The dominant concern is hepatotoxicity. Everything else is secondary.

• Common (>10%):

  • ALT / AST elevation (often 2-5x ULN even on a 4-6 week cycle)
  • HDL crash 30-50%
  • LDL elevation (often 20%+)
  • Blood pressure elevation (systolic +10-20 mmHg typical)
  • Water retention (face, ankles, abs)
  • Acne (chest, back)
  • Hair shedding (DHT-pathway, irreversible if androgenic alopecia is genetic)
  • HPG-axis suppression
  • Sleep disruption
  • Mood lability / aggression for some users
  • Increased appetite

• Less common (1-10%):

  • Gynecomastia (palpable lump under areola, can require surgical excision)
  • Bilirubin elevation (early cholestasis signal)
  • GGT elevation (cholestatic pattern)
  • Polycythemia (hematocrit >52%)
  • Erectile dysfunction (post-cycle, during HPG recovery)
  • Insulin resistance / dysglycemia
  • Cardiomyopathy / LV hypertrophy (with extended use)

• Rare-serious (<1%):

  • Cholestatic jaundice (typically 1-4 months in)
  • Peliosis hepatis (blood-filled cystic liver lesions)
  • Hepatic adenoma (with rare malignant transformation to HCC)
  • Acute hepatic failure (more commonly with stacked orals or extended duration)
  • Thromboembolic events (DVT, PE, stroke) from polycythemia + lipid + BP triple-hit
  • Persistent secondary hypogonadism (HPG axis fails to recover even at 12+ months)

• Watch periods:

  • Week 2-3: ALT/AST should be checked. >3x ULN warrants taper/stop discussion.
  • Week 4-5: Bilirubin, GGT — early cholestasis signals.
  • Anytime: jaundice, dark urine + light stool, pruritus without rash, RUQ pain → STOP IMMEDIATELY. Get to ED if jaundice present.
  • BP at home weekly; sustained >150/95 → stop.

• Drug-induced liver injury (DILI) onset: Most commonly 1-4 months into chronic dosing. A 4-6 week cycle is in the "risk-narrowed but not risk-zero" window. Cholestasis can present at end-of-cycle or up to 2-4 weeks after cessation.