A 27-year-old man comes to the physician with fatigue, erectile dysfunction, and muscle weakness. He says, "I am losing my muscles despite working out every day in the gym." He has no past medical history. He had taken over-the-counter supplements to improve his endurance but now cannot afford them as he was recently laid off from his job. He requests a prescription to improve his fatigue and sex drive. He has no headaches, peripheral vision loss, weight gain, decrease in facial hair growth, or joint pain.
His vital signs are normal, and BMI is 26 kg/m². He is a well-built, muscular man with minimal gynecomastia. The testes are small and soft. The remainder of the physical examination is normal.
Initial laboratory results show normal chemistry profile and hematocrit of 52%.
Which of the following laboratory abnormalities would most likely be present on further evaluation?

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11ec193a_97c3_9eed_853d_4f16a1728b8e_MD0002_00 This patient's presentation is suggestive of testosterone deficiency (fatigue, erectile dysfunction, and atrophic testes) from cessation of anabolic-androgenic steroid use. Anabolic steroids and exogenous testosterone suppress the pituitary-testicular axis, resulting in decreased testicular size and function. The suppression is reversible when anabolic steroids are stopped, but reversal of hypogonadism may take months. Some features such as gynecomastia may not be reversible. However, as long as patients continue use, they may not have erectile dysfunction despite low laboratory values of endogenous testosterone, luteinizing hormone, and follicle-stimulating hormone. This is due to the presence of adequate levels of circulating exogenous androgens. Instead, these patients may present due to infertility, which is reversible once androgen abuse is stopped. (Choice A) Men with prolactinomas typically have galactorrhea (not present in this patient), decreased libido, and erectile dysfunction. They may also complain of headaches and peripheral vision loss from tumor impingement. (Choice B) Although this patient is fatigued, he has no other symptoms of hypothyroidism such as constipation, hair loss, cold intolerance, cognitive dysfunction, or weight gain. (Choice C) This patient's increased hematocrit is due to anabolic-androgenic steroid use. Similarly, when testosterone is used for the treatment of hypogonadism, it can result in erythrocytosis. Transferrin saturation will be normal in these conditions and hence not useful in this patient. (Choice D) Features of acromegaly include frontal bossing, enlargement of hands and feet, carpal tunnel syndrome, arthritis, and sleep apnea. This patient has no features suggestive of acromegaly. Educational objective: Laboratory testing in patients with anabolic-androgenic steroid abuse shows increased hematocrit and decreased levels of endogenous testosterone, luteinizing hormone, and follicle-stimulating hormone. __________ References: Long term perturbation of endocrine parameters and cholesterol metabolism after discontinued abuse of anabolic androgenic steroids. (http://www.ncbi.nlm.nih.gov/pubmed/21884791) Conservative management of azoospermia following steroid abuse. (http://www.ncbi.nlm.nih.gov/pubmed/9308797)

A 27-Year-Old Man Comes to the Physician with Fatigue, Erectile