Anabolic steroid abuse

What are anabolic steroids?

Anabolic steroids are synthetic substances related to the male sex hormones ( androgens ). They promote the growth of skeletal muscle (anabolic effects) and the development of male sexual characteristics (androgenic effects), and also have some other effects. The proper term for these compounds is "anabolic-androgenic" steroids.

Anabolic steroids were developed in the late 1930s primarily to treat hypogonadism , a condition in which the testes do not produce sufficient testosterone for normal growth, development, and sexual functioning. The primary medical uses of these compounds are to treat delayed puberty, some types of impotence, and wasting of the body caused by HIV infection or other diseases. During the 1930s, scientists discovered that anabolic steroids could facilitate the growth of skeletal muscle in laboratory animals. This led to use of the compounds first by bodybuilders and weightlifters, and then by athletes in other sports.

Commonly abused steroids

More than 100 different anabolic steroids have been developed, but they require a prescription to be used legally in the United States. Most steroids that are used illegally are smuggled in from other countries, illegally diverted from U.S. pharmacies, or made in hidden laboratories.

What are steroidal supplements?

In the United States, supplements such as dehydroepian-drosterone ( DHEA ) and androstenedione (street name Andro ) can be purchased legally without a prescription through many commercial sources, including health food stores. They are often referred to as dietary supplements, although they are not food products. They are often taken because the user believes they have anabolic effects. Steroidal supplements can be converted into testosterone (an important male sex hormone) or a similar compound in the body. Whether such conversion produces sufficient quantities of testosterone to promote muscle growth or whether the supplements themselves promote muscle growth is unknown. Little is known about the side effects of steroidal supplements. If large quantities of these compounds substantially increase testosterone levels in the body, they also are likely to produce the same side effects as anabolic steroids.

Why do people abuse anabolic steroids?

One of the main reasons people give for abusing steroids is to improve their performance in sports. Among competitive bodybuilders, steroid abuse has been estimated to be very high. Among other athletes, the incidence of abuse probably varies depending on the specific sport. Another reason people give for taking steroids is to increase their muscle size and/or reduce their body fat. This group includes some people who have a behavioral syndrome known as muscle dysmorphia . A person with muscle dysmorphia has a distorted image of his or her body. Men with this condition think that they look small and weak, even if they are large and muscular. Similarly, women with the syndrome think that they look fat and flabby, even though they are actually lean and muscular.

Some people who abuse steroids have experienced physical or sexual abuse. They are trying to increase their muscle size to protect themselves. In one series of interviews with male weightlifters, 25 percent who abused steroids reported memories of childhood physical or sexual abuse, compared with no reports among those who did not abuse steroids. In a study of women weightlifters, twice as many of those who had been raped reported using anabolic steroids and/or another purported muscle-building drug, compared to those who had not been raped. Moreover, almost all of those who had been raped reported that they markedly increased their bodybuilding activities after the attack. They believed that being bigger and stronger would discourage further attacks because men would find them either intimidating or unattractive.

Finally, some adolescents abuse steroids as part of a pattern of high-risk behaviors. These adolescents also take risks such as drinking and driving, carrying a gun, not wearing a helmet on a motorcycle, and abusing other illicit drugs. Conditions such as muscle dysmorphia, a history of physical or sexual abuse, or a history of engaging in high-risk behaviors may increase the risk of initiating or continuing steroid abuse. However, researchers agree that most steroid abusers are psychologically normal when they start abusing the drugs.

How are anabolic steroids used?

Anabolic steroids are either taken orally, injected into the muscle, or rubbed on the skin as gels or creams. Doses taken by abusers can be 10 to 100 times higher than the doses used for medical conditions. Steroid abusers typically "stack" the drugs. This means that they take two or more different anabolic steroids. They mix oral and/or injectable types and sometimes even include compounds that are designed for veterinary use. Abusers think that the mixed steroids produce an effect on muscle size that is greater than the effects of each drug individually. This theory has not been tested scientifically.

Often, steroid abusers also "pyramid" their doses in cycles of six to 12 weeks. At the beginning of a cycle, the person starts with low doses of the drugs being stacked and then slowly increases the doses. In the second half of the cycle, the doses are slowly decreased to zero. This is sometimes followed by a second cycle in which the person continues to train without drugs. Abusers believe that pyramiding allows the body time to adjust to the high doses and the drug-free cycle allows the body's hormonal system time to recuperate. As with stacking, the perceived benefits of pyramiding and cycling have not been scientifically proven.

What are the health consequences of steroid abuse?

Anabolic steroid abuse has been associated with a wide range of adverse side effects. Some are physically unattractive, such as acne and breast development in men. Others are life threatening, such as heart attacks and liver cancer . Most are reversible if the abuser stops taking the drugs, but some are permanent.

Hormonal system

Steroid abuse disrupts the normal production of hormones in the body, causing both reversible and irreversible changes. Changes that can be reversed include reduced sperm production and shrinking of the testicles (testicular atrophy). Irreversible changes include male-pattern baldness and breast development ( gynecomastia ). In one study of male bodybuilders, more than half had testicular atrophy, and more than half had gynecomastia. Gynecomastia is thought to occur due to the disruption of normal hormone balance.

In the female body, anabolic steroids cause masculinization. Breast size and body fat decrease, the skin becomes coarse, the clitoris enlarges, and the voice deepens. Women may experience excessive growth of body hair but lose scalp hair. With continued administration of steroids, some of these effects are irreversible.

Musculoskeletal system

Rising levels of testosterone and other sex hormones normally trigger the growth spurt that occurs during puberty and adolescence. When these hormones reach certain levels, they signal the bones to stop growing, locking a person into his or her maximum height. When a child or adolescent takes anabolic steroids, the resulting artificially high sex hormone levels can signal the bones to stop growing sooner than they normally would have done.

Cardiovascular system

Steroid abuse has been associated with cardiovascular diseases (CVD), including heart attacks and strokes , even in athletes younger than 30. Steroids contribute to the development of CVD, partly by changing the levels of lipoprotein s that carry cholesterol in the blood. Steroids, particularly the oral types, increase the level of low-density lipoprotein ( LDL ) and decrease the level of high-density lipoprotein ( HDL ). High LDL and low HDL levels increase the risk of atherosclerosis , a condition in which fatty substances are deposited inside arteries and disrupt blood flow. If blood is prevented from reaching the heart, the result can be a heart attack. If blood is prevented from reaching the brain, the result can be a stroke. Steroids also increase the risk that blood clots will form in blood vessels, potentially disrupting blood flow and damaging the heart muscle so that it does not pump blood effectively.

Liver

Steroid abuse has been associated with liver tumors and a rare condition called peliosis hepatis , in which blood-filled cysts form in the liver. Both the tumors and the cysts sometimes rupture, causing internal bleeding.

Skin

Steroid abuse can cause acne, cysts, and oily hair and skin.

Infection

Many abusers who inject anabolic steroids use nonsterile injection techniques or share contaminated needles with other abusers. In addition, some steroid preparations are manufactured illegally under non-sterile conditions. These factors put abusers at risk for acquiring life-threatening viral infections, such as HIV and hepatitis B and C. Abusers also can develop infective endocarditis , a bacterial illness that causes a potentially fatal inflammation of the inner lining of the heart. Bacterial infections also can cause pain and abscess formation at injection sites.

What effects do anabolic steroids have on behavior?

Case reports and small studies indicate that anabolic steroids, particularly in high doses, increase irritability and aggression . Some steroid abusers report that they have committed aggressive acts, such as physical fighting, committing armed robbery, or using force to obtain something. Some abusers also report that they have committed property crimes, such as stealing from a store, damaging or destroying others' property, or breaking into a house or a building. Abusers who have committed aggressive acts or property crimes generally report that they engage in these behaviors more often when they take steroids than when they are drug-free.

Anabolic steroids have also been reported to cause other behavioral effects, including:

• Euphoria
• Increased energy
• Sexual arousal
• Mood swings
• Distractibility
• Forgetfulness
• Confusion

The extent to which steroid abuse contributes to violence and behavioral disorders is unknown. As with the health complications of steroid abuse, the prevalence of extreme cases of violence and behavioral disorders seems to be low, but it may be underreported or underrecognized.

Are anabolic steroids addictive?

An undetermined percentage of steroid abusers become addicted to the drugs. They continue to take steroids in spite of physical problems, negative effects on social relations, or nervousness and irritability. They spend large amounts of time and money obtaining the drugs. When they stop taking the drugs, they experience withdrawal symptoms such as:

• Mood swings
• Fatigue
• Restlessness
• Loss of appetite
• Insomnia
• Reduced sex drive
• The desire to take more steroids

The most dangerous of the withdrawal symptoms is depression , because it sometimes leads to suicide attempts. Untreated, some depressive symptoms associated with anabolic steroid withdrawal have been known to persist for a year or more.

What treatments are effective for steroid abuse?

Few studies of treatments for anabolic steroid abuse have been conducted. Current knowledge is based largely on the experiences of a small number of physicians who have worked with patients undergoing steroid withdrawal. The physicians have found that supportive therapy is sufficient in some cases. Patients are educated about what they may experience during withdrawal and are evaluated for suicidal thoughts.

If symptoms are severe or prolonged, medications or hospitalization may be needed. Some medications that have been used for treating steroid withdrawal restore the hormonal system after its disruption by steroid abuse. Other medications target specific withdrawal symptoms. For example antidepressants are used to treat depression and analgesics are used for head-aches and muscle and joint pains. Some patients require assistance beyond simple treatment of withdrawal symptoms and are treated with behavioral therapies .