Introduction
Androgens—the primary being testosterone and its potent intracellular metabolite dihydrotestosterone (DHT)—drive the development and maintenance of male phenotype, regulate protein anabolism, affect behavior, and exert complex feed-back control over the hypothalamic–pituitary–gonadal (HPG) axis. Therapeutically, natural and synthetic androgens (collectively “anabolic-androgenic steroids,” AAS) are indispensable in endocrinology, hematology, geriatrics, gynecology, and even palliative care.
1. Chemical Classification
| Group | Prototype(s) | Key Structural Feature | Relative Androgenic : Anabolic Activity |
| C-19 3-ketosteroids | Testosterone, testosterone enanthate, cypionate | 17β-hydroxy-4-androstene-3-one | 1 : 1 |
| 17α-Alkylated derivatives | Methyltestosterone, fluoxymesterone, oxandrolone, stanozolol | 17α-alkyl blocks hepatic oxidation | 1 : 2–10 (anabolic-favored) |
| 19-Nor derivatives | Nandrolone decanoate, norethandrolone | Absence of C-19 methyl; often esterified at 17β | 0.4 : 8 |
| Others | Danazol (isoxazole ring); DHT analogs (mesterolone) | Modified A or B ring | Variable |
2. Biosynthesis & Regulation
2.1 Sites & Pathways
• Leydig cells (testes) produce ~95 % of circulating testosterone in adult males; remainder from adrenal zona reticularis and peripheral conversion.
• Substrate: cholesterol → pregnenolone (CYP11A1) → 17α-hydroxypregnenolone (CYP17A1) → dehydroepiandrosterone (DHEA) → androstenedione (3β-HSD) → testosterone (17β-HSD).
• In target tissues with 5α-reductase type II (prostate, skin, external genitalia) testosterone → DHT (3- to 10-fold higher affinity for the androgen receptor, AR). In adipose and brain aromatase converts testosterone to estradiol, mediating bone maturation, libido, and metabolic effects.
2.2 Hypothalamic–Pituitary Control
• GnRH pulses (q60–90 min) stimulate anterior pituitary LH and FSH. LH acts on Leydig cells (cAMP–PKA) → testosterone; FSH acts on Sertoli cells (spermatogenesis).
• Negative feedback: testosterone and estradiol ↓ GnRH and LH; inhibin B from Sertoli cells ↓ FSH.
• Chronic exogenous AAS suppress GnRH/LH/FSH → testicular atrophy and infertility.
3. Physiology & Molecular Mechanisms
3.1 Androgen Receptor (AR) Biology
• Nuclear receptor superfamily; on ligand binding, AR dimerizes, translocates to nucleus, binds androgen response elements (AREs), recruits co-regulators, and alters transcription.
• Tissue-specific co-activators produce androgen vs. anabolic selectivity; hence synthetic steroids seek favorable dissociation.
• Non-genomic mechanisms (ERK, PI3K activation) under study.
3.2 Organ-System Effects
• Embryologic: Wolffian duct differentiation (epididymis, vas deferens); DHT drives external genital virilization.
• Puberty: growth spurt, laryngeal enlargement, facial/body hair; epiphyseal closure (via estrogen).
• Adult males: spermatogenesis support, libido, erectile function, muscle mass, bone density, erythropoiesis (↑ EPO), sebum production.
• Females: adrenal/ovarian androgens (~200 µg/day) influence libido, hair follicles; excess → hirsutism.
• Metabolic: ↓ HDL, ↑ LDL (17α-alkyl AAS), visceral adiposity reduction, insulin sensitization at physiologic levels but resistance at supraphysiologic.
4. Pharmacodynamics
4.1 Dose–Response & Selectivity
• Physiologic replacement aims for serum testosterone 300–1 000 ng/dL.
• Anabolic : androgenic ratio increases with 19-nor and 17α-alkyl agents; yet at high doses all compounds virilize.
• DHT analogs (mesterolone) do not aromatize → minimal estrogenic effects but exacerbate baldness/prostate enlargement.
4.2 Tissue-Specific Modulation
• AR polymorphisms (CAG repeat length) modulate sensitivity.
• 5α-reductase inhibitors (finasteride) attenuate prostate-skin actions while sparing muscle, showcasing enzymatic compartmentalization.
5. Pharmacokinetics
| Preparation | Route | t½ (release) | Key Points |
| Testosterone cypionate/enanthate 100–200 mg | IM oil depot | 8–10 days | Peaks 24–48 h, steady decline; inject q2–4 wk |
| Testosterone undecanoate 1 000 mg | Deep IM | 10–14 wks | Requires REMS (pulm oil microembolism) in US |
| Testosterone undecanoate 80 mg caps | Oral (with fat) | 2–5 h | Absorbed via lymphatics, bypass 1st-pass; BID |
| Transdermal 2–10 mg/day (gel, patch) | Topical | N/A | Stable physiology-like peaks; skin transfer risk |
| Buccal 30 mg BID | Mucoadhesive | 3–4 h | Gum irritation common |
| 17α-Alkyl (methyltestosterone 10–50 mg) | Oral | 3–4 h | Hepatotoxic, rarely used today |
• Protein binding: 40 % to sex hormone–binding globulin (SHBG), 58 % albumin, 2 % free.
• Metabolism: hepatic 17-ketosteroid reduction, oxidation → conjugated glucuronides excreted in urine; minor renal 5 % unchanged.
• 17α-alkylation resists inactivation, hence oral activity and hepatotoxicity.
6. Therapeutic Indications
6.1 Endocrine Replacement
• Primary hypogonadism (Klinefelter, anorchia, post-orchiectomy, chemo/RT).
• Secondary hypogonadism (pituitary/hypothalamic disease) if fertility not required.
• Delayed puberty (careful low-dose IM testosterone).
• Female-to-male (FTM) gender-affirming therapy.
6.2 Catabolic & Hematologic States
• Burns, severe trauma, chronic wasting (HIV, COPD)—agents like oxandrolone (2.5 mg PO BID) expedite nitrogen balance and wound healing.
• Anemia of chronic renal failure/aplastic anemia (historical; EPO supplanted). Nandrolone stimulates erythropoiesis.
6.3 Osteoporosis & Menopausal Symptoms
• Limited role; androgen + estrogen combos explored in women with hypoactive sexual desire disorder (HSDD).
6.4 Hereditary Angioedema
• Danazol, stanozolol induce hepatic C1-esterase inhibitor synthesis; prophylaxis 100–600 mg/day.
6.5 Metastatic Breast Cancer (rare)
• Fluoxymesterone palliates hormone-responsive tumors in postmenopausal women; largely replaced by aromatase inhibitors.
7. Adverse Effects
7.1 Androgenic/Virilizing
• Acne, seborrhea, male-pattern baldness, hirsutism (women), deep voice.
• Clitoromegaly, menstrual irregularity, infertility.
• Premature epiphyseal closure in children → stunted height.
7.2 Cardiovascular–Metabolic
• Polycythemia (Hct > 54 %) → hyperviscosity, stroke risk; monitor q6 mo.
• ↓ HDL-C (17α-alkyl > injectable), ↑ LDL-C; endothelial dysfunction; MI reports with high-dose AAS.
7.3 Hepatotoxicity
• Cholestatic jaundice, peliosis hepatis, hepatocellular adenoma → carcinoma (predominantly 17α-alkyl compounds). Elevate liver enzymes and alkaline phosphatase; routine monitoring.
7.4 Prostate & Lower Urinary Tract
• ↑ PSA, prostate volume; symptomatic BPH exacerbation. Current evidence does not prove causation of de-novo prostate cancer, but may accelerate subclinical disease.
7.5 Behavioral & Neuropsychiatric
• Mood swings, irritability, hypomania (“roid rage”), dependence syndrome per DSM-5.
7.6 Others
• Sleep apnea worsening; gynecomastia (via aromatization) → treat with tamoxifen or surgery.
• Injection-site pain, pulmonary oil microembolism (testosterone undecanoate).
8. Contra-Indications & Precautions
• Absolute: Carcinoma of prostate or male breast; pregnancy/breastfeeding; polycythemia.
• Relative: Untreated sleep apnea, severe BPH LUTS, hematocrit >50 %, uncontrolled CHF, active hepatic disease, hyperlipidemia.
• Pre-therapy screening: DRE + PSA ≥40 y, hematocrit, LFTs, lipid profile. Recheck 3, 6, 12 mo then annually.
9. Drug Interactions
• Anticoagulants (warfarin)—androgens ↓ clotting factors II, VII, IX, X → ↑ INR.
• Cyclosporine—nephrotoxicity potentiation.
• Insulin & oral hypoglycemics—enhanced hypoglycemia (↑ insulin sensitivity).
• Corticosteroids/diuretics—additive edema.
• Hepatic enzyme inducers (rifampin, carbamazepine) accelerate androgen metabolism (esp. oral).
10. Anti-androgens & Modulating Agents (Brief Reference)
| Class | Example | Mechanism | Clinical Use |
| 5α-Reductase inhibitors | Finasteride, dutasteride | Block T → DHT | BPH, alopecia |
| AR antagonists | Flutamide, bicalutamide, enzalutamide | Competitive inhibitor; enzalutamide also impairs nuclear translocation | Prostate Ca |
| GnRH super-agonists/antagonists | Leuprolide, degarelix | ↓ LH/FSH after flare | Prostate Ca, transgender, precocious puberty |
| Androgen biosynthesis blocker | Abiraterone (CYP17A1) | ↓ T & cortisol; co-administer prednisone | mCRPC |
| Selective AR modulators (SARMs) | Ostarine (investigational) | Partial agonist muscle-bone, antagonist prostate | Sarcopenia (research) |
11. Illicit & Athletic Misuse
• Supraphysiologic AAS cycles (500–3 000 mg/wk, stacks) combined with growth hormone, insulin, SERMs (“PCT”) for physique enhancement.
• Complications: hepatic rupture, sudden cardiac death (hypertrophic cardiomyopathy, arrhythmias), tendon rupture, hypogonadotropic hypogonadism, psychosis.
• Doping detection: testosterone : epitestosterone (T/E) ratio >4, carbon isotope ratio (^13C/^12C), urinary long-term metabolites (LTMs) like 17-norandrosterone (nandrolone).
• Education and harm-reduction clinics increasingly necessary.
12. Special Populations
12.1 Pediatrics
• Growth velocity monitoring; use short-acting esters for pubertal induction (50 mg IM q4w).
• Risk of early epiphyseal fusion requires bone-age checks.
12.2 Women
• Use lowest effective dose; monitor virilization. Testosterone 300 µg/day transdermal studied for HSDD.
• Pregnancy category X—teratogenic (female fetuses virilize).
12.3 Geriatrics
• Declining endogenous T (“late-onset hypogonadism”). Benefits: ↑ bone mass, muscle strength, mood. Risks: erythrocytosis, CV events; trials ongoing (TRAVERSE).
12.4 Chronic Kidney/Liver Disease
• Nandrolone used in dialysis cachexia; caution in cirrhosis due to hepatotoxicity of 17α-alkyl forms.
13. Monitoring & Follow-Up Protocol
- Baseline: CBC, PSA, DRE, LFTs, lipids, fasting glucose/HbA1c, sleep apnea screen, BP.
- 3 months: clinical assessment, serum trough T, CBC, PSA; adjust dose to mid-normal range.
- 6–12 months: repeat labs, bone densitometry q2 y if osteoporosis risk.
- Counsel on application site transference (gels) and birth-defect risk to pregnant partners.
- Discontinue if hematocrit >54 %, PSA rise >1.4 ng/mL in 12 mo, or severe adverse event.
14. Future & Investigational Directions
• Oral non-alkylated pro-drugs (T-ester nano-emulsions, LPCN 1144) to overcome first-pass metabolism without liver toxicity.
• Selective Androgen Receptor Modulators (SARMs)—phase III for cachexia, osteoporosis.
• Gene therapy: CRISPR correction of androgen insensitivity; AAV-mediated Leydig-specific steroidogenic enzymes.
• Neurosteroid research: androgens modulate cognition, depression; potential therapy for neurodegenerative disease.
• Male contraception: combination of topical testosterone + progestin, or PgP-enhanced oral dimethandrolone undecanoate suppressing spermatogenesis (phase II trials).
15. Summary
Androgens orchestrate a vast array of developmental, reproductive, metabolic, and behavioral functions. Therapeutically, they correct gonadal failure, combat catabolism, and relieve rare gynecologic or hematologic disorders. Their pharmacodynamic actions arise from nuclear AR modulation, amplified in some tissues by enzymatic conversion to DHT or estradiol. Clinical use requires careful pharmacokinetic tailoring—intramuscular esters, transdermal systems, or less favored 17α-alkylated orals—to maintain physiologic serum levels while minimizing adverse events such as erythrocytosis, hepatotoxicity, and prostate enlargement. Vigilant monitoring, appreciation of drug interactions, and knowledge of anti-androgen strategies are essential for safe practice. Finally, ongoing innovation—SARMs, novel oral formulations, and contraceptive regimens—promises to refine androgen pharmacology for both therapy and harm reduction.
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