Anabolic Steroids Flashcards
Anabolic Steroids
Anabolic steroid use
Anabolic steroid use is associated with several serious long-term health consequences.
Cardiac morbidity and mortality are increased by anabolic steroid use, although the precise mechanism of this effect is unclear.
Hepatic side effects also occur secondary to chronic vascular injury: these include hepatocellular carcinoma and hepatic adenoma.
Psychiatric illness is also commonly co-morbid with anabolic steroid use.
Additionally, users who inject anabolic steroids have an increased risk of blood-borne viruses if needles are shared between individuals.
Due to the above concerns, patients should be strongly counselled to stop using anabolic steroids. There is no requirement for tapering of doses. Many of the above blood test abnormalities normalise once anabolic steroid consumption ceases. The expert recommendation is for lifelong monitoring for potential complications, initially annually with frequency reducing once blood markers normalise and in the absence of apparent adverse effects.
Brooks J, Ahmad I, Easton G. Anabolic steroid use. BMJ 2016;353:i5023.
Anabolic Steroids - Example Question
A 35-year-old man was assessed in endocrinology clinic after being referred by his GP for advice on management of the consequences of the patient’s use of anabolic steroids. The patient reported that he had been using anabolic steroids intermittently for the previous 10 years to augment his weight-training regime. Having recently become aware of the potential adverse health consequences , the patient now wished to know how he could safely stop his anabolic steroid use.
The patient described his pattern of anabolic steroid use: typically, he had been taking a ‘cycle’ of one or more oral synthetic testosterone derivatives for between 6-12 weeks, prior to a 3-4 week break in his use of steroids. The patient stated this strategy was an attempt to minimise his risk of side effects. The patient had not received any medical supervision of his anabolic steroid use, relying instead on discussions with friends at his gym and information from online forums. The patient declined to disclose the source from which he had obtained his supply of medications.
The patient stated that he believed his anabolic steroid use had contributed to his male pattern baldness and also had caused intermittent breakouts of acne on his chest and face. The patient was not aware of any other symptoms related to his steroid use, although stated that he was concerned about possible lasting cardiac side effects. The patient had no other significant medical history and took no other regular medications. He did not consume cigarettes, alcohol or recreational drugs.
General examination of the patient revealed a muscular and lean adult male in apparent good health. A cardiovascular system examination noted a forceful but not displaced apex beat. Mild gynaecomastia was present but gastrointestinal examination was otherwise unremarkable. Using an orchidometer the patient’s testicular volume was estimated as 16 ml. Although anxious about the possible health consequences of his anabolic steroid use, the patient did not seem to be significantly depressed or anxious.
Haemoglobin 173 g / dL
Sodium 148 mmol / L
Potassium 3.6 mmol / L
Alkaline phosphatase 135 U / L (reference 35-100)
ALT 32 U / L (reference 3-36)
Bilirubin 20 micromol / L (reference < 26)
Prolactin 469 mU / L (reference 80 - 400)
Luteinising hormone 0.9 IU / L (reference 1.8 - 8.6)
Follicle-stimulating hormone 1.2 mU / ml (reference 1.5 - 12.4)
Fasting LDL cholesterol 4.1 mmol / L (reference < 3.0)
Fasting HDL cholesterol 1.0 mmol / L (reference > 1.2)
HbA1C 45 mmol / mol (reference < 42)
What is the appropriate advice to the patient regarding the safe cessation of anabolic steroid use?
Convert patient to prescribed testosterone replacement and taper over 1 year Taper anabolic steroid use over period of 6 months > Stop immediately, tapered withdrawal not required Taper anabolic steroid use over period of 6 weeks Convert patient to prescribed testosterone replacement and continue lifelong
The patient has typical side effects and examination findings associated with long-standing anabolic steroid use. These include male pattern baldness, acne, gynaecomastia and testicular atrophy (typical adult male testicular volume around 25 mL). His blood tests also demonstrate typical abnormalities including erythropoiesis, hypernatraemia, hypokalaemia, cholestatic liver function tests, deranged lipid profile, evidence of elevated serum glucose and typical hormone profile abnormalities.
Anabolic Steroid Use - Hormone Profile
Elevated testosterone:epitestosterone ratio; suppressed luteinising hormone; suppressed follicle-stimulating hormone
Anabolic Steroid Use and Hormone Profile - Example Question
A 30-year-old man was referred to endocrinology clinic for the assessment of the adverse consequences of anabolic steroid use. The patient reported that he had recently decided to stop using anabolic steroids, having been a regular user for the previous 5 years to support his body-building training. The patient cited the potential health risks of long-term anabolic steroid use as the reason behind his decision to cease his use.
The patient had followed a regime of an intramuscular injection of long-acting synthetic testosterone derivative every two weeks. The patient took a 4-week break from anabolic steroids every 12 weeks, in an attempt to limit the adverse side-effects. The patient denied ever having used oral or topical synthetic testosterone preparations and had always used sterile injecting equipment.
The patient stated that he had developed significant gynaecomastia and also suffered significant male pattern baldness since starting to use anabolic steroids. In addition, 2 years previously he had suffered a ruptured right biceps tendon while exercising, requiring a surgical repair and had a prolonged period of rehabilitation. There was no history of symptoms suggestive of cardiac or liver disease. The patient took no regular prescribed medications and reported an alcohol consumption of between 15 to 20 units per week.
General examination of the patient revealed a highly muscular and lean adult male. Moderate gynaecomastia was present, but there were no other signs of chronic liver disease. Examination of the cardiovascular and respiratory systems was unremarkable.
Please see below for the available results of blood tests taken prior to the patient’s attendance at the clinic.
HbA1C 47 mmol / mol (reference < 42)
Total cholesterol 6.1 mmol / L (reference < 5.0)
Fasting LDL cholesterol 5.0 mmol / L (reference < 3.0)
Fasting HDL cholesterol 1.1 mmol / L (reference > 1.2)
Prolactin 490 mU / L (reference 80 - 400)
Luteinising hormone result pending
Follicle-stimulating hormone result pending
Testosterone result pending
Epitestosterone result pending
What pattern of results for the pending blood tests is consistent with the patient’s anabolic steroid use?
Elevated testosterone:epitestosterone ratio; normal luteinising hormone; normal follicle-stimulating hormone Suppressed testosterone:epitestosterone ratio; elevated luteinising hormone; suppressed follicle-stimulating hormone Suppressed testosterone:epitestosterone ratio; suppressed luteinising hormone; suppressed follicle-stimulating hormone > Elevated testosterone:epitestosterone ratio; suppressed luteinising hormone; suppressed follicle-stimulating hormone Normal testosterone:epitestosterone ratio; elevated luteinising hormone; elevated follicle-stimulating hormone
The patient has developed some of the typical unwanted effects associated with anabolic steroid use; namely gynaecomastia and accelerated male pattern baldness. In addition, tendon rupture is frequently associated with anabolic steroid use due to the disproportionate enhancement of muscle bulk compared to tendon strength. Other common unwanted effects include acne, testicular atrophy (or clitoral hypertrophy in females), impaired glucose tolerance and a deranged blood lipid profile. More worryingly, anabolic steroid use is also associated with serious liver disease and an increased mortality from heart disease.
Epitestosterone is a naturally occurring stereoisomer of testosterone produced by the testes. In healthy males, the testosterone:epitestosterone ratio is typically 1:1. However, exogenous administration of testosterone does not increase levels of epitestosterone, so anabolic steroid use is associated with an increase in the testosterone:epitestosterone ratio (typically to greater than 4:1). In anti-doping testing for competitive sports, an elevated testosterone:epitestosterone ratio is considered possible evidence of anabolic steroid use.
Physiological production of testosterone is promoted by the release of the gonadotropins luteinising hormone and follicle stimulating hormone by the pituitary gland. Both these hormones increase the number of testosterone-producing Leydig cells in the testes, with luteinising hormone also increasing testosterone production by Leydig cells. Elevated testosterone levels reduce gonadotropin production via negative feedback to the hypothalamus (causing reduced gonadotropin releasing hormone production) and the pituitary gland. Therefore, high levels of exogenous testosterone will act to suppress luteinising hormone and follicle stimulating hormone.
Brooks J, Ahmad I, Easton G. Anabolic steroid use. BMJ 2016;353:i5023.
Anabolic Steroids - Reversibility of Effects upon stopping: Example Question
A 37-year-old man attends endocrinology clinic for assessment of the unwanted effects of long-term anabolic steroid use. The patient had been a competitive bodybuilder, who had used anabolic steroids to enhance his training regime, but now stated that he had ‘retired’ from bodybuilding last week and so stopped using steroids. The patient was concerned about the long-term health consequences of his previous use.
The patient described a 10-year period of anabolic steroid use. Typically he would take a daily oral formulation of a synthetic testosterone supplemented by an intramuscular injection of a longer acting agent every few weeks. The patient would take breaks from anabolic steroid use intermittently throughout the year, to reduce unwanted effects and also to evade anti-doping testing arranged by the organisers of the competitions in which he competed. The patient stated that he had never shared or reused needles when injecting himself with anabolic steroids.
The patient reported a range of unwanted effects he had developed secondary to his anabolic steroid use. These included severe acne affecting the patient’s face and chest, intermittent symptoms of gastrointestinal dysfunction, and male pattern baldness. When asked directly, the patient reported that he had suffered from erectile dysfunction and scrotal discomfort towards the end of his use of anabolic steroids. The patient did not report any other concerns, in particular, he denied symptoms associated with heart or liver disease. The patient had no other significant past medical history and disclosed being a former user of recreational drugs, including cocaine.
Examination of the patient’s cardiovascular and respiratory symptoms was unremarkable except for moderate pitting oedema to the level of the mid-tibia bilaterally. Examination of the abdomen noted mild bilateral gynaecomastia but no other signs of chronic liver disease. The patient’s testicular volume was estimated as 18 ml bilaterally. A brief mental state examination did not reveal any evidence of a significant mood or anxiety disorder.
HbA1C 47 mmol / mol (reference < 42)
Fasting LDL cholesterol 4.5 mmol / L (reference < 3.0)
Fasting HDL cholesterol 1.0 mmol / L (reference > 1.2)
Prolactin 501 mU / L (reference 80 - 400)
Luteinising hormone 1.4 IU / L (reference 1.8 - 8.6)
Follicle-stimulating hormone 1.2 mU / ml (reference 1.5 - 12.4)
Transthoracic echocardiogram Normal systolic and diastolic function; no left ventricular hypertrophy; normal valvular function
Which of the patient’s unwanted effects will be irreversible with cessation of steroid use?
Pitting oedema Erectile dysfunction Scrotal pain > Male pattern baldness Gastrointestinal dysfunction
Anabolic steroid use is associated with a wide variety of unwanted effects. Morbidity and mortality from cardiac diseases are increased, although the precise mechanism of this effect is unknown. In addition, serious liver disease - for example, hepatocellular carcinoma - is also associated with anabolic steroid use. There are a variety of less dangerous but troubling unwanted effects as described below, some of which will be irreversible with cessation of anabolic steroid use. Due to the potential risk to long-term health, anabolic steroid users should be strongly advised to stop their use. No tapering of the dose is required. Active or former users should be monitored lifelong for evidence of complications.
Reversible unwanted effects of anabolic steroids include: Increased appetite Gastrointestinal dysfunction Mood swings Anxiety Acne Oedema Libido change Scrotal pain Erectile dysfunction Menstrual irregularities
Irreversible unwanted effects of anabolic steroids include: Hirsutism Voice pitch changes Male pattern baldness Skin striae or keloid scarring Chest pain Clitoral hypertrophy Short stature due to premature fusion of growth plates
It is unclear whether other unwanted effects are reversible with cessation of anabolic steroids; for example, gynaecomastia, testicular atrophy and infertility. Some limited studies suggest that normal sperm production and fertility return following cessation of anabolic steroid use, although on a timescale ranging from 4 months to 5 years.
The patient also has a typical pattern of hormonal irregularities associated with anabolic steroid use. A deranged lipid profile and impaired glucose tolerance are also frequently observed. The patient’s echocardiogram is reassuringly normal, which suggests that his leg oedema will resolve with cessation of anabolic steroid use.
Brooks J, Ahmad I, Easton G. Anabolic steroid use. BMJ 2016;353:i5023.
Anabolic Steroids - Reversible and Irreversible Effects
Anabolic steroid use is associated with a wide variety of unwanted effects. Morbidity and mortality from cardiac diseases are increased, although the precise mechanism of this effect is unknown. In addition, serious liver disease - for example, hepatocellular carcinoma - is also associated with anabolic steroid use. There are a variety of less dangerous but troubling unwanted effects as described below, some of which will be irreversible with cessation of anabolic steroid use. Due to the potential risk to long-term health, anabolic steroid users should be strongly advised to stop their use. No tapering of the dose is required. Active or former users should be monitored lifelong for evidence of complications.
Reversible unwanted effects of anabolic steroids include: Increased appetite Gastrointestinal dysfunction Mood swings Anxiety Acne Oedema Libido change Scrotal pain Erectile dysfunction Menstrual irregularities
Irreversible unwanted effects of anabolic steroids include: Hirsutism Voice pitch changes Male pattern baldness Skin striae or keloid scarring Chest pain Clitoral hypertrophy Short stature due to premature fusion of growth plates
Typical SE of Anabolic Steroid Use
Male pattern baldness, acne, gynaecomastia and testicular atrophy (typical adult male testicular volume around 25 mL) (or clitoral hypertrophy in females)
In addition, tendon rupture is frequently associated with anabolic steroid use due to the disproportionate enhancement of muscle bulk compared to tendon strength.
Blood tests demonstrate typical abnormalities including erythropoiesis, hypernatraemia, hypokalaemia, cholestatic liver function tests, deranged lipid profile, evidence of elevated serum glucose and typical hormone profile abnormalities.
More worryingly, anabolic steroid use is also associated with serious liver disease and an increased mortality from heart disease.
