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. 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.
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."
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. In a 2006 survey of 500 anabolic-androgenic steroids users, 78.4% were nonathletic and noncompetitive bodybuilders. 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. The method of choice for administration for the majority of AAS users (99.2%) was self-administrable injections. 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.
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.
The clinician might suspect exogenous intake of androgens in the following situations:
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).
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.
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.
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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