ANABOLIC STEROIDS

Anabolic steroids are synthetic versions of the naturally occurring male sex hormone, testosterone. They are more properly called anabolic-androgenic steroids (AASs), because they have both bodybuilding (anabolic) effects and masculinizing (androgenic) effects. The masculinizing effects of testosterone cause male characteristics to appear during puberty in boys, such as enlargement of the penis, hair growth on the face and pubic area, muscular development, and deepened voice. Females also produce natural testosterone, but ordinarily in much smaller amounts than males.

AASs are sometimes referred to simply as steroids. Steroid means only that a substance either resembles cholesterol in its chemical structure or is made from cholesterol in the body. Thus, AASs are one kind of steroid. (They are not to be confused with an entirely different group of steroids called corticosteroids—of which prednisone and cortisone are examples—which are commonly used to treat illnesses such as arthritis, colitis, and asthma. In contrast to anabolic steroids, corticosteroids can cause muscle tissue to be wasted.) AASs are also referred to as ergogenic drugs, which means performance-enhancing. Street or slang terms for AASs include "roids" and "juice."

Soon after testosterone was first isolated and synthesized in the laboratory in 1935, a number of synthetics were created to be used as medicines. The synthetic forms were developed because natural testosterone did not work very long when given as a pill or injection (it is subject to rapid breakdown in the body). Bodybuilders may have begun using AASs to build muscle size and strength as early as the 1940s. Olympic athletes started to use these drugs in the 1950s. Most of this use went undetected, however, because the technology of drug testing did not allow reliable detection of AASs in the urine until the 1976 Olympic Games. Even so, anabolic steroids did not become a household word until Canadian sprinter, Ben Johnson, tested positive for AASs at the Seoul Olympic Games in 1988. In the same year, a study reported that 6.6 percent of American male high school seniors had tried AASs. This study made it clear that elite athletes were not the only ones taking these drugs. By 1991, AASs were added by federal law to the list of Schedule III of the Controlled Substances Act. Schedule III Controlled Substances are recognized to have value as prescribed medicines, but also have a potential for abuse that may lead to either low to moderate physical dependence or high psychological dependence. Table 1 lists the names of some AASs that bodybuilders have used. Hundreds of AASs have been synthesized, and more comprehensive lists exist (Wright & Cowart, 1990; Yesalis, 2000).

Two naturally occurring steroids, dehydroepiandrosterone (DHEA) and androstenedione, are used by the body to make testosterone and estrogen (Corrigan, 1999). The benefits and adverse effects of synthetic DHEA and androstenedione are mostly unknown, but they are commonly believed to have anabolic and androgenic effects. Unlike other AASs, DHEA and androstenedione are neither regulated by the Food and Drug Administration nor listed as controlled substances in the United States. DHEA has been sold over-the-counter as a nutritional supplement in the United States since 1994, even though the International Olympic Committee, many U.S. sports organizations, and some countries such as Australia ban it.

GENERAL CHEMICAL STRUCTURE

Testosterone has a four-ring structure composed of nineteen carbon atoms. Accordingly, the carbon atoms are labeled by number from one to nineteen (see Figure 1). Many synthetic forms of testosterone are made by adding either an alkyl group or an ester to the seventeen-carbon atom. An alkyl group is a chain of carbon and hydrogen atoms. An ester is formed by reacting an acidic chain of carbon and hydrogen atoms to the-OH group on the seventeen-carbon atom. In general, when an alkyl group is added to the seventeen-carbon atom, the resulting drug can be taken as a pill; however, these so-called seventeen-alkylated AASs are relatively toxic to the liver and are more likely to cause negative effects on cholesterol levels. By contrast, when an ester is formed at the seventeen-carbon atom, an injectable form of testosterone is created that is less toxic to the liver and cholesterol levels. Other AASs are created by making modifications at other carbon atoms.

MEDICAL AND NONMEDICAL USES

AASs are prescribed by physicians to treat a variety of medical conditions (Bagatell & Bremner, 1996). The most accepted use is for treating boys and men unable to produce normal levels of their own testosterone, a condition known as testosterone deficiency orhypogonadism. AASs are also used to treat a rare skin condition called hereditary angioedema, certain forms of anemia (deficiency of red blood cells), advanced breast cancer, and endometriosis (a painful condition in females in which tissue usually found only in the uterus develops in other body parts). AASs are also combined with female hormones to treat distressing symptoms that can accompany menopause. Experimentally, AASs have been used to treat a condition in which bone loss occurs (osteoporosis), to treat impotency and low sexual desire, and as a male birth control pill. In addition, AASs have been used in the treatment of Acquired Immune Deficiency Syndrome (AIDS) to stimulate appetite, weight gain, strength, and improvements in mood. Most of these medical uses are uncommon, either because the conditions are rare (such as angioedema) or because other treatments are preferred (such as erythropoeitin for anemia). Nevertheless, AASs are important medicines to have available.

Nonmedically, AASs are used to enhance athletic performance, physical appearance, and fighting ability. Since society endows people who look physically fit and attractive with many benefits and recognition, some individuals see AASs as a means to those benefits. Three groups of AAS users have been described:

1. The athlete group aims to win at any cost. The athlete also believes, sometimes correctly, that the competition is using AASs. The anticipated rewards to the athlete are the glory of victory, social recognition and popularity, and financial incentives (college scholarships, major league contracts).
2. The aesthete group aims to create a beautiful body, as if to make the body into a work of art. Aesthetes may be competitive bodybuilders, or aspiring models, actors, or dancers. They put their bodies on display to obtain admiration and financial rewards.
3. This group of AAS users seeks to enhance their ability to fight or intimidate. They include body guards, security guards, prison guards, police, soldiers, bouncers, and gang members. These people depend on fighting for their very survival.

Whether AASs actually work to improve performance and appearance has been debated. Invariably, users believe AASs do work, but some scientific studies have failed to show an effect. However, there are serious limitations to how these studies were done and what they could show. In general, most researchers agree that AASs can work in some individuals to enhance muscle size and strength when combined with a proper exercise program and diet (Bagatell & Brenner, 1996; Bhasin et al., 1996). By contrast, AASs probably do not improve performance of aerobic or endurance activities (Yesalis, 2000).

CONSEQUENCES OF USE

AASs have been associated with a variety of undesirable effects. The most severe consequence attributed to their use is death. One study of mice given AASs revealed a shortened life span (Bronson & Matherne, 1997). In humans, the distinction between fatalities that occur among relatively healthy athletes who use AASs and patients with illnesses (such as anemia) who are prescribed AASs is important, because ill patients are already at a higher risk for an early death. Nevertheless, reported deaths in nonmedical steroid users (such as athletes and aesthetes) have occurred from liver disease, cancer, heart attacks, strokes, and suicide (Yesalis, 2000; Pope & Brower, 2000). Clearly, anyone using AASs should have their health monitored by a physician.

Psychiatric Effects.

Another serious, life-threatening consequence has been violent aggression toward other people. Both the medical literature and newspapers contain reports of previously mild-mannered individuals who committed murder and lesser assaults while taking AASs (Thiblin et al., 1997). Although reports of severe violence generate both alarm and widespread attention, the total number of such reports is small. Moreover, the effects of AASs on violent behavior vary widely depending on the social circumstances and the characteristics of the individual. Nevertheless, most but not all studies in humans have found that high doses of AASs increase feelings and thoughts of aggressiveness (Yesalis & Cowart, 1998). Although an increase in feelings and thoughts of violence does not always lead to violent behavior, it can be very distressing to the individual and to those around him or her. "Roid rage" is a slang expression used to describe the aggressive feelings, thoughts, and behaviors of AAS users.

Other psychiatric effects of AASs include mood swings and psychosis (Pope & Brower, 2000). AAS users commonly report that they feel energetic, confident, and even euphoric during a cycle of use. They may have a decreased need for sleep or find it difficult to sleep because of their high energy level. Such feelings may give way to feeling down, depressed, irritable, and tired between cycles of use. With continued use of high AAS doses, moods may shift suddenly, so that the user feels on top of the world one moment, irritable and aggressive the next, and then depressed or nervous. The appetite may also swing widely with cycles of use (Wright & Cowart, 1990). During a cycle on AASs, huge quantities of food may be consumed to support the body's requirements for muscle growth and energy. During the "off cycles," appetite may diminish.

The term "psychosis" means that a person cannot distinguish between what is real and what is not. For example, a person may believe that other people intend harm when no real threat exists; or a person may believe that an impossible, life-threatening stunt can be performed with no problem. Such false beliefs are called delusions. The psychotic person may also experience hallucinations, such as hearing a voice that is not there. Fortunately, most psychiatric effects of AASs tend to disappear soon after AASs are stopped, although a depressed mood may last for several months. Obviously, when suicides, homicides, or legal consequences from assault have occurred, they cannot be reversed simply by stopping one's use of AASs.

Effects on the Liver.

AASs can affect the liver in various ways, but the seventeen-alkylated AASs are more toxic to the liver than other AASs. Most commonly, AASs cause the liver to release extra amounts of enzymes into the bloodstream that can be easily measured by a blood test. The liver enzymes usually return to normal levels when AASs are stopped. The liver also releases a substance called bilirubin, which in high amounts can cause the skin and eyes to turn yellow (a condition called jaundice). As many as 17 percent of patients treated with the seventeen-alkylated AASs develop jaundice (Yesalis, 2000). Nonmedical AAS users can also develop jaundice. Although untreated jaundice can be dangerous and even fatal, jaundice usually disappears within several weeks of stopping AASs. Jaundice can also signal other dangerous conditions of the liver, such as hepatitis, so a physician should always treat it. Another condition that occurs among patients treated with AASs is peliosis hepatis, in which little sacs of blood form in the liver. Death can occur from bleeding if one of the sacs ruptures. Finally, liver tumors may occur in 1 to 3 percent of individuals (including athletes) using high doses of the seventeen-alkylated AASs for more than two years (Yesalis, 2000). Rare cases of liver tumors have been reported with other types of AASs as well. Some of the tumors are cancerous, and although more than half of the tumors disappeared when AASs were stopped, others resulted in death.

Potential to Affect the Heart.

AASs can cause changes in cholesterol levels (Yesalis, 2000). Low amounts of a certain kind of cholesterol (high-density lipoprotein cholesterol) in the blood are known to increase the risk of heart attacks. AASs, especially the seventeen-alkylated ones, cause a lowering of this so-called good form of cholesterol. When AASs are stopped, however, cholesterol levels return to normal. Another risk factor for heart attacks and strokes is high blood pressure. Studies have shown that AASs can cause small increases in blood pressure, which return to normal when AASs are stopped. As a result of strenuous exercise, many athletes develop an enlarged heart that is not harmful. Some, but not all studies, suggest that AAS users can develop a harmful enlargement of the heart. As noted previously, heart attacks and strokes have been reported in AAS users, but studies are needed to determine if AAS users have a higher risk of heart attacks and strokes than non-users (Yesalis, 2000).

Sexual Side Effects.

AASs can alter the levels of several sex-related hormones in the body, resulting in many adverse effects (Wright & Cowart, 1990; Yesalis & Cowart, 1998). In males, the prostate gland can enlarge, making it difficult to urinate; the testes shrink; and sterility can occur. The effects on the prostate, the testes, and sterility reverse when AASs are stopped; however, at least one case of prostate cancer has been reported, an exception to reversibility. Males can also develop enlarged breast tissue from taking AASs, an effect medically termed "gynecomastia" (it is referred to by male users as "bitch tits"). Gynecomastia occurs because testosterone is chemically changed in the body to the female hormone, estrogen. Thus, the male user experiences higher amounts of estrogen than normal. Painful lumps in the male breast may persist after stopping AASs, and they sometimes require surgical removal. Females, however, may undergo shrinkage of their breasts, as a response to higher amounts of male hormone than normal. Menstrual periods become irregular and sterility can occur in females as well. Deepened voice and an enlarged clitoris are effects in females, which do not always reverse after stopping AASs. Women may also develop excessive hair growth in typically masculine patterns, such as on the chest and face. Finally, both males and females may experience increases and decreases in their desire for sex.

Other Effects.

In children of both sexes before the onset of puberty, AASs can initiate the characteristics of male puberty and cause the bones to stop growing prematurely. The latter effect can result in shorter adult heights than would otherwise occur. AASs can cause premature baldness in some individuals, and it can cause acne. The acne is reversible with cessation of AASs. Other possible effects include small increases in the number of red blood cells, worsening of a condition called sleep apnea (in which afflicted persons stop breathing for short intervals during sleep), and worsening of muscle twitches (known as tics) in those who are predisposed.

Patterns of Illicit Use.

AASs are commonly smuggled from countries where they are obtained over-the-counter without a prescription, and then sold illegally in the United States. Dealers and users typically connect in weight-lifting gyms. Users report that AASs are relatively easy to obtain.

Steroids are taken as pills, through skin patches, and by injection (Bagatell & Bremner, 1996). Injection occurs into large muscle groups (buttocks, thigh, or shoulder) or under the skin, but not into veins. Cases of acquired immune deficiency syndrome (AIDS) have been reported in steroid users due to needle sharing. Steroids are often taken in cycles of six to twelve weeks on the drugs, followed by six to twelve weeks off. At the beginning of a cycle, small doses are taken with the intent to build to larger doses, which are then tapered at the end of a cycle. Illicit users typically consume ten to one hundred times the amounts ordinarily prescribed for medical purposes, requiring them to combine or "stack" multiple steroid drugs. The actual dose cannot always be determined, however, because illicit steroids may contain both falsely labeled and veterinary preparations. (Drugs purchased on the illicit market do not always contain what the labels indicate, and law-enforcement officials have confiscated vials contaminated with bacteria.)

Steroid users commonly take other drugs, each with their own risks, to manage the unpleasant side effects of steroids, to increase the body-building effects, and/or to avoid detection by urine testing (Wright & Cowart, 1990). For example, estrogen blockers, such as tamoxifen or clomiphene, are taken to prevent breast enlargement. Water pills (diuretics) are taken both to dilute the urine prior to drug testing and to eliminate fluid retention so that muscles will look more defined. Human chorionic gonadotropin (HCG) is an injectable, nonsteroidal hormone that stimulates the testicles to produce more testosterone and to prevent them from shrinking. Human growth hormone is another nonsteroidal hormone that is taken to increase muscle and body size.

Addictive Potential.

As with other drugs of abuse, dependence on AASs occurs when a user reports several of the following symptoms: Inability to stop or cut down use, taking more drugs than intended, continued use despite having negative effects, tolerance, and withdrawal. "Tolerance" refers to needing more of a drug to get the same effect that was previously obtained with smaller doses, or of having diminished effects with the same dose. In terms of the anabolic effects, tolerance was demonstrated in animals in the 1950s. In recent studies, 12 to 18 percent of nonmedical AAS users reported tolerance (Yesalis, 2000; Copeland et al., 2000). Whether tolerance develops to the mood-altering effects of AASs is unknown. Withdrawal refers to the uncomfortable effects users experience when they stop taking AASs. As noted previously, many of the undesirable effects reverse when AASs are stopped, however, others can begin—such as depressed mood, fatigue, loss of appetite, difficulty sleeping, restlessness, decreased sex drive, headaches, muscle aches, and a desire for more AASs (Copeland et al., 2000). The depression can become so severe that suicidal thoughts occur. The risk of suicide described previously is thought to be highest during the withdrawal period.

Studies indicate that between 14 and 57 percent of nonmedical AAS users develop dependence on AASs (Yesalis, 2000), and rare cases have been reported in women (Copeland et al., 2000). These studies support the addition of AASs to the list of Schedule III controlled substances. Nevertheless, AASs may differ from other drugs of abuse in several ways. First, neither physical nor psychological dependence on AASs has been reported to occur when AASs are prescribed for treating medical conditions. This differentiates the AASs from the opioid pain killers and the sedative-hypnotics. Second, dependence may develop primarily to the muscle-altering effects of AASs, rather than the mood-altering effects. Some researchers have questioned whether AASs produce dependence at all, because most definitions of dependence require that drugs be taken primarily for their mood-altering effects. Third, AAS users appear more preoccupied with their bodies and how they look than do users of other drugs of dependence.

SUMMARY

The anabolic-androgenic steroids are related to the male sex hormone, testosterone. They have both masculinizing and bodybuilding effects. AASs are useful to treat a variety of mostly uncommon medical conditions. They are sometimes used for the nonmedical purposes of enhancing athletic performance and physical appearance. Most researchers agree with users that AASs can increase muscle size and strength in some individuals when combined with a proper exercise program and diet. Many are also concerned about the potential for harmful effects with AASs, especially when the patterns of illicit use are considered. Drugs obtained on the illicit market may be contaminated, falsely labeled, or may contain substances not approved for human use. Multiple steroid and nonsteroidal drugs are combined, and AAS doses may exceed therapeutic doses by ten to one hundred times. Although the seventeen-alkylated AASs are commonly used because pills are more convenient than injections, they are more toxic to the liver and cholesterol levels than the injectable testosterone esters. Nevertheless, injections carry their own risks from improper injection techniques to dirty and shared needles.

The most serious side effects of AASs seem relatively uncommon, such as deaths or near-deaths from liver disease, heart attacks, strokes, cancer, suicide, and homicidal aggression. Most other side effects appear to be reversible when AASs are stopped, such as altered cholesterol levels, some liver effects, most psychiatric effects, testicular shrinkage, sterility, high blood pressure, and acne. Exceptions to reversibility include lumps in the male breast, deepened voice and enlarged clitoris in females, and cessation of bone growth in children. Moreover, some individuals may develop dependence on AASs, making it difficult for them to stop using. Stopping use can also produce distressing withdrawal symptoms, the worst of which is suicidal depression. Finally, studies of the long-term effects of using AASs are lacking, so safety cannot be assumed with the high-dose use of these drugs.

BIBLIOGRAPHY

Bagatell, C. J., and Bremmer, W. J. (1996). Drug therapy: Androgens in men—uses and abuses. New England Journal of Medicine, 334, 707-714.

Bhasin, S., et al. (1996). The effects of supraphysiological doses of testosterone on muscle size and strength in normal men. New England Journal of Medicine, 335, 1-7.

Bronson, F. H., and Matherne, C. M. (1997). Exposure to anabolic-androgenic steroids shortens life span of male mice. Medicine and Science in Sports and Exercise, 29, 615-619.

Copeland, J., Peters, R., and Dillon, P. (2000). Anabolic-androgenic steroid use disorders among a sample of Australian competitive and recreational users. Drug and Alcohol Dependence, 60, 91-96.

Corrigan, A. B. (1999). Dehydroepiandrosterone and sport. Medical Journal of Australia, 171(4), 206-208.

Pope, JR., H. G., and Brower, K. J. (2000). Anabolicandrogenic steroid abuse. In B. J. Sadock and V. A. Sadock (Eds.), Comprehensive textbook of psychiatry (pp. 1085-1095). Philadelphia: Lippincott Williams & Wilkins.

Wright, J. E., and Cowart, V. S. (1990). Anabolic steroids: altered states. Carmel, IN: Benchmark Press.

Thiblin, I., Kristiansson, M., and Rajs, J. (1997). Anabolic androgenic steroids and behavioural patterns among violent offenders. Journal of Forensic Psychiatry, 8, 299-310.

Yesalis, C. E., Ed. (2000). Anabolic steroids in exercise and sport. Champaign, IL: Human Kinetics.

Yesalis, C. E., and Cowart, V. S. (1998). The steroids game. Champaign, IL: Human Kinetics.

Kirk J. Brower

Anabolic Steroids

Anabolic steroids are synthetic versions of the naturally occurring male sex hormone, testosterone. They have two main effects: they build muscle size and strength, and they bring about male characteristics in the body. Testosterone causes male characteristics to appear during puberty in boys, including enlargement of the penis, hair growth on the face and pubic area, muscular development, and deepened voice. Females also produce natural testosterone, but ordinarily in much smaller amounts than males.

Although anabolic steroids are sometimes referred to simply as steroids, they are in fact only one kind of steroid. They are not to be confused with corticosteroids, such as prednisone and cortisone, which are commonly used to treat illnesses such as arthritis, colitis, and asthma. Street or slang terms for anabolic steroids include "roids" and "juice."

Bodybuilders and Olympic athletes began using these drugs in the middle of the twentieth century. In 1998 a study reported that 6.6 percent of American male high-school seniors had tried anabolic steroids. This study made it clear that elite athletes were not the only ones taking these drugs. By 1991 anabolic steroids were added by federal law to a list of controlled substances that are recognized to have value as prescribed medicines but also have a potential for abuse. Some synthetic anabolic steroids are neither regulated by the Food and Drug Administration nor listed as controlled substances in the United States and have been sold over the counter as nutritional supplements in the United States since 1994.

Medical Uses of Anabolic Steroids

Anabolic steroids are prescribed by physicians to treat a variety of medical conditions. The most accepted use is for treating boys and men unable to produce normal levels of their own testosterone, a condition known as testosterone deficiency or hypogonadism. Anabolic steroids are also used to treat:

• a rare skin condition called hereditary angioedema
• certain forms of anemia (deficiency of red blood cells)
• advanced breast cancer
• endometriosis (a painful condition in females in which tissue usually found only in the uterus develops in other body parts)
• osteoporosis, a condition in which bone loss occurs
• impotency and low sexual desire
• as a male birth control pill
• Acquired Immune Deficiency Syndrome (AIDS) to stimulate appetite, weight gain, strength, and improvements in mood

Nonmedical Uses of Anabolic Steroids

Nonmedically, anabolic steroids are used to enhance athletic performance, physical appearance, and fighting ability. Because society tends to reward people who look physically fit and attractive with many benefits and recognition, some individuals see anabolic steroids as a means to those benefits. There are three groups of users:

1. The athlete group aims to win at any cost. The athlete also believes, sometimes correctly, that the competitor is using anabolic steroids. The athlete seeks to attain the glory of victory, social recognition and popularity, and financial rewards such as college scholarships or major league contracts.
2. The aesthete group aims to create a beautiful body, as if to make the body into a work of art. Aesthetes may be competitive bodybuilders, or aspiring models, actors, or dancers. They put their bodies on display to obtain admiration and financial rewards.
3. The fighter group seeks to enhance the ability to fight or intimidate. They include body guards, security guards, prison guards, police, soldiers, bouncers, and gang members. These people depend on fighting for their very survival.

Whether anabolic steroids actually work to improve performance and appearance has been debated. Invariably, users believe they do, but some studies have failed to confirm this view.

The Consequences of Anabolic Steroid Use

Anabolic steroids have been associated with a variety of dangerous effects. In some cases anabolic steroids have even been fatal. Reported deaths in nonmedical users have occurred from liver disease, cancer, heart attacks, strokes, and suicide. Clearly, anyone using anabolic steroids should have his or her health monitored by a physician.

Psychiatric Effects. A serious, life-threatening consequence has been violent aggression toward other people. Previously mild-mannered individuals have committed murder and lesser assaults while taking anabolic steroids. Although such incidents are uncommon, most studies have found that high doses of anabolic steroids increase feelings and thoughts of aggressiveness. "Roid rage" is a slang expression used to describe the aggressive feelings, thoughts, and behaviors the drugs can produce.

Anabolic steroids can induce mood swings. Users commonly report that they feel energetic, confident, and even euphoric during a cycle of use. They may have a decreased need for sleep or find it difficult to sleep because of their high energy level. Such feelings may give way to feeling down, depressed, irritable, and tired between cycles of use. The appetite may also swing widely. During on cycles, huge quantities of food may be consumed to support the body's requirements for muscle growth and energy. During off cycles, appetite may diminish.

Psychosis, an even more dangerous consequence, means that a person cannot distinguish between what is real and what is not. For example, a psychotic person may believe that other people intend harm when no real threat exists, or that an impossible, life-threatening stunt can be performed without difficulty. Such false beliefs are called delusions. Most psychiatric effects of anabolic steroids tend to disappear soon after use is discontinued, although a depressed mood may last for several months.

Effects on the Liver. Anabolic steroids can affect the liver in various ways. Those available in pill form are more toxic to the liver than injectable forms of the drug. Most commonly, anabolic steroids cause the liver to release extra amounts of enzymes into the bloodstream. The liver enzymes usually return to normal levels when anabolic steroids are stopped. The liver also releases a substance called bilirubin, which in high amounts can cause the skin and the whites of the eyes to turn yellow (a condition called jaundice). Medical as well as nonmedical users can develop jaundice, a dangerous condition if left untreated. Jaundice can also signal other dangerous conditions of the liver, such as hepatitis. Liver tumors have been reported, some of them cancerous. Although more than half of the tumors disappeared when anabolic steroids were stopped, others resulted in death.

Effects on the Heart. Anabolic steroids can cause a decrease in a form of cholesterol known as good cholesterol. This effect in turn can increase the risk of heart attacks. When anabolic steroids are stopped, cholesterol levels return to normal. Studies have shown that anabolic steroids can cause small increases in blood pressure, also a risk factor for heart attacks and strokes. As a result of strenuous exercise, many athletes develop an enlarged heart that is not harmful. Some, but not all studies, however, suggest that drug users can develop an enlargement of the heart that is harmful.

Sexual Side Effects. Anabolic steroids can alter the levels of several sex-related hormones in the body, resulting in many adverse effects. In males, the prostate gland can enlarge, making it difficult to urinate; the testicles may shrink; and sterility can occur. These effects are, with few exceptions, reversible when anabolic steroids are stopped.

Male users can also develop enlarged breast tissue. Testosterone is changed in the body to estrogen, the female hormone, and thus the male anabolic steroid user has more estrogen than is normal. Painful lumps in the male breast may persist after stopping anabolic steroids, and they sometimes require surgical removal. Females, however, may undergo shrinkage of their breasts, as a response to higher amounts of male hormone than normal. Menstrual periods become irregular and sterility can occur in females as well. Anabolic steroid use in females may cause the voice to deepen and the clitoris to enlarge. These effects do not always reverse after stopping anabolic steroids. Women may also develop excessive hair growth in typically masculine patterns, such as on the chest and face. Finally, both males and females may experience increases and decreases in their desire for sex.

Other Effects. In children of both sexes before the onset of puberty, anabolic steroids can bring on the characteristics of male puberty. They can also cause the bones to stop growing prematurely, which can result in shorter adult heights than would otherwise occur. Anabolic steroid use can cause premature baldness in some individuals, and it can cause acne. The condition called sleep apnea (which causes people to stop breathing for short intervals during sleep) is worsened by taking anabolic steroids, as are tics, or muscle twitches, in those who already suffer from them.

Patterns of Illegal Anabolic Steroid Use

Anabolic steroids are commonly smuggled from countries where they are obtained over the counter without a prescription, and then sold illegally in the United States. Dealers and users typically connect in weight-lifting gyms. Users report that anabolic steroids are relatively easy to obtain.

Steroids can be taken as pills, through skin patches, and by injection. Injection occurs into large muscle groups (buttocks, thigh, or shoulder) or under the skin, but not into veins. Cases of AIDS have been reported in steroid users due to needle sharing. Illicit users (those who use the drugs illegally) typically consume 10 to 100 times the amounts ordinarily prescribed for medical purposes. The actual dose cannot always be determined, however, because drugs purchased on the illegal market do not always contain what the labels indicate. Law-enforcement officials have confiscated vials contaminated with bacteria.

Anabolic steroid users often use other drugs in order to:

• manage the unpleasant steroid side effects
• increase body-building effect
• avoid detection by urine testing

These drugs may themselves cause a range of side effects.

The Addictive Potential of Anabolic Steroids

As with other drugs of abuse, dependence on anabolic steroids occurs when a user reports several of the following symptoms:

• inability to stop or cut down use
• taking more drugs than intended
• continued use despite having negative effects
• tolerance, or needing more of a drug to get the same effect that was previously obtained with smaller doses
• withdrawal, or the uncomfortable effects experienced when use of the drug is stopped

As noted, many of the undesirable effects go away when anabolic steroids are stopped. However, stopping steroids may cause other symptoms to begin, such as depressed mood, fatigue, loss of appetite, difficulty sleeping, restlessness, decreased sex drive, headaches, muscle aches, and a desire for more anabolic steroids. The depression can become so severe that suicidal thoughts occur. The risk of suicide described previously is thought to be highest during the withdrawal period.

Studies indicate that between 14 percent and 57 percent of nonmedical users develop dependence on anabolic steroids, primarily in terms of the muscle-altering effects rather than the mood-altering effects. Some researchers have questioned whether anabolic steroids produce dependence at all, because most definitions of dependence require that drugs be taken primarily for their mood-altering effects.

see also Addiction: Concepts and Definitions; Adolescents, Drug and Alcohol Use; Complications from Injecting Drugs; Tolerance and Physical Dependence.

Anabolic steroids

Definition

Anabolic steroids are compounds, derived from testosterone, which promote tissue growth and repair. Because they have been used improperly by body builders and other athletes, they are controlled substances under United States federal law.

Description

As of 2004, there are four anabolic steroids available:

• nandrolone
• oxandrolone
• oxymetholone
• stanzolol

Although these products have different labeled uses, they are very similar in action and side effects and may be used interchangeably, subject to differences in route of administration and duration of action.

General use

Anabolic steroids are used for the following conditions:

• catabolic states such as chronic infections, extensive surgery, burns , or severe trauma
• anemia associated with renal insufficiency, sickle cell anemia , aplastic anemia, and bone marrow failure
• angioedema
• growth failure, including the short stature associated with Turner's syndrome

Precautions

Anabolic steroids are not recommended for young children because the drugs may cause an early end to the growth of long bones, which results in short stature. Anabolic steroids should be used with great care in girls, because the drugs have masculinizing properties. The drugs should be reserved for situations in which the benefits outweigh the risk. Anabolic steroids have been associated with liver cancer , and they have psychological effects, such as contributing to rage attacks.

Side effects

Anabolic steroids cause masculinization of females, including hair growth or loss, enlargement of the clitoris, and deepening of the voice. These effects are not reversible, even when the drug is promptly discontinued. In males past the age of puberty , side effects include increased urinary frequency, breast tenderness and enlargement, and frequent erections. In both males and females, anabolic steroids cause swelling of the feet, liver problems, and stomach upset.

This list of side effects is incomplete; many additional effects have been reported. Specialized drug references maintain for a complete list for each individual drug, including analysis of psychological effects of these drugs that contribute to rage attacks.

Interactions

Anabolic steroids have an anticoagulant effect. They should be used with care in combination with other drugs that have the same effect, including warfarin, nonsteroidal anti-inflammatory drugs (NSAIDs), and aspirin. Simultaneous use of anabolic steroids and corticosteroids will increase the risk of foot and ankle swelling. The combination is very likely to cause acne . Anabolic steroids may also lower blood glucose levels. They should be used with extreme care in patients taking insulin or other antidiabetic drugs. Other drug interactions have also been reported.

Parental concerns

Because of the nature of the adverse effects of anabolic steroids, their use should be restricted to cases where the benefits clearly outweigh the risks. Regular blood testing for blood counts and liver function is essential. Parents should observe the patient carefully for signs of liver damage, including headache , unpleasant breath odor, and black tarry stools.

KEY TERMS

Anabolic —Refers to metabolic processes characterized by the conversion of simple substances into more complex compounds.

Catabolism —A process of metabolism that breaks down complex substances into simple ones.

Testosterone —Male hormone produced by the testes and (in small amounts) in the ovaries. Testosterone is responsible for some masculine secondary sex characteristics such as growth of body hair and deepening voice. It also is sometimes given as part of hormone replacement therapy to women whose ovaries have been removed.

Turner syndrome —A chromosome abnormality characterized by short stature and ovarian failure caused by an absent X chromosome. It occurs only in females.

Resources

BOOKS

Anabolic Steroids: A Medical Dictionary, Bibliography, and Annotated Guide to Internet References. San Diego, CA: Icon Group International, 2003.

Taylor, William N. Anabolic Steroids and the Athlete. Jefferson, NC: McFarland & Co., 2002.

WEB SITES

"Anabolic Steroids." MedlinePlus. Available online at <www.nlm.nih.gov/medlineplus/druginfo/uspdi/202035.html>.

"Steroids (Anabolic-Androgenic.)" National Institute on Drug Abuse. Available online at <www.nida.nih.gov/Infofax/steroids.htm/> (accessed December 18, 2004).

Samuel Uretsky, PharmD

Anabolic Steroids

Of all of the substances ingested by athletes to gain a competitive edge, anabolic steroids are the most notorious. Steroids have taken on a broad, and sometimes inaccurate, range of meanings in the public consciousness, as the term is popularly and incorrectly used to describe any type of drug that enhances athletic performance.

Steroids are a class of substances that share a fat-soluble, carbon-based molecular structure. Unlike water-soluble minerals like potassium and sodium, steroids are stored in cell tissues. Vitamin D, testosterone (the naturally occurring male hormone), and a range of anti-inflammatory compounds, such as corticosteroids, are steroids. Anabolic steroids are a form of synthesized testosterone, which is primarily intended to stimulate muscle growth.

Anabolic steroids were first produced in the 1930s, when the international medical community began to better understand the relationship between testosterone and the development and maintenance of increased muscle mass. Russian weightlifters were the first athletes known to use steroids in a monitored, medically supervised sense; it was discovered that when anabolic steroids were ingested in cycles ranging from 14 to 30 days, the muscle-building and work capacities of the athlete were increased. Russian success in the 1952 Olympics spurred steroid research and development in the United States. By 1958, anabolic steroids were broadly available, and through the 1960s steroids became popular, albeit on an underground basis, finding a ready market among athletes in sports that placed a premium on strength and power.

Anabolic steroids have a number of limited conventional medical applications, chiefly when the body produces too little testosterone, or to combat muscle wasting caused by disease. Dreams of enhanced performance gave anabolic steroids their athletic preeminence. Athletes who are driven to succeed are often prepared to assume risks; in the early days of steroid popularity, that risk was the unknown, as relatively little research existed as to the long-term effects of these substances on the human body. It is now beyond dispute that anabolic steroids are an exceedingly harmful substance on the body when ingested.

Anabolic steroids will assist an athlete to train harder, with fewer rest periods required, and they help the body produce muscle mass at a greater rate than can be achieved in conventional training. Track and field events, particularly the Olympic sprint competitions in 1988, were the first dramatic worldwide proof of the power of steroids. Canadian Ben Johnson shattered the existing Olympic and world records in the 100-m sprint; Johnson was later stripped of his medal when it was determined that he and others on the Canadian track team had engaged in years of systematic steroid use.

In recent years, prominent international soccer players, track athletes, and American baseball and football players have all been exposed to have illegally taken steroids. Despite the presence of competitive sanctions in virtually all professional and international amateur competitions, coupled with unassailable evidence of the physical and psychological risk to steroid users, its use has been documented in significant numbers in North America and Europe among athletes as young as 14 years. A significant industry devoted to the science of masking steroid use when the athlete is tested at competition—usually through urine sample—has enjoyed a parallel growth to the use of the drug itself.

Steroids have been declared illegal in all international sport events, due primarily to the very serious physical risks they pose to all athletes who ingest them. These risks include liver disease, high blood pressure and cholesterol, acne, severe mood swings (often referred to as "roid rage"), and psychological dependence.

Men who take anabolic steroids are also prone to develop prostate disease; women are more susceptible to baldness and disrupted menstrual cycles.

The pursuit of athletic excellence will inevitably include the challenge of surpassing an established physical limit. Anabolic steroids represent risks to the modern athlete that far outweigh any short-term competitive benefits that may be gained through their use.

see also Doping tests; Muscle mass and strength; Nandrolone; Stimulants; World Anti-Doping Agency (WADA).

Anabolic Steroids

Anabolic steroids are synthetic chemicals that mimic the effects of the male sex hormone testosterone. Some athletes seeking increased muscular strength and size abuse anabolic steroids. They may reach their goal of increased strength in the short term but risk serious medical complications in the long term.

"Anabolic" denotes the ability to induce protein synthesis, particularly in muscle cells. As a result, isometric muscle strength increases. These steroids are also androgenic, which means that they cause changes characteristic of males, such as growth of facial hair, loss of scalp hair, deepening of the voice, skin oiliness, and aggressive behavior.

A female taking anabolic steroids experiences irregular menstrual periods and atrophy of the breasts and uterus, and develops the male-associated characteristics. A male may develop an enlarged prostate and atrophy of the testicles.

Steroid abuse stunts height, increases weight, dampens immunity, and can damage the kidneys, liver, and heart. Blood vessels may become blocked with fatty plaque. The liver may develop tumors, and infertility is common. Psychiatric symptoms include depression, delusions, and violent tendencies, sometimes called "'roid rage."

Athletes call anabolic steroids 'roids, juice, pump, or hype. Some of the one hundred varieties are oxymetholone, oxandrolone, and stanozolol (taken orally) and nandrolone and boldenone (taken by injection). Abusers may take one huge dose seeking instant strength, slowly build up the dose (pyramiding), or "stack" different types of steroids. Whatever the delivery route, the message to the body is the same: there's too much testosterone; halt normal production.

Despite the well-known side effects of anabolic steroids, use among athletes is widespread, perhaps because of the example set by professional baseball, basketball, and hockey players who use them. However, the National Football League, International Olympic Committee, and National Collegiate Athletic Association ban their use. Still, about 30 percent of college and professional athletes use anabolic steroids, as do 10 to 20 percent of high school athletes. Among U.S. bodybuilders, studies show that steroid use exceeds 80 percent.

Olympic athletes have often been punished for steroid use. After Canadian Ben Johnson flew past his competitors in the 100-meter run in the 1988 summer Olympics, officials rescinded his gold medal when a urine test revealed stanozolol in Johnson's system. His natural testosterone level was only 15 percent of a normal male's. Shot-putters, discus throwers, wrestlers, and swimmers have also been known to use anabolic steroids. In 2000, a urine test on U.S. shot-putter C. J. Hunter revealed one thousand times the allowable limit of nandrolone.

Anabolic steroids do have legitimate medical uses. They were first synthesized in the 1930s to treat underdeveloped testes and resulting testosterone deficiency. In the 1950s, they were used to treat anemia and muscle-wasting disorders and to bulk up patients whose muscles had atrophied from extended bed rest. In the 1960s, anabolic steroids were used to treat some forms of dwarfism. Today anabolic steroids are being studied for their ability to alleviate the extreme body wasting associated with acquired immunodeficiency syndrome (AIDS). Their most common use, however, remains among athletes seeking a quick competitive edge.

see also Endocrine System; Hormones; Male Reproductive System; Muscle

Ricki Lewis

Bibliography

American Academy of Pediatrics. Steroids: Play Safe, Play Fair. <http://www.aap.org/family/steroids.htm>.

Dobs, Adrian Sandra. "Is There a Role for Androgenic Anabolic Steroids in Medical Practice?" The Journal of the American Medical Association 281, no. 14 (1999) :1326.

National Institute of Drug Abuse. Anabolic Steroid Abuse. <http://www.nida.nih.gov/ResearchReports/Steroids/anabolicsteroids2.html>.