Anabolic Steroid Use Disorder
- Article Author:
- Sanad AlShareef
- Article Author:
- Srinivasa Gokarakonda
- Article Editor:
- Raman Marwaha
- Updated:
- 11/2/2020 7:07:01 AM
- For CME on this topic:
- Anabolic Steroid Use Disorder CME
- PubMed Link:
- Anabolic Steroid Use Disorder
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 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 hypogonadism, impotence in men, delayed puberty in adolescent boys. For women, they can be used to treat breast cancer, endometriosis, osteoporosis, and muscle loss in patients with cancer or HIV. However, some people misuse anabolic steroids for various reasons. For example, athletes misuse anabolic steroids to enhance performance and prolong endurance. Non-athletic people misuse anabolic steroids to increase body weight and lean muscle mass without increasing the body's fat mass.[1][2][3][4] The potential side effects of anabolic steroid misuse are significant, and health care providers should be aware of patients at risk of anabolic-androgenic steroid misuse.
Etiology
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 be suffering from 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
The prevalence of AAS has steadily increased over the last two decades[5]. Due to the increasing prevalence, the potential health hazards of anabolic steroids are also rising. A meta-analysis of 187 studies demonstrated that being athletic and/or male were significant predictors of AAS. The prevalence in males was 6.4%, compared to 1.6% in females.[6] According to NIDA(2018), anabolic steroid misuse is predominately seen in male weightlifters in their 20s or 30s. According to the 2016 NIDA-funded Monitoring, the Future study, anabolic steroid use continues to be a concern in 12th graders. A study in Germany showed that 48.1% of AAS abusers, who frequented fitness centers, received their supply from healthcare providers.[7][8] In a 2006 survey of 500 AAS users, 78.4% were nonathletic and non-competitive bodybuilders.[9][10] The method of choice for administration for the majority of AAS users (99.2%) was self-administrable injections.[6] Of concern was that as high as 13% reported unsafe practices for injecting the steroids, such as sharing needles, reusing needles, and sharing vials.[11]
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 suppresses 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 competing in sports.[6]
Cardiovascular risk of AAS includes myocardial dysfunction, coronary atherosclerosis[12]; hypertension, life-threatening arrhythmia, and sudden death[13]. Concentric Left ventricular hypertrophy is commonly seen in long term steroid users even after discontinuation of AAS[14]. Prolonged use of AAS will also lead to elevation of LDL and reduction of HDL, conferring an increased risk of the cardiac event[13].
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
- Females 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.
- Males 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, who demonstrates behavioral changes such as aggression, depression, or irritability, or with blood work changes such as deficient luteinizing hormone (LH) concentration, high hematocrit, and low sex hormone-binding globulin (SHBG).[15]
Treatment / Management
- If a clinician has a patient who admits to illicit androgens use, they are 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.
- 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 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.[16]
- Moreover, healthcare providers should obtain a careful history and drug-use habits in patients presenting with hypogonadism before prescribing testosterone.
Toxicity and Side Effect Management
- Common side effects of androgens include severe acne, menstrual irregularities, hirsutism, and deepening of women's voice. Gynecomastia, shrinking of testicles, azoospermia, and infertility can appear in men; and mood changes and aggression (“roid rage”), stunted height, and early puberty. All groups can experience high blood pressure, changes in cholesterol, liver diseases such as cysts, heart diseases such as coronary artery disease, kidney diseases, and 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 misuse and serious adverse effects. The majority (99.2%) of users reported side effects from AAS.[10] In observational studies on males who used anabolic steroids, there was also higher coronary plaque formation volume when compared to non-users. Moreover, approximately 71% of the anabolic steroid users had impaired ability to pump blood efficiently, leading to lower-than-normal left ventricle ejection fraction.[17][18]
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 may use other drugs to help reduce side effects such as depression, irritability, and lack of sleep.[19][20][21]
Complications
- Androgens have numerous side effects. Complications include cardiac hypertrophy, decreased serum HDL cholesterol, hypogonadism after discontinuing exogenous androgens, and neuropsychiatric concerns.[22] 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, the use of androgens correlated highly with drinking and driving, cigarette smoking, illicit drug use, and alcohol misuse.[23][24]
- Anabolic steroids are completely prohibited in sports, whether in- or out-of-competition. The following organizations prohibit anabolic steroids intake: National Collegiate Athletic Association (NCAA), International Olympic Committee (IOC), U.S. Anti-Doping Agency (USADA), and World Anti-Doping Agency (WADA).
- Anabolic steroid misuse 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 anabolic steroids that get smuggled into the USA.[25]
Deterrence and Patient Education
The potential adverse cardiovascular effects from long-term anabolic steroid use are significant, and health care providers need to increase patient awareness and implement protocols to help detect at-risk patients.
Enhancing Healthcare Team Outcomes
Clinicians should target treating depression, body-image, and dysmorphia and associated detrimental behavioral patterns in groups at risk of anabolic-androgenic steroid misuse.