Current Approaches to Support Patients to Withdraw From Image and Performance Enhancing Drugs

Image and performance-enhancing drugs (IPEDs) include agents such as androgens, growth hormone, and erythropoietin, which are used to enhance appearance and physical performance. Androgens, also known as anabolic-androgenic steroids (AAS), are the most used IPEDs worldwide. While historically associated with elite athletes, androgen abuse is now widely prevalent among recreational athletes, with a lifetime prevalence of 6.4% in men. Androgens, testosterone and its derivatives, promote muscle growth, lipolysis and haematopoiesis and, thus, physical strength, endurance, and muscularity. However their abuse is associated with significant adverse effects across multiple organ systems. Androgen abuse is associated with cardiovascular complications, hepatic dysfunction, psychiatric disorders, and endocrine disruption, notably suppression of the hypothalamic-pituitary-gonadal axis, leading to androgen-induced hypogonadism. Symptoms of androgen-induced hypogonadism, such as fatigue, low mood, and sexual dysfunction, are common following cessation and may persist for months to years even when there has been biochemical recovery. Psychiatric disorders include mood disorders, anxiety and suicidality, highlighting the complexity of androgen withdrawal management. Current clinical approaches prioritise complete cessation, supported by non-judgmental, multidisciplinary care. Management strategies include 'watch-and-wait' for hormonal recovery, although this can be prolonged and is not always associated with restoration of well-being. Pharmacological interventions include selective oestrogen receptor modulators, hCG, aromatase inhibitors or prescribed testosterone therapy. These therapies remain unlicensed and lack robust evidence, with treatment outcomes that are uncertain and highly variable. Psychological support and harm-reduction services, play a key role in engagement. In the absence of standardised guidelines and the increasing burden of androgen-related harm, further research is essential to optimise evidence-based care for affected individuals.