Anabolic steroids (anabolic-androgenic steroids) are often used to enhance physical performance and promote muscle growth. When used inappropriately, chronically at high doses and without medical supervision, they can cause erratic and irrational behavior and a wide range of physical adverse effects.
Anabolic steroids include testosterone and any drugs chemically and pharmacologically related to testosterone that promote muscle growth; numerous drugs are available. Anabolic steroids are used clinically to treat low testosterone levels in male hypogonadism Male Hypogonadism Hypogonadism is defined as testosterone deficiency with associated symptoms or signs, deficiency of spermatozoa production, or both. It may result from a disorder of the testes (primary hypogonadism)... read more . Additionally, because anabolic steroids are anticatabolic and improve protein utilization, they are sometimes given to burn, bedbound, or other debilitated patients to prevent muscle wasting.
Some physicians prescribe anabolic steroids to patients with AIDS-related wasting or with cancer. However, there are few data to recommend such therapy and little guidance on how supplemental androgens may affect underlying disorders. Testosterone has been reputed to benefit wound healing and muscle injury, although few data support these claims.
Anabolic steroids are used illicitly to increase lean muscle mass and strength; resistance training and a certain diet can enhance these effects. There is no direct evidence that anabolic steroids increase endurance or speed, but substantial anecdotal evidence suggests that athletes taking them can perform more frequent high-intensity workouts.
Estimates of lifetime incidence of anabolic steroid abuse range from 0.5 to 5% of the population, but subpopulations vary significantly (eg, higher rates for bodybuilders and competitive athletes). In the US, the reported rate of use is 6 to 11% among high school–aged males, including an unexpected number of nonathletes, and about 2.5% among high school–aged females.
Pathophysiology Caused by Anabolic Steroids
Anabolic steroids have androgenic effects (eg, changes in hair or in libido, aggressiveness) and anabolic effects (eg, increased protein utilization, increased muscle mass). Androgenic effects cannot be separated from the anabolic, but some anabolic steroids have been synthesized to minimize the androgenic effects.
There is limited acute toxicity with a single dose. Adverse effects of anabolic steroids vary significantly by dose and drug. There are few adverse effects at physiologic replacement doses (eg, methyltestosterone 10 to 50 mg/day or its equivalent). Athletes may use doses 10 to 50 times this range. At high doses, some effects are clear; others are equivocal (see table ). Uncertainties exist because most studies involve abusers who may not report doses accurately and who also use black market drugs, many of which are counterfeit and contain (despite labeling) varying doses and substances.
Athletes may take a fixed dose of one or multiple kinds of steroids for a certain period, stop, then start again (cycling) several times a year. Intermittently stopping the drugs is believed to allow endogenous testosterone levels, sperm count, and the hypothalamic-pituitary-gonadal axis to return to normal. Anecdotal evidence suggests that cycling may decrease harmful effects and the need for increasing drug doses to attain the desired effect.
Athletes frequently use multiple kinds of anabolic steroids simultaneously (a practice called stacking). They may use different routes of administration (oral, IM, or transdermal) simultaneously. Starting from a small dose and increasing the dose gradually, and tapering the dose of the same anabolic steroid to zero is referred to as pyramiding. Stacking and pyramiding are intended to increase receptor binding and minimize adverse effects, but these benefits have not been proved. To avoid positive anti-doping tests, athletes may stop using long-lasting steroids and replace them with shorter-acting formulations (bridging).
Symptoms and Signs of Anabolic Steroid Use
The most characteristic sign of anabolic steroid use is a rapid increase in muscle mass. The rate and extent of increase are directly related to the doses taken. Patients taking physiologic doses have slow and often unnoticeable growth; those taking megadoses may increase lean body weight by several pounds per month. Increases in energy level and libido (in men) occur but are more difficult to quantify.
Psychologic effects (usually only with very high doses) are often noticed by family members:
Wide and erratic mood swings
Increased aggressiveness (“roid rage”)
Increased acne is common in both sexes; libido may increase or, less commonly, decrease; aggressiveness and appetite may increase. Gynecomastia, testicular atrophy, and decreased fertility may occur in males. Virilizing effects (eg, alopecia, enlarged clitoris, hirsutism, deepened voice) are common among females. Also, breast size may decrease; vaginal mucosa may atrophy; and menstruation may change or stop. Virilization and gynecomastia may be irreversible.
Diagnosis of Anabolic Steroid Use
Usually a clinical diagnosis
Sometimes urine testing
Although elite athletes are tested for anabolic steroid use by anti-doping agencies, there is no practical diagnostic test to evaluate for surreptitious anabolic steroid use in the general patient population. When a patient presents with signs and symptoms of chronic anabolic steroid use, it is important to have anabolic steroid use in differential diagnoses. It might be useful to measure serum testosterone, follicle-stimulating hormone, and luteinizing hormone levels, since they are more commonly available tests. Exogenous testosterone and anabolic steroids decrease gonadotropin levels.
When testing to detect anabolic steroids is done, urine analysis is by gas chromatography-mass spectrophotometry.
Testosterone taken exogenously is indistinguishable from endogenous testosterone by gas chromatography-mass spectrophotometry. However, if high levels of testosterone are detected, the ratio between testosterone and epitestosterone (an endogenous steroid that chemically is nearly identical to testosterone) is measured. A testosterone:epitestosterone ratio > 6:1 is suggestive of exogenous testosterone use.
Treatment of Anabolic Steroid Use
Cessation of use
The main treatment for users of anabolic steroids is cessation of use. Although physical dependence does not occur, psychologic dependence, particularly in competitive bodybuilders and athletes, may exist. Gynecomastia Gynecomastia This photo shows enlarged breast tissue in a male patient. Gynecomastia is hypertrophy of breast glandular tissue in males. It must be differentiated from pseudogynecomastia, which is increased... read more may require surgical reduction. A person who uses injectable formulations should be updated on tetanus vaccination Tetanus-Diphtheria Vaccine A vaccine for tetanus alone is available, but the tetanus vaccine is typically combined with those for diphtheria and/or pertussis. The vaccine for diphtheria is available only in combination... read more .
Prevention of Anabolic Steroid Use
Physicians caring for adolescents and young adults should be alert to the signs of steroid abuse and teach patients about its risks. Education about anabolic steroids should start by the beginning of middle school. Use of programs that teach alternative, healthy ways to increase muscle size and improve performance through good nutrition and weight training techniques may help. Presenting both risks and benefits of anabolic steroid use seems to be a more effective way to educate adolescents about the negative effects of illicit steroid use.
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
Findtreatment.gov: Listing of licensed US providers of treatment for substance use disorders