Persistent Secondary Hypogonadism Following Chronic Opioid and Anabolic Steroid Exposure: A Case Report of Long-Term Testosterone Replacement Therapy and Its Complications.

Secondary hypogonadism is a clinically significant consequence of hypothalamic-pituitary-gonadal (HPG) axis suppression and may result from multiple exposures, including chronic opioid and anabolic steroid use. Long-term treatment strategies for persistent secondary hypogonadism, particularly testosterone replacement therapy (TRT) and its complications, remain incompletely characterized. This case describes a male patient with a history of both opioid and anabolic steroid exposure who developed persistent acquired secondary hypogonadism, with potential contributions from both opioid-induced androgen deficiency (OPIAD) and anabolic steroid-induced hypogonadism (ASIH). The patient subsequently underwent approximately 13 years of TRT, with sustained symptomatic benefit but clinically significant complications including erythrocytosis and late-onset gynecomastia. At the time gynecomastia was documented, serum estradiol testing and breast imaging were not available in the records reviewed, and the diagnosis was based primarily on patient-reported symptoms. This case highlights the challenges of determining the etiology of persistent HPG axis suppression following multiple suppressive exposures and emphasizes the importance of longitudinal monitoring for complications associated with prolonged TRT.