The use of testosterone among athletes has long been a topic of both intrigue and concern. While it plays a vital role in muscle growth, recovery, and overall athletic performance, improper or excessive use can lead to significant health risks, including hormonal imbalances, cardiovascular issues, and long-term dependency.

This topic explores the delicate balance between natural hormone optimization and the ethical, medical, and regulatory challenges associated with testosterone use in sports.

Why do athletes use testosterone?

Athletes use testosterone primarily to enhance their physical performance, strength, and recovery. Testosterone, a key hormone in muscle growth and repair, offers several benefits that appeal to athletes, such as:

• Increased Muscle Mass and Strength: Testosterone promotes protein synthesis, which helps build and maintain muscle tissue, leading to improved power and endurance.
• Enhanced Recovery: It reduces muscle damage and speeds up recovery after intense workouts or competitions, allowing athletes to train harder and more frequently.
• Boosted Red Blood Cell Production: Higher testosterone levels can increase red blood cell production, improving oxygen delivery to muscles and enhancing stamina and endurance.
• Improved Performance: Testosterone can lead to better athletic performance by increasing energy, aggression, and competitiveness during physical activities.

Is testosterone use by athletes legal?

The use of testosterone by athletes is highly regulated and often illegal in competitive sports unless prescribed for legitimate medical reasons. Here’s an overview:

• Banned in Most Sports: Synthetic testosterone and anabolic steroids are classified as performance-enhancing drugs (PEDs) and are prohibited by major sporting organizations, including the World Anti-Doping Agency (WADA) and the International Olympic Committee (IOC).
• Therapeutic Use Exemptions (TUEs): In rare cases, athletes with a diagnosed medical condition, such as hypogonadism, may be granted a TUE to use testosterone legally. However, obtaining a TUE requires strict documentation and approval from relevant authorities.
• Testing and Penalties: Athletes are regularly tested for banned substances, including testosterone. Elevated levels or evidence of synthetic testosterone use can result in penalties such as suspensions, fines, or lifetime bans.
• Legal in Non-Competitive Contexts: Outside of regulated sports, testosterone use may be legal with a valid prescription. However, even recreational use without medical oversight carries significant health risks.

Complications of testosterone use by athletes?

Athletes who use testosterone, especially in high doses or without medical supervision, face numerous health complications. These risks can affect multiple systems in the body and have both short- and long-term consequences. Here are the key complications:

Physical Health Risks:

• Cardiovascular Issues: Increased risk of heart attacks, strokes, and high blood pressure. Testosterone can elevate LDL (“bad”) cholesterol levels and decrease HDL (“good”) cholesterol.
  • Liver Damage: Oral testosterone or anabolic steroids can strain the liver, leading to liver dysfunction or tumors.
  • Hormonal Imbalances: Suppression of natural testosterone production, leading to testicular atrophy (shrinkage of testicles). Gynecomastia (development of breast tissue in men) due to hormone imbalances.
  • Reproductive Issues: Reduced sperm production, infertility, and erectile dysfunction.
  • Musculoskeletal Problems: Increased risk of tendon injuries due to rapid muscle growth that outpaces tendon adaptation.
  • Acne and Skin Issues: Excess testosterone can increase oil production in the skin, leading to severe acne or skin infections.

Psychological and Behavioral Risks:

• Mood Swings and Aggression: High doses can cause “roid rage,” characterized by heightened aggression and irritability.
  • Depression and Anxiety: Long-term use can disrupt brain chemistry, leading to mood disorders after stopping use.
  • Addiction: Dependence on testosterone or anabolic steroids can develop, making it difficult to stop using.

Long-Term Risks:

• Prostate Health: Increased risk of prostate enlargement or cancer in some individuals.
  • Kidney Damage: Long-term use can harm kidney function due to increased strain on the renal system.
  • Immune System Suppression: Chronic testosterone abuse may impair immune responses, increasing the risk of infections.
  • Premature Aging and Death: Long-term abuse has been linked to shortened life expectancy due to cumulative health damage.

Social and Career Consequences:

• Bans from Competitions: Positive tests for testosterone can result in suspensions or lifetime bans from sports.
  • Stigma and Reputation Damage: Athletes caught using testosterone often face public backlash and damage to their careers.

Negative effects of testosterone use on fertility and erection?

The use of testosterone, especially in excessive or synthetic forms, can have serious negative effects on fertility and erectile function in athletes. These effects occur primarily because external testosterone disrupts the body’s natural hormonal balance. Below is an overview of these complications:

Negative effects on fertility:

• Suppression of Natural Testosterone Production: When athletes use synthetic testosterone, the body detects the high levels and stops producing its own testosterone. This suppression of natural testosterone reduces the production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which are critical for sperm production.
  • Reduced Sperm Production (Oligospermia): Testosterone use directly decreases sperm count, leading to oligospermia (low sperm count) or even azoospermia (complete absence of sperm). Long-term use can cause prolonged or even permanent infertility.
  • Altered Sperm Quality: Testosterone use can reduce sperm motility (ability to swim) and increase the number of abnormally shaped sperm, further impairing fertility.
  • Shrinking of Testicles (Testicular Atrophy): The suppression of testicular function can lead to testicular shrinkage, further impacting sperm production and fertility.
  • Difficulty Recovering Fertility: For some individuals, fertility does not fully recover after stopping testosterone use, especially after prolonged or high-dose abuse.

Negative effects on erection:

• Erectile Dysfunction (ED): Excess testosterone can disrupt the body’s natural hormonal balance, leading to erectile dysfunction when the body becomes reliant on external sources of testosterone. When synthetic testosterone is stopped, the suppressed natural testosterone levels may not recover quickly, further worsening ED.
  • Decreased Libido: While testosterone is linked to increased sex drive, chronic misuse or dependency can result in a paradoxical decrease in libido over time. Hormonal imbalances caused by testosterone misuse may impair sexual desire.
  • Conversion to Estrogen: Some synthetic testosterone converts into estrogen (via aromatization), leading to high estrogen levels, which can negatively affect erections and sexual performance.
  • Psychological Effects: Testosterone misuse can lead to mood swings, anxiety, or depression, which can indirectly contribute to erectile dysfunction and reduced sexual satisfaction.

Are complications of testosterone use reversible?

The negative effects of testosterone use by athletes on fertility and erection can be partially or fully reversible, but this depends on several factors, including the duration, dosage, and frequency of use, as well as individual health conditions. Here’s a detailed breakdown:

Fertility:

Stopping testosterone use can lead to a gradual recovery of sperm production, but it may take 6–12 months or longer. The effects of testosterone on fertility, such as reduced sperm production or testicular atrophy, can often be reversed, but the degree of recovery varies:

• Mild or Short-Term Use: In cases of short-term or low-dose testosterone use, the body’s natural hormonal balance and sperm production often recover within a few months after discontinuing use. Sperm count typically begins to rise as the hypothalamic-pituitary-gonadal (HPG) axis resumes its function.
• Prolonged or High-Dose Use: Long-term use or abuse of testosterone can cause more significant suppression of sperm production and testicular function, making recovery slower and less predictable. For some individuals, natural fertility may not return completely, especially if damage to the testes has occurred.
• Supportive Treatments for Recovery: Medications like clomiphene citrate (Clomid) or human chorionic gonadotropin (hCG) can stimulate the production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which are essential for sperm production. In severe cases, assisted reproductive technologies (e.g., in vitro fertilization) may be required.

Erection

The effects of testosterone misuse on erectile function are often reversible, though recovery timelines and outcomes depend on individual circumstances:

• Post-Testosterone Erectile Dysfunction: After stopping testosterone, the body may take time to restart its natural testosterone production. During this period, erectile dysfunction (ED) and reduced libido are common.
• Recovery can take several weeks to months, depending on the duration and intensity of testosterone use.
• Hormonal Recovery: Natural testosterone levels usually return as the HPG axis resumes function, restoring erectile function and libido. Some individuals may experience faster recovery with the help of medications like hCG or aromatase inhibitors to restore hormonal balance.
• Permanent Damage: In rare cases, prolonged testosterone misuse can cause irreversible damage to hormone regulation, leading to chronic ED that may require ongoing medical treatment (e.g., testosterone replacement therapy or ED medications).

Factors Affecting Reversibility:

• Age: Younger individuals typically recover faster due to more robust reproductive and hormonal systems.
• Health: Underlying health issues (e.g., obesity, diabetes) can slow recovery.
• Duration and Dose: Prolonged, high-dose testosterone use can cause more severe and long-lasting effects.
• Lifestyle: Proper nutrition, exercise, and stress management can promote recovery.

Treatment of complications

Treating the negative effects of testosterone use by athletes on fertility and erections involves addressing the underlying hormonal imbalances and restoring the body’s natural hormonal production. Here’s an overview of the treatment approaches:

Treatment for Fertility Issues

Testosterone use suppresses natural sperm production and testicular function, but these effects can often be treated with appropriate interventions:

• Discontinue testosterone use
• Post-cycle therapy
• Lifestyle modifications: nutrition, exercise,  stress management
• Assisted reproductive technologies (ART)

Treatment for ED

Testosterone misuse can lead to hormonal imbalances and erectile dysfunction, which may require tailored treatment:

• Address hormonal imbalances
• ED medications
• Testosterone replacement therapy (TRT): this approach is only recommended for those with documented hypogonadism under medical supervision.
• Psychotherapy or counseling

Summary

Testosterone use among athletes is often aimed at enhancing performance, increasing muscle mass, and improving recovery. However, misuse can lead to serious health risks, including fertility problems, erectile dysfunction, hormonal imbalances, and testicular shrinkage. Long-term use may cause irreversible damage to reproductive health. While some effects are treatable through discontinuation, post-cycle therapy, and medical interventions, recovery can be slow and uncertain. Athletes are encouraged to prioritize natural performance enhancement methods and seek professional guidance before considering testosterone use.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKIYE