driving the person to seek professional evaluation and treatment. (The NIH's National Institute on Drug Abuse defines “cycling” as taking the steroids—sometimes at doses as much as hundreds of times higher than recommended—for six to 12 weeks or longer, stopping for several weeks, and then starting again. Another commonly used method of steroid use, “stacking,” en-tails taking several different types of steroids at high doses.)
Although the term “anabolic steroids” has negative connotations, it encompasses testosterone gels and injectables that are legitimate medical treatments for various conditions. For example, many aging men with naturally declining levels of the hormone—characterized by low energy, low mood, sexual dysfunction, and trouble concentrating—are prescribed a synthetic testosterone which, by definition, is an anabolic steroid. Nevertheless, many of these men require the care of a urologist when their testosterone treatments need to be re-evaluated, such as when spermatogenesis is affected.
Reproductive problems most common
Among both former and active users of anabolic steroids, the most common presentations in the urology setting are infertility and sex-ual dysfunction. “If they're still on steroids, they typically will have high testosterone levels and low—almost zero, undetectable—luteinizing hormone [LH] and follicle- stimulating hormone [FSH] levels,” explains Stanton Honig, MD, associate clinical professor of urology at the University of Connecticut School of Medicine and an editorial advisory board member of Renal & Urology News. “If they have used steroids in the past and are now off them, they may still have a low LH, low FSH, and low testosterone because they may not rebound.”
Dr. Honig, who specializes in male reproduction and sexual dysfunction issues, sees around two patients per month who are trying to reverse the detrimental effects of anabolic steroids on spermatogenesis. In his experience, these effects can be reversed in about 80% of these men so that sperm is in the ejaculate or can be retrieved from the testicles for in vitro fertilization with or without medical therapy, he reports. About 20% of anabolic steroid users remain permanently azoospermic. In many cases, sperm production can be restored even in current users of anabolic steroids if they stop using the drugs, according to Dr. Honig. However, “it may take three months, six months, nine months, 12 months, even up to two years to see a return,” he cautions. “The bodybuilders will take much longer. The longer they've been on the drug, the less likely they are to respond. But if they've just been on it for a couple of months or a couple of cycles and stop, they will bounce back and have good sperm parameters.”
Anabolic steroids—drugs derived from testosterone—eventually shut down the body's own ability to produce this hormone by suppressing the hypothalamic-pituitary-gonadal axis. The exogenous testosterone signals the pituitary gland that there is enough testosterone, causing the pituitary to stop producing LH and, as a result, less intratesticular testosterone.
After stopping the steroids, “the patient comes in with an incredibly low testosterone level, which leaves him feeling poorly—depressed and no sex drive,” explains andrologist Thomas M. Jaffe, MD, assistant professor of urology at University of Pittsburgh Medical Center.
A male contraceptive
The seemingly obvious solution to persistently low testosterone after prior anabolic steroid abuse would be to raise the man's testosterone levels by administering more testosterone. This treatment actually will have the opposite effect. “Putting an infertility patient on testosterone is the wrong thing,” Dr. Honig said, noting that exogenous testosterone potentially can be a male contraceptive.
Dr. Jaffe echoes that message. “When a young man, interested in achieving a pregnancy with his partner, has a borderline-low testosterone level, the worst thing to do is give him testosterone because it will shut down sperm production,” Dr. Jaffe says. “The more testosterone is raised, the lower the sperm count will go, so it's almost like using steroids again.”
This piece of information is as important as it is counterintuitive to some practitioners, as illustrated by a case described by male-factor infertility specialist Daniel H. Williams IV, MD, assistant professor of urology at the University of Wisconsin School of Medicine and Public Health in Madison.
“I have a patient who was using a testosterone gel for just three or four months. His primary care doctor found him to be hypogonadal but put him on testosterone to try to boost his sperm count,” Dr. Williams recounts. “His sperm count went from low to zero. And it has taken me almost a year and a half of using different medical treatments to reverse that effect.”
Because non-specialists may not be keeping up with the literature on this subject, it is up to the urologist to adjust the treatment regimen. This usually means using medications to “jump start” the pituitary gland's production of LH.
This, in turn, will stimulate the production of testosterone in the testicles. Commonly used agents are clomiphene citrate (Clomid) and LH analogs such as human chorionic gonadotropin (HCG), sometimes with synthetic FSH treatment. Aro-matase inhibitors also may be enlisted to combat low testosterone levels in infertile males. All these medications require careful monitoring by the urologist.
In some cases, the wait-and-see approach is more practical than medical management, at least initially. “I'm in a region with a lot of blue-collar people whose insurance does not cover testosterone-boosting drugs like Clomid or HCG,” Dr. Jaffe explains. “So, if the patient hasn't been a very heavy user of anabolic steroids, I just give his levels time to come back up. Most of the guys I've seen with this problem are in their mid-20s, so they've got time to have children; there's not a big rush.”
Dr. Jaffe monitors the testosterone levels and sperm counts of these patients every three months. “In my particular patient population, you start seeing slow but steady improvements in sperm production. Again, these are men who probably haven't done more than one or two anabolic steroid cycles in general. Most guys I've taken care of have rebounded within three to six months; the longest took a year.”
Yet there's little rhyme or reason as to who will suffer stubborn or even permanent effects of anabolic steroid use. “For a lot of these guys, it's just one cycle of steroids and they might never have their sperm production return to normal levels,” Dr. Jaffe says. “Then there are guys who have done numerous cycles and they're okay.”
Identifying abusers
Some males who have used anabolic steroids indeed fit the stereotype of the overly muscled physique. “Typically, they are obviously big, bodybuilder-looking types,” Dr. Honig observes.
Such physical effects are not always obvious, however. “In terms of my patients, if they hadn't told you they used steroids you never would have known,” Dr. Jaffe states.
Verbal clues may be as unreliable as visual ones. Consider Dr. Honig's usual experience with patients who have used performance-enhancing anabolic steroids: “They are often in complete denial. It usually takes three or four times of asking before they'll admit that they've used anabolic steroids.”
Some patients are more forthcoming. “Most of the guys I've treated have come out and said, ‘I've used steroids; is that why I'm having a problem?'” Dr. Jaffe says. “Sometimes they feel guilty about having used the drugs.”
Blood tests can shed light on the matter. “If you suspect anabolic steroid use, you can draw testosterone levels,” Dr. Honig said. “If the normal range is typically 200 to 800 mg/dL, active users might have 1,500 to 2,000 mg/dL.” Dr. Jaffe adds that LH levels are also a good indicator of steroid use. “If they're taking testosterone, then their luteinizing hormone levels should probably be pretty low—maybe almost undetectable.”
Distinguishing between natural and synthetic testosterone is a more difficult task. Some professionals believe that high levels of the testosterone derivative epitestosterone can help differentiate, but Dr. Williams is doubtful. “Even though most men have a general testosterone-to-epitestosterone ratio of about 1-to-1, some men have natural ratios that are higher. So, that test is an unreliable marker for exogenous testosterone use.”
Oral testosterone is no longer prescribed in North America because it can cause liver damage, but two currently popular forms of treatment for men with low testosterone are the topical gels, such as AndroGel and Testim, and the injectable formulations. “Both treatments are safe to prescribe if they're being administered by an experienced medical professional who understands the risks and benefits of testosterone replacement therapy and who knows how to monitor the levels and make the necessary adjustments,” Dr. Williams says.
Men who have engaged in the cycling of anabolic steroids long enough to deplete their endogenous testosterone production now are grappling with erectile dysfunction. They may be able to achieve erections again after a period of testosterone supplementation alone, but this quality-of-life issue often re-quires a quicker resolution with a multimodal approach. “Treat these patients with testosterone supplementation plus an agent such as Viagra, Levitra, or Cialis,” Dr. Jaffe advises.
Beyond testosterone treatment
When Dr. Williams started his urology training, he did not expect testosterone use and hypogonadism to be part of his practice. “Traditionally, low testosterone and testosterone treatments were part of the practice of the internal medicine doctor who was trained in endocrinology,” he recalls. “I didn't think that I was going to be talking to patients about testosterone as opposed to kidney stones or prostate cancer.”
As urologists evolve as the go-to providers of men's overall and sexual health, “we may be the ones who discover the low testosterone levels,” Dr. Williams points out. “These issues are becoming an important part of our practice.”
Toward that end, what is the scope of the urologist's role in the management of men who use anabolic steroids that are not medically indicated? “It's absolutely the urologist's duty to explain the dangers of this behavior to the patient,” Dr. Jaffe declares. “The patient has to know that he's going to need testosterone supplementation for the rest of his life if he keeps on using. If his own body doesn't make testosterone and he doesn't supplement the testosterone he'll have issues with bone health, cognitive function, and potential problems with cholesterol and triglyceride metabolism, to name a few health issues.”
Users should also be warned about obtaining these substances on the black market. “Not only is it illegal, but this is particularly scary because no one is monitoring these men's levels, and we don't know anything about the quality of the medications they're using,” Dr. Williams says. “How pure are they? Are they injecting veterinarian-grade testosterone? Who knows what they're getting or how much of it they're using.”
An endocrinologist's view
Depending on the referral patterns of a given region or insurer, or the specialization of a particular area's physicians, a man with urologic problems stemming from hormonal imbalances may be sent to an endocrinologist rather than a urologist.
“There is enough overlap between endocrinologists and urologists that we're distant cousins,” says Bradley D. Anawalt, MD, an endocrinologist himself who recently reviewed the impact of anabolic steroids on hormones for fellow scientists and the media.
Dr. Anawalt, professor of medicine and staff physician in general internal medicine and endocrinology for the VA Puget Sound Health Care System in Seattle, believes that either type
of professional can care for men who have sexual problems related to anabolic steroid use.
“It's not so much the discipline that matters; the key is to have some experience and expertise in the administration of hormone therapy,” he emphasizes. “Any patient who comes in with a history of anabolic steroid use, specifically if they have sexual dysfunction or problems with infertility, should be considered for hormone therapy for restoration of the ability to conceive, and that could be done by anybody who has expertise in that area.”
Dr. Anawalt urges urologists to be attuned to the possibility of anabolic steroid use even in unlikely suspects. “Anabolic steroid abuse is an everyday abuse problem,” he affirms. “Oftentimes the users aren't athletes or bodybuilders; they can just be average Joes who want to look a little more muscular. Doctors may be seeing these folks and not recognizing them.”
He also points out that since steroid use among high school students is currently close to 5%, urologists are going to be seeing many of these boys when they reach their 20s and 30s and come in seeking help for infertility. “You might not necessarily think to ask, ‘Oh, did you used to use anabolic steroids?' So it's important to be aware of this possibility.”
In most commercially available assays the ballpark normal ranges for LH and FSH is 1-10 IU/L. An LH or an FSH level less than 1 IU/L should be cause for concern, Dr. Anawalt says. “In a young man, that means one of two things: a problem with the hypothalamus-pituitary, or a problem of taking drugs that are turning off LH and FSH. And a lot of these guys taking anabolic steroids will have testosterone levels lower than the typical range of 300 to 1,000 ng/dL because they are not taking testosterone.”
To avoid feeling depressed, fatigued, and—in Anawalt's words—“just kind of crummy” in the
course of discontinuing anabolic steroid use, the patient may benefit from being weaned off the substances. The trick is to find a regimen that combines a shorter half-life and a much lower dosage. “Many of the anabolic steroids being used non-medically have a very long half-life, whereas I'll give the person a testosterone patch with a short half-life that washes out pretty quickly, to help wean them off,” Dr. Anawalt explains. “And, they're often using prodigious doses of androgenic steroids. In one study people were taking 10 to 12 times the normal replacement dose.”
Instead, Dr. Anawalt gives a replacement dose of 1 to 1.5 times the usual replacement dosage for the treatment of male hyogonadism. “So it's a big drop, but it doesn't make the patient feel quite so bad. It's a way to gently bring him back down to normal without letting him go cold-turkey.”
Men who are anxious to impregnate their partner are not candidates for this type of approach because the high doses of testosterone involved will quell sperm production, Dr. Anawalt says.
Anabolic steroid users may be at increased risk for hepatopathy, cardiovascular disease, and cholesterol problems. “Urologists could order a fasting lipid panel for these patients to determine whether there are any significant abnormalities,” suggests Dr. Anawalt. “Or they may choose to refer the patient to an endocrinologist for such testing. Either way, the key to it is to be aware of the potential for health problems and to recognize that you have to address them.”
In 1994, the Substance Abuse and Mental Health Services Administration's National Household Survey on Drug Abuse revealed that nearly 1.1 million Americans—0.5% of the adult population—said they had used anabolic steroids. The youngest users are largely found in middle schools and high schools nationwide. Urologic problems can begin after just one cycle of use, eventually driving the person to seek professional evaluation and treatment. (The NIH's National Institute on Drug Abuse defines “cycling” as taking the steroids—sometimes at doses as much as hundreds of times higher than recommended—for six to 12 weeks or longer, stopping for several weeks, and then starting again. Another commonly used method of steroid use, “stacking,” en-tails taking several different types of steroids at high doses.)
Although the term “anabolic steroids” has negative connotations, it encompasses testosterone gels and injectables that are legitimate medical treatments for various conditions. For example, many aging men with naturally declining levels of the hormone—characterized by low energy, low mood, sexual dysfunction, and trouble concentrating—are prescribed a synthetic testosterone which, by definition, is an anabolic steroid. Nevertheless, many of these men require the care of a urologist when their testosterone treatments need to be re-evaluated, such as when spermatogenesis is affected.
Reproductive problems most common
Among both former and active users of anabolic steroids, the most common presentations in the urology setting are infertility and sex-ual dysfunction. “If they're still on steroids, they typically will have high testosterone levels and low—almost zero, undetectable—luteinizing hormone [LH] and follicle- stimulating hormone [FSH] levels,” explains Stanton Honig, MD, associate clinical professor of urology at the University of Connecticut School of Medicine and an editorial advisory board member of Renal & Urology News. “If they have used steroids in the past and are now off them, they may still have a low LH, low FSH, and low testosterone because they may not rebound.”
Dr. Honig, who specializes in male reproduction and sexual dysfunction issues, sees around two patients per month who are trying to reverse the detrimental effects of anabolic steroids on spermatogenesis. In his experience, these effects can be reversed in about 80% of these men so that sperm is in the ejaculate or can be retrieved from the testicles for in vitro fertilization with or without medical therapy, he reports. About 20% of anabolic steroid users remain permanently azoospermic. In many cases, sperm production can be restored even in current users of anabolic steroids if they stop using the drugs, according to Dr. Honig. However, “it may take three months, six months, nine months, 12 months, even up to two years to see a return,” he cautions. “The bodybuilders will take much longer. The longer they've been on the drug, the less likely they are to respond. But if they've just been on it for a couple of months or a couple of cycles and stop, they will bounce back and have good sperm parameters.”
Anabolic steroids—drugs derived from testosterone—eventually shut down the body's own ability to produce this hormone by suppressing the hypothalamic-pituitary-gonadal axis. The exogenous testosterone signals the pituitary gland that there is enough testosterone, causing the pituitary to stop producing LH and, as a result, less intratesticular testosterone.
After stopping the steroids, “the patient comes in with an incredibly low testosterone level, which leaves him feeling poorly—depressed and no sex drive,” explains andrologist Thomas M. Jaffe, MD, assistant professor of urology at University of Pittsburgh Medical Center.
A male contraceptive
The seemingly obvious solution to persistently low testosterone after prior anabolic steroid abuse would be to raise the man's testosterone levels by administering more testosterone. This treatment actually will have the opposite effect. “Putting an infertility patient on testosterone is the wrong thing,” Dr. Honig said, noting that exogenous testosterone potentially can be a male contraceptive.
Dr. Jaffe echoes that message. “When a young man, interested in achieving a pregnancy with his partner, has a borderline-low testosterone level, the worst thing to do is give him testosterone because it will shut down sperm production,” Dr. Jaffe says. “The more testosterone is raised, the lower the sperm count will go, so it's almost like using steroids again.”
This piece of information is as important as it is counterintuitive to some practitioners, as illustrated by a case described by male-factor infertility specialist Daniel H. Williams IV, MD, assistant professor of urology at the University of Wisconsin School of Medicine and Public Health in Madison.
“I have a patient who was using a testosterone gel for just three or four months. His primary care doctor found him to be hypogonadal but put him on testosterone to try to boost his sperm count,” Dr. Williams recounts. “His sperm count went from low to zero. And it has taken me almost a year and a half of using different medical treatments to reverse that effect.”
Because non-specialists may not be keeping up with the literature on this subject, it is up to the urologist to adjust the treatment regimen. This usually means using medications to “jump start” the pituitary gland's production of LH.
This, in turn, will stimulate the production of testosterone in the testicles. Commonly used agents are clomiphene citrate (Clomid) and LH analogs such as human chorionic gonadotropin (HCG), sometimes with synthetic FSH treatment. Aro-matase inhibitors also may be enlisted to combat low testosterone levels in infertile males. All these medications require careful monitoring by the urologist.
In some cases, the wait-and-see approach is more practical than medical management, at least initially. “I'm in a region with a lot of blue-collar people whose insurance does not cover testosterone-boosting drugs like Clomid or HCG,” Dr. Jaffe explains. “So, if the patient hasn't been a very heavy user of anabolic steroids, I just give his levels time to come back up. Most of the guys I've seen with this problem are in their mid-20s, so they've got time to have children; there's not a big rush.”
Dr. Jaffe monitors the testosterone levels and sperm counts of these patients every three months. “In my particular patient population, you start seeing slow but steady improvements in sperm production. Again, these are men who probably haven't done more than one or two anabolic steroid cycles in general. Most guys I've taken care of have rebounded within three to six months; the longest took a year.”
Yet there's little rhyme or reason as to who will suffer stubborn or even permanent effects of anabolic steroid use. “For a lot of these guys, it's just one cycle of steroids and they might never have their sperm production return to normal levels,” Dr. Jaffe says. “Then there are guys who have done numerous cycles and they're okay.”
Identifying abusers
Some males who have used anabolic steroids indeed fit the stereotype of the overly muscled physique. “Typically, they are obviously big, bodybuilder-looking types,” Dr. Honig observes.
Such physical effects are not always obvious, however. “In terms of my patients, if they hadn't told you they used steroids you never would have known,” Dr. Jaffe states.
Verbal clues may be as unreliable as visual ones. Consider Dr. Honig's usual experience with patients who have used performance-enhancing anabolic steroids: “They are often in complete denial. It usually takes three or four times of asking before they'll admit that they've used anabolic steroids.”
Some patients are more forthcoming. “Most of the guys I've treated have come out and said, ‘I've used steroids; is that why I'm having a problem?'” Dr. Jaffe says. “Sometimes they feel guilty about having used the drugs.”
Blood tests can shed light on the matter. “If you suspect anabolic steroid use, you can draw testosterone levels,” Dr. Honig said. “If the normal range is typically 200 to 800 mg/dL, active users might have 1,500 to 2,000 mg/dL.” Dr. Jaffe adds that LH levels are also a good indicator of steroid use. “If they're taking testosterone, then their luteinizing hormone levels should probably be pretty low—maybe almost undetectable.”
Distinguishing between natural and synthetic testosterone is a more difficult task. Some professionals believe that high levels of the testosterone derivative epitestosterone can help differentiate, but Dr. Williams is doubtful. “Even though most men have a general testosterone-to-epitestosterone ratio of about 1-to-1, some men have natural ratios that are higher. So, that test is an unreliable marker for exogenous testosterone use.”
Oral testosterone is no longer prescribed in North America because it can cause liver damage, but two currently popular forms of treatment for men with low testosterone are the topical gels, such as AndroGel and Testim, and the injectable formulations. “Both treatments are safe to prescribe if they're being administered by an experienced medical professional who understands the risks and benefits of testosterone replacement therapy and who knows how to monitor the levels and make the necessary adjustments,” Dr. Williams says.
Men who have engaged in the cycling of anabolic steroids long enough to deplete their endogenous testosterone production now are grappling with erectile dysfunction. They may be able to achieve erections again after a period of testosterone supplementation alone, but this quality-of-life issue often re-quires a quicker resolution with a multimodal approach. “Treat these patients with testosterone supplementation plus an agent such as Viagra, Levitra, or Cialis,” Dr. Jaffe advises.
Beyond testosterone treatment
When Dr. Williams started his urology training, he did not expect testosterone use and hypogonadism to be part of his practice. “Traditionally, low testosterone and testosterone treatments were part of the practice of the internal medicine doctor who was trained in endocrinology,” he recalls. “I didn't think that I was going to be talking to patients about testosterone as opposed to kidney stones or prostate cancer.”
As urologists evolve as the go-to providers of men's overall and sexual health, “we may be the ones who discover the low testosterone levels,” Dr. Williams points out. “These issues are becoming an important part of our practice.”
Toward that end, what is the scope of the urologist's role in the management of men who use anabolic steroids that are not medically indicated? “It's absolutely the urologist's duty to explain the dangers of this behavior to the patient,” Dr. Jaffe declares. “The patient has to know that he's going to need testosterone supplementation for the rest of his life if he keeps on using. If his own body doesn't make testosterone and he doesn't supplement the testosterone he'll have issues with bone health, cognitive function, and potential problems with cholesterol and triglyceride metabolism, to name a few health issues.”
Users should also be warned about obtaining these substances on the black market. “Not only is it illegal, but this is particularly scary because no one is monitoring these men's levels, and we don't know anything about the quality of the medications they're using,” Dr. Williams says. “How pure are they? Are they injecting veterinarian-grade testosterone? Who knows what they're getting or how much of it they're using.”
An endocrinologist's view
Depending on the referral patterns of a given region or insurer, or the specialization of a particular area's physicians, a man with urologic problems stemming from hormonal imbalances may be sent to an endocrinologist rather than a urologist.
“There is enough overlap between endocrinologists and urologists that we're distant cousins,” says Bradley D. Anawalt, MD, an endocrinologist himself who recently reviewed the impact of anabolic steroids on hormones for fellow scientists and the media.
Dr. Anawalt, professor of medicine and staff physician in general internal medicine and endocrinology for the VA Puget Sound Health Care System in Seattle, believes that either type
of professional can care for men who have sexual problems related to anabolic steroid use.
“It's not so much the discipline that matters; the key is to have some experience and expertise in the administration of hormone therapy,” he emphasizes. “Any patient who comes in with a history of anabolic steroid use, specifically if they have sexual dysfunction or problems with infertility, should be considered for hormone therapy for restoration of the ability to conceive, and that could be done by anybody who has expertise in that area.”
Dr. Anawalt urges urologists to be attuned to the possibility of anabolic steroid use even in unlikely suspects. “Anabolic steroid abuse is an everyday abuse problem,” he affirms. “Oftentimes the users aren't athletes or bodybuilders; they can just be average Joes who want to look a little more muscular. Doctors may be seeing these folks and not recognizing them.”
He also points out that since steroid use among high school students is currently close to 5%, urologists are going to be seeing many of these boys when they reach their 20s and 30s and come in seeking help for infertility. “You might not necessarily think to ask, ‘Oh, did you used to use anabolic steroids?' So it's important to be aware of this possibility.”
In most commercially available assays the ballpark normal ranges for LH and FSH is 1-10 IU/L. An LH or an FSH level less than 1 IU/L should be cause for concern, Dr. Anawalt says. “In a young man, that means one of two things: a problem with the hypothalamus-pituitary, or a problem of taking drugs that are turning off LH and FSH. And a lot of these guys taking anabolic steroids will have testosterone levels lower than the typical range of 300 to 1,000 ng/dL because they are not taking testosterone.”
To avoid feeling depressed, fatigued, and—in Anawalt's words—“just kind of crummy” in the
course of discontinuing anabolic steroid use, the patient may benefit from being weaned off the substances. The trick is to find a regimen that combines a shorter half-life and a much lower dosage. “Many of the anabolic steroids being used non-medically have a very long half-life, whereas I'll give the person a testosterone patch with a short half-life that washes out pretty quickly, to help wean them off,” Dr. Anawalt explains. “And, they're often using prodigious doses of androgenic steroids. In one study people were taking 10 to 12 times the normal replacement dose.”
Instead, Dr. Anawalt gives a replacement dose of 1 to 1.5 times the usual replacement dosage for the treatment of male hyogonadism. “So it's a big drop, but it doesn't make the patient feel quite so bad. It's a way to gently bring him back down to normal without letting him go cold-turkey.”
Men who are anxious to impregnate their partner are not candidates for this type of approach because the high doses of testosterone involved will quell sperm production, Dr. Anawalt says.
Anabolic steroid users may be at increased risk for hepatopathy, cardiovascular disease, and cholesterol problems. “Urologists could order a fasting lipid panel for these patients to determine whether there are any significant abnormalities,” suggests Dr. Anawalt. “Or they may choose to refer the patient to an endocrinologist for such testing. Either way, the key to it is to be aware of the potential for health problems and to recognize that you have to address them.”
