Anabolic Steroid Use Disorder


Article Author:
Sanad AlShareef


Article Editor:
Raman Marwaha


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
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William Gossman
Hassam Zulfiqar
Navid Mahabadi
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Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
6/4/2019 12:21:02 AM

Introduction

The term "anabolic" means to use body energy to promote growth and regulate constructive metabolism. Androgen use has become a major public health concern due to the transition of use of androgens from strictly sports to a much a wider spectrum of the population. Androgens stimulate and precipitate the development of male sex characteristics. Anabolic-androgenic steroids (AAS) are steroidal androgens which include natural androgens such as male sex hormone testosterone or could be synthetic to mimic the action of the endogenous male hormone. Anabolic steroids and androgens are medically prescribed (orally or injectable) to treat hormonal imbalance for conditions such as hypogonadism, impotence in men, delayed puberty in adolescent boys, breast cancer in women, endometriosis, osteoporosis, and muscle loss in HIV and cancer patients. However, some people misuse anabolic steroids for various reasons. For example, athletes abuse anabolic steroids to enhance performance and prolong endurance. Non-athletic people misuse anabolic steroids to increase body weight and lean muscle mass without increasing fat mass in the body.[1][2][3][4] The potential side effects from anabolic steroid abuse are significant, and health care providers should be aware of patients at risk of anabolic-androgenic steroid misuse.

Etiology

Anabolic-steroid misuse can occur at any age. Approximately 3 to 4 million Americans used anabolic-androgenic steroids to increase muscle mass whether for sports to increase their performance or cosmetic purposes such as enhancing their appearance. People who have misused steroids may possibly be suffering muscle dysmorphia which is a behavioral syndrome. The popular term used for the anabolic steroids is “steroids,” and other common names are "roids," "juice," "andro," "gear," and "stackers."

Epidemiology

Due to the increasing prevalence of androgen misuse, the potential health hazards of anabolic steroids are increasing; however, the risk of androgen abuse is probably highly underestimated. Many surveys on drug abuse/misuse do not include steroids. A study in Germany showed that 48.1% of androgen steroid abusers who frequented fitness centers received their supply from healthcare providers.[5][6] In a 2006 survey of 500 anabolic-androgenic steroids users, 78.4% were nonathletic and noncompetitive bodybuilders.[7][8] A meta-analysis of 187 studies demonstrated that being athletic and/or male were significant predictors of anabolic steroids abuse. Moreover, the data revealed that the prevalence of males was 6.4%, compared to 1.6% in females.[9] The method of choice for administration for the majority of AAS users (99.2%) was self-administrable injections.[9] Of concern was that as high as 13% reported unsafe practices for injecting the steroids, such as sharing needles, reusing the same needles, and sharing vials.[10]

Pathophysiology

Androgens help in the development of male secondary characteristics. Therefore, a female who uses anabolic-androgen steroids will note side effects such as hirsutism, acne, temporal male-pattern hair recession, deepening of the voice, and clitoromegaly. Some women will experience oligomenorrhea or even amenorrhea, as well as breast atrophy. The long term complication from exogenous androgens intake in men is hypogonadism. Exogenous androgens intake suppress the normal testicular function (sperm and testosterone production). Eventually, with prolonged use, testicular volume decreases which leads to a compromise of male fertility. In a retrospective study, 21% of 382 men with hypogonadism receiving testosterone treatment reported taking exogenous androgens. For men who have a history of taking androgens and then stopping them, the sperm count returns to normal after approximately four months to a year. Older men would take a longer time to recover than younger men after discontinuation. Androgen intake may lead to low sperm count, small testes, high hemoglobin and hematocrit values, low serum to non-detectable serum LH, and low sex hormone-binding globulin. These findings should raise the suspicion of exogenous androgen intake in men who are competing in sports.[9]

History and Physical

The clinician might suspect exogenous intake of androgens in the following situations:

  • Child or adolescent who is experiencing early development of secondary sexual characteristics, decrease in height, and premature closure of epiphyses
  • Female who is experiencing temporal hair recession, hirsutism, acne, irregular menses, breast atrophy, deepening of the voice (irreversible), clitoromegaly, decrease in total body fat, and increase in muscle mass
  • Male who is exhibiting rapid increased in muscle mass and strength and experiencing changes such as gynecomastia, small testes, low sperm count, impotence, and acne

Evaluation

Exogenous administration of androgens should be suspected in a patient who is in a competitive sport or activity, demonstrating changes of behavior such as aggression, depression or irritability, or showing blood work changes such as deficient luteinizing hormone (LH) concentration, high hematocrit, and low sex hormone-binding globulin (SHBG).[11]

Treatment / Management

  • If a clinician has a patient who admits to illicit androgens use, he or she is not legally obligated to report the patient (whether the patient is a minor or not). However, advising and educating the patient on the risks and complications from anabolic-androgen steroid misuse is the clinician’s duty and obligation towards the patient.
  • For patients who abuse androgens, especially for extended periods, a percentage of them will have difficulty stopping them because of the increased side effects during the recovery period. A male patient who ceases androgen intake will experience a period of pituitary-testicular axis recovery during which time he/she might experience symptoms such as fatigue, decreased libido, sexual dysfunction, and depression. Testicular function normally returns after several months; older patients will need more time to recover.
  • The most effective treatment for anabolic-steroid users who are seeking treatment is to provide a combination of behavioral therapy, a strong support system, and symptomatic relief with medications. The clinician could help in the process of recovery from addiction to steroids by prescribing pain medications for muscle pains and headaches, and also antidepressants. Other appropriate medications may be used to help restore the hormonal imbalance.

Differential Diagnosis

  • Clinicians should investigate the use of anabolic-androgenic steroids in middle-aged males and young men who present with coronary artery disease (CAD) and left ventricular dysfunction.[12]
  • Moreover, healthcare providers should obtain a careful history and drugs-use habits in patients presenting with hypogonadism before prescribing testosterone.

Toxicity and Side Effect Management

  • The most common side effects of androgens include severe acne, menstrual irregularities, hirsutism and deepening of the voice in women. Gynecomastia, shrinking of testicles, azoospermia, and infertility can appear in men; and mood changes and aggression (“roid rage”), stunted height and early puberty in adolescence. All groups can experience high blood pressure, changes in cholesterol, liver disease such as cysts, heart diseases such as coronary artery disease, kidney diseases, the risk of infections due to unsterile injections. 
  • In the United States of America, anabolic steroids classify as schedule III controlled substances because of their high potential for abuse and serious adverse effects. The majority (99.2%) of users reported side effects from AAS.[8] In observational studies in which males who used anabolic steroids, there was also higher coronary plaque formation volume compared to non-users. Moreover, approximately 71% of the anabolic steroid users had impairment of ability to efficiently pump blood leading to lower-than-normal left ventricle ejection fraction.[13][14]

Prognosis

Patients who misuse steroids are usually reluctant to stop taking them because of the potential side effects during withdrawal.  Withdrawal symptoms include fatigue, sleep problems, loss of appetite, decreased libido, and steroid cravings. Among the most serious withdrawal symptoms is depression which could lead to suicidal ideation and attempts. Steroids do not precipitate the same type of high as many other drugs; however, patients who abuse steroids could are diagnosable with substance use disorder. Studies have shown that patients who misuse steroids could potentially use other drugs to help and reduce side effects such as depression, irritability, and lack of sleep.[15][16][17]

Complications

  • Androgens have various side effects. Complications include cardiac hypertrophy, decreased serum HDL cholesterol, hypogonadism after discontinuation of exogenous androgens and neuropsychiatric concerns.[18] Many studies show an association between the nonmedical use of androgens and increases in risky and criminal behavior among the androgen intake abusers. In a survey of 10000 to 15000 college students, use of androgens correlated highly with drinking and driving, cigarette smoking, illicit drug use, and alcohol abuse.[19][20]
  • Anabolic steroids are completely prohibited in sports whether in- or out-of-competition. The following organizations prohibit anabolic steroids intake in sports: National Collegiate Athletic Association (NCAA), International Olympic Committee (IOC), U.S. Anti-Doping Agency (USADA), and World Anti-Doping Agency (WADA).
  • Anabolic steroid abuse occurs at sports competitions and gyms; one can buy these drugs on the street or purchase them via mail order. Most of the illegal use of androgens is due to anabolic steroids that get smuggled into the USA.[21]

Deterrence and Patient Education

The potential adverse cardiovascular effects from long-term anabolic steroid use are significant, and health care providers need to bring awareness among patients and implement protocols to help detect patients at risk.

Enhancing Healthcare Team Outcomes

Clinicians should target treating depression, body-image, and dysmorphia and associated detrimental behavioral patterns at groups who are at risk of anabolic-androgenic steroid abuse.


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Anabolic Steroid Use Disorder - Questions

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What adverse effect is not a common manifestation from taking anabolic-androgenic steroids?



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A 17-year-old wrestler complains of acne worsening over that past few months. Exam is remarkable for bulky muscles, oily hair, severe acne vulgaris, gynecomastia, and small testicles. Select the most likely drug he is abusing.



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The World Anti-Doping Agency (WADA) is the organization that oversees anti-doping policies and determines the list of substances and doping methods that are banned from sports. If a healthy and athletic patient presents to the office, and the provider develops the suspicion that this patient has an illicit androgen use, which of the following is the next most appropriate action to take regarding this patient?



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A 21-year old male with no significant past medical history presents to the clinic for his annual physical exam. He denies tobacco use, alcohol, or non-prescription drugs. Family history is significant for diabetes from the paternal side of his family. The patient reports that he is interested in joining a triathlon and has been following a more rigorous workout schedule. He also admits that he has been under lots of pressure for a faster time within his team to be selected with other team members to compete internationally. The patient is interested in learning what the World Anti-Doping Agency (WADA) testing methods. What are the methods utilized by WADA for detecting exogenous testosterone use?



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A 30-year-old male comes to an emergency department with severe agitation. He is irritable, hostile, and grandiose. On physical examination, he has high blood pressure, is febrile, and has tremors. Which of the following substance did he most probably take?



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Anabolic Steroid Use Disorder - References

References

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Kaushik M,Sontineni SP,Hunter C, Cardiovascular disease and androgens: a review. International journal of cardiology. 2010 Jun 25;     [PubMed]
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