Anabolic steroids: what do you need to know?

Anabolic steroids are used to enhance physical performance and muscle growth. If taken long-term in high doses and without medical supervision, they can cause bizarre and irrational behavior and a wide range of somatic side effects.

Anabolic steroids include testosterone and other drugs that are pharmacologically related to testosterone and cause muscle growth. Anabolic steroids have androgenic effects (e.g., changes in hair growth, libido, aggression) and anabolic effects (e.g., increased protein utilization, changes in muscle mass). Androgenic effects cannot be separated from anabolic effects, but some anabolic steroids have been synthesized to minimize androgenic effects.

Testosterone is rapidly broken down in the liver; oral testosterone is inactivated too quickly to be effective, and injectable testosterone must be modified (e.g., through esterification) to slow absorption and delay breakdown. Analogs modified through 17-b-alkylation are often effective orally, but may cause more side effects. Preparations for transdermal administration are also available.

Side effects vary depending on the dose and the drug. At physiological doses for replacement therapy (e.g. methyltestosterone 10-50 mg/day or its analogues) side effects are minor. Athletes can use 10-50 times higher doses. At high doses, some effects are noticeable, while others are not obvious. There is uncertainty because most studies include patients who cannot accurately report the doses consumed, as well as those who buy drugs on the black market, many of which are counterfeit and contain (contrary to the label) different substances in different concentrations.

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Side effects of anabolic steroids

Pronounced

• Erythrocytosis
• Abnormal lipid profile (decreased HDL, increased LDL)
• Liver disorders (hepatitis, adenoma)
• Mood disorders (at high doses)
• Androgenic effects: acne, hair loss, masculinity and hirsutism in women
• Gonadal suppression (decreased sperm quality, testicular atrophy)
• Gynecomastia
• Premature closure of the epiphyses

Moderately expressed

• Hypertension/ left ventricular hypertrophy
• Worsening of prostate hypertrophy and pre-existing carcinoma
• Liver carcinoma
• Weakly expressed
• Increased risk of sudden death in athletes
• Significant mood disturbances at low doses
• Primarily for 17-b-alkylated drugs.

HDL - high-density lipoproteins, LDL - low-density lipoproteins, LVH - left ventricular hypertrophy.

In clinical practice, anabolic steroids are used to treat low testosterone levels. In addition, because anabolic steroids have anticatabolic effects and improve protein utilization, they are sometimes prescribed to burn, bedridden, and other weakened patients to prevent muscle wasting. Some physicians prescribe these drugs to patients with wasting due to AIDS and cancer. However, there is insufficient evidence to recommend this treatment and little information about how androgens affect the underlying disease. Testosterone is thought to be effective in treating wounds and muscle damage, although there is no evidence to support this.

Anabolic steroids are abused to increase muscle mass and strength; these effects are enhanced when combined with increased training and proper diet. There is no direct evidence that anabolic steroids increase endurance or speed, but there is clear anecdotal evidence that athletes taking anabolic steroids can perform more frequent, high-intensity workouts. Muscle hypertrophy is definitely present.

Lifetime prevalence rates of anabolic steroid abuse range from 0.5% to 5% of the population, with significant differences among different groups (e.g., higher rates among bodybuilders and competitive athletes). In the United States, prevalence rates are 6% to 11% among high school-aged males and about 2.5% among college-aged females.

Athletes may take steroids for a period of time, stop, and then resume (as in cycling) several times a year. Intermittent administration is thought to normalize endogenous testosterone levels, sperm parameters, and hypothalamic-pituitary-gonadal relationships. There is some evidence that such cyclic administration reduces adverse effects and the need to increase the dose to achieve the desired effect.

Athletes often use multiple drugs at the same time (called stacking) and different routes of administration (oral, intramuscular, transdermal). Increasing the dose during a cycle (multi-staging) can result in 5-100 times the physiological dose. Stacking and multi-staging result in increased receptor clotting and minimized side effects, but this benefit is unproven.

Symptoms and signs

The most characteristic symptom is a rapid increase in muscle mass. The degree and severity of the increase are directly related to the dose taken. Patients taking physiological doses experience a slow and minor increase in muscle mass; those taking megadoses may experience an increase in lean body mass of several pounds per month. Increases in energy levels and libido (in men) are observed, but are less easily detected.

Psychological effects (usually with very high doses) are usually noticed by the family: marked mood swings, irrational behavior, increased aggression, irritability, increased libido, depression.

Common complaints include increased acne and gynecomastia, and in women, masculinization effects. Some effects may be irreversible (e.g., alopecia, clitoral enlargement, hirsutism, deepening of the voice). In addition, breast size may decrease, the vaginal mucosa may atrophy, menstruation may be disrupted or cease, libido may increase or decrease less frequently, aggression and appetite may increase.

Diagnosis, prognosis and treatment

Urine tests can usually identify anabolic steroid users. Metabolites of anabolic steroids can be detected in urine for up to 6 months (and even longer for some types of anabolic steroids) after cessation of use.

Physicians caring for adolescents and young adults should be alert to signs of steroid abuse and educate patients about the risks. Education about anabolic steroids should begin in middle school.

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