Controversies of androgen use in prostate cancer treatment, bodybuilding, and hypogonadism management: A scoping review

Background:

Androgens are central to male physiology, influencing sexual development, muscle mass, and overall health. however, their medical use and societal misuse remain deeply controversial. In oncology, Androgens are central to the development and progression of prostate cancer. In sports and bodybuilding, synthetic androgen abuse is widespread, with surveys suggesting that up to 3–4 million individuals in the United States have used anabolic steroids, often starting in adolescence. In endocrinology, testosterone replacement therapy (TRT) is a cornerstone of hypogonadism management, yet its use in older men remains debated due to uncertain cardiovascular and prostate safety. These controversies make androgen use a uniquely complex issue for public health and society.

Methods:

This scoping review was conducted following a systematic approach. The search was conducted on four databases Scopus, Science Direct, PubMed, and CINAHL (Cumulated Index to Nursing and Allied Health Literature). Once the initial pool of literature was identified, the next step involved screening. Inclusion criteria were defined as articles (1) published in English language, (2) published articles between 2010 and 2025, and (3) full text articles following quantitative, qualitative, or mixed-method designs conducted on adult populations.

Results:

Prostate cancer growth is primarily driven by androgens; therefore, androgen deprivation therapy (ADT) continues to play a central role in its management. However, long-term ADT can lead to resistance through an adaptive upregulation of androgens receptors, resulting in castration-resistant prostate cancer, a more aggressive form. Recent clinical trials, including TRANSFORMER and RESTORE, have introduced a surprising approach in overcoming this resistance by administering high doses of testosterone, known as bipolar androgen therapy (BAT), highlighting a novel therapeutic approach despite its contradiction to well-established principles.

In bodybuilding, synthetic androgen abuse persists despite regulation, driven by performance enhancement goals and cultural ideals of hypermasculinity. This practice carries significant risks, including cardiovascular disease, hepatic dysfunction, infertility, and psychiatric effects such as aggression and mood disorders. Black-market access and social media promotion continue to normalize use, complicating prevention and regulation.

In hypogonadism, TRT is a standard for androgen deficiency. However, its use in elderly remains controversial. Concerns remain regarding the cardiovascular effects, prostate health, and long-term risks, despite conflicting evidence. Even though agencies like the Food Drug Administration (FDA) of America have warned about risks, the use of testosterone keeps increasing, driven by society’s emphasis on youth and masculinity.

Conclusions:

The controversies surrounding androgen use highlight the delicate balance between therapeutic innovation, medical risk, and societal influence. In prostate cancer, emerging strategies such as bipolar androgen therapy challenge long?standing treatment dogma, while in bodybuilding, misuse underscores the dangers of unregulated access and cultural pressures. In hypogonadism, unresolved safety concerns demand cautious, highlight the need for individualized, evidence-based prescribing. Together, these controversies illustrate the dual nature of androgens as both therapeutic agents and substances of misuse. Future research must clarify long-term risks, refine patient selection, and address the cultural drivers of androgen use to balance clinical benefit with public health protection.

Dr. Mohammed Dibas is a recent graduate of Al-Najah University Medical School in Palestine with a strong interest in oncology and medical research. His passion for oncology began early in his medical training and continues to grow as he pursues opportunities to bridge clinical practice with scientific inquiry. He is dedicated to advancing medical knowledge through research, particularly in oncology, and aims to contribute to improving patient outcomes by integrating evidence-based approaches into clinical care.