The challenge of upholding a zero-tolerance policy for AAS abuse, despite popular misconceptions of androgen physiology and pervasive attempts to dope among athletes and physicians, remains a daunting and evolving task for the anti-doping community. Strict criteria are enforced under which a TUE for testosterone use may be granted, to maintain the integrity of sport. Misrepresentation in TUE applications is extending to amateur athletes, as testosterone prescription outside of FDA guidance increases and sport organizations broaden their efforts to police doping at all levels of competition. Another strategy used is to dope with testosterone under the guise that the athlete has a true medical condition that requires testosterone treatment, using the therapeutic use exemption (TUE) mechanism. This review will discuss the strategies used to avoid detection based on the pharmacology, biochemistry, and genetics of AAS metabolism and testing principles.

Since the International Olympic Committee (IOC) began testing athletes for AAS in the 1970s, athletes and their teams have endeavored to beat the system to avoid doping violations and/or sanctions derived from positive test results. Androgenic-anabolic steroids (AAS) are potent and widely used performance-enhancing substances (PES).

Years used runonly to avoid detection