Erectile Dysfunction and Related Variables Due to Anabolic Steroid Use: A Review of Reviews

Six systematic reviews on AAS-induced ED: four rated critically low confidence, one low, one medium

Journal: Actas Urológicas Españolas | Published: 2026-02-12 | Type: Systematic review (review of reviews) | PMID: 41690470 Authors: García Vidal M, Vázquez Méndez A, Mollinedo Cardalda I, De Oliveira I (Universidad de Vigo, Grupo de Investigación Isaúde, Pontevedra, Spain) Funding/COI: No funding listed; authors declare no competing interests

Summary

This umbrella review searched six databases for systematic reviews on anabolic androgenic steroid (AAS) use and erectile dysfunction in men, ultimately including six eligible reviews. By its own AMSTAR-2 assessment, five of those six have critically low or low methodological confidence. The consistent finding across all six: prolonged AAS use disrupts the hypothalamic-pituitary-testicular (HPT) axis, suppressing endogenous testosterone and reproductive function, leading to hypogonadism and ED. The mechanism is well-understood; what this paper actually documents is how weak the formal review literature behind it is.

Claims

• Six systematic reviews met inclusion criteria after searching Medline, Scopus, PubMed, CINAHL, ScienceDirect, and SPORTDiscus (July 2025 search date)
• AMSTAR-2 quality ratings: 4 reviews critically low confidence, 1 low confidence, 1 medium confidence
• Primary affected population across reviews: men aged 28–33 years engaged in weightlifting, powerlifting, or bodybuilding
• Common finding: prolonged AAS use reduces endogenous testosterone, gonadotropins, and reproductive function
• ED and hypogonadism reported as downstream consequences of HPT-axis suppression
• Most current AAS users are non-professional athletes seeking aesthetic or performance gains, not elite competitors

Study Quality

This is a systematized review of reviews — a design that synthesizes existing systematic reviews rather than primary studies. The authors applied AMSTAR-2, the appropriate instrument for evaluating included reviews, and reported the results honestly: the underlying evidence base is mostly compromised. Four of six constituent reviews scored critically low confidence, meaning their conclusions carry substantial uncertainty. Only one reached medium confidence. No quantitative synthesis was performed; conclusions are narrative.

The review itself does not report primary study counts, individual sample sizes from underlying trials, or effect sizes from the included systematic reviews — a significant gap. A review of reviews should at minimum convey the scale and direction of the primary evidence, not just qualitative agreement across methodologically weak reviews.

Red Flags

• 4 of 6 included reviews rated critically low confidence on AMSTAR-2 — the evidence base is compromised at its foundation, not just at this review's level
• No effect sizes, confidence intervals, or pooled statistics reported; the paper cannot quantify how much AAS use increases ED risk
• No primary sample sizes from underlying studies reported, making it impossible to assess the weight of evidence behind the conclusions
• Authors are from a physiotherapy faculty, not urology or andrology — clinical interpretation depth may be limited
• No funding source disclosed for this review itself
• Conclusion language ("appears to have a negative impact") is appropriately hedged but adds little beyond established HPT-axis pharmacology

Strengths

• AMSTAR-2 audit is honestly reported — the authors don't obscure that most constituent reviews are weak
• Six-database search with a defined cutoff date (July 2025) provides methodological transparency
• Correctly frames the target population as predominantly recreational rather than elite athletes — a meaningful demographic clarification for prevalence discussions
• No COI declared

Verdict

The finding that exogenous androgens suppress the HPT axis and cause hypogonadism and ED is mechanistically established and not in dispute. This review of reviews doesn't quantify or strengthen that case — it audits the existing review literature and finds it largely unreliable. That audit is the paper's one genuinely useful output: a documented record that five of six systematic reviews on AAS and ED are near-worthless by AMSTAR-2 standards. File it as evidence of a weak literature, not as evidence of the association itself.