Background: Hypogonadism is a common problem in middle-aged males and often encountered in the primary care setting. Failure to accurately diagnose hypogonadism can lead to unintended consequences like missing secondary causes or enabling anabolic steroid abuse. Case Presentation: A 44-year-old male presented to the endocrinology clinic for further evaluation of abnormal testosterone levels. The patient had received a diagnosis of hypogonadism and was prescribed weekly testosterone injections, which he took for several weeks, but then discontinued therapy due to ineffective response. Serial laboratory evaluation revealed contradictory results and upon further investigation, an anabolic steroid screen returned positive for boldenone, an androgen used in veterinary medicine. After 4 months, his labs were repeated and showed a low TT and free T, with LH and FSH inappropriately normal. Therapy was restarted using an FDA-approved formulation of testosterone and on subsequent follow-up, the patient had an improvement clinically and his repeat TT levels were normal, with free T slightly elevated. Conclusion: There are two main takeaway points from this case that we would like to emphasize. First, that a complete diagnostic evaluation of hypogonadism is vital to avoid missing potential secondary causes. Second, initiating TRT prematurely can obscure the diagnostic workup and potentially facilitate testosterone abuse.

Keywords: case report, hypogonadism, hypothalamic-pituitary-gonadal axis, accurate diagnosis, complete diagnostic pathway, testosterone replacement therapy, anabolic steroid abuse.