Friday, March 18, 2005

Anabolic Steroids

This article, Steroid Medical Realities Outweigh Steroid Myths, argues that physicians need to do a better job recognizing when our patients are using anabolic steroids. Some clues:
"Physicians need to recognize the signs and symptoms of steroid abuse," says Gary Wadler, MD, an associate professor of clinical medicine at New York University, and a member of the World Anti-Doping Agency. "It has to go into their differential diagnoses. I particularly emphasize this for pediatricians."

Signs and symptoms of anabolic steroid use may include:

  • Behavioral and psychological changes - including aggression, impulsiveness, and depression
  • Breast enlargement (men)
  • Breast shrinkage (women)
  • Body hair (women)
  • Deepening of voice (women)
  • Male-pattern baldness (men and women)
  • Acne
  • Striae in axilla
  • Testicle shrinkage
  • Menstrual abnormalities
  • Abnormal cholesterol distribution marked by very low levels of HDL
  • Dramatic changes in muscularity and athletic performance
  • And, finally, "The look," as Dr. Roberts calls it - "a little too buff, a little too much muscle and a little too enhanced."

The evidence regarding the adverse effects of steroid use is sometimes conflicting:
Here's a rundown on what is known -- and what is not.

  • Cardiovascular. Experts list heart and stroke risks as among their biggest worries. Steroids reduce HDL cholesterol, raise LDL, impair glucose tolerance, and increase levels of triglycerides, clotting factors, C-reactive protein, and insulin. Case reports and cohort series have linked steroids to hypertrophic cardiomyopathy, myocardial infarction, sudden cardiac death, and thrombotic events, but so far it's difficult to prove a direct causal connection.
    "The data are scant," says Dr. Wadler, "But from looking at case reports I have been convinced that (anabolic steroid use) represents a cardiovascular risk." Others agree.

  • Hepatic. "Oral anabolic agents are hepatotoxic," says Dr. Yesalis. They lead to cholestatic jaundice, peliosis hepatis (a condition in which microscopic pools of blood are present throughout the liver parenchyma, which may lead to congestion and necrosis), and hepatocellular hyperplasia and adenomas -- problems that are mostly reversible when steroid use ends.
    Although some allege a steroid connection to liver cancer, "that hasn't been established," says Dr. Yesalis. But even benign tumors pose a risk. "If a benign tumor ruptures, you hemorrhage to death," says Dr. Yesalis, as at least two case studies have documented.

  • Masculinization of females. A number of hormonal changes occur when females use the primary male sex hormone. "Permanent masculinization can take place," says Dr. Yesalis.

  • Male reproductive abnormalities. These include testicular shrinkage, and a reduction in endogenous testosterone, sperm count, and sperm motility.

  • Growth plates. Ironically, to become more muscular, some steroid users may be giving up stature because androgens hasten epiphyseal closure. "High doses can shut down their growth plates," says Dr. Yesalis.

  • Erythrocytosis. Erythrocytosis is a common side effect of pharmacologic doses of all androgens, probably due largely to direct androgen stimulation of erythropoiesis.

  • Musculoskeletal injuries. Case studies have attributed tendon injuries and neuropathies to steroids. Researchers haven't yet established a cause-effect link.

  • Prostatic cancer. Case reports, but evidence lacking.

  • Compromised immune function. Evidence lacking.