Illicit steroids have moved beyond the headlines of the sports page. Olympic medalist Marion Jones drew jail time for lying about her familiarity with the performance-enhancing drugs, and televised Congressional hearings into the matter put baseball superstar Roger Clemens on the hot seat.
But the abuse of anabolic-androgenic steroids is not limited to elite athletes. In fact, it may be no farther away than the adolescent in your examining room—who is all too likely to return home with no one the wiser.
For advice on addressing this often overlooked substance problem, The Clinical Advisor consulted Suraj Achar, MD, assistant clinical professor in family medicine and associate director in sports medicine at the University of California, San Diego (UCSD) School of Medicine, and Eric Morse, MD, president of the International Society for Sport Psychiatry and sport psychiatrist for North Carolina State University in Raleigh.
Q: Just what are steroids?
Dr. Achar: Natural compounds made in the testes and adrenals, steroids are important for body and brain development in both men and women. Steroids have some medical applications: they are commonly given to men with hypogonadism and patients with wasting diseases, such as anorexia, cancer, and end-stage HIV or chronic obstructive pulmonary disease.
Synthetic steroids were first developed by scientists in Germany during World War II to make soldiers more aggressive. These substances were used by bodybuilders in the late 1930s and became widely used by athletes in strength sports as early as the 1950s.
Q: How serious is steroid abuse among youngsters?
Dr. Achar: Available data come from surveys based on self-reports, so they aren’t terribly reliable. But steroid abuse is probably more prevalent than most people think (Figure 1). Recent studies of 8th, 10th, and 12th graders found that about 3% of the students admit to some steroid use. Approximately 500,000 adolescents have used steroids at some point in time, according to the surveys, and about half that many are currently using them.
Q: How dangerous are steroids?
Dr. Achar: Steroids can have a broad spectrum of medical consequences, but in teenagers, the major ones to worry about involve damage to the brain and heart.
Adolescents already have increased rates of suicide and injury, and taking steroids—or stopping them quickly—increases that risk. Rage and recklessness also go up. The cardiac impact is more insidious and may not become obvious until the youngsters are 10-15 years older. It is known that steroids increase LDL and BP and can produce structural changes in the heart (e.g., increased size). Some of these effects are long-term and persist even after teenagers stop taking steroids. You’ll occasionally hear about young adults who abused steroids during adolescence dying of heart attacks in their 30s and 40s.
Steroids can elevate liver enzymes, too, but I have never heard of a serious case of liver disease in an adolescent user. Testes undergo shrinkage that may last for a year after patients stop the steroids. A proportion of the steroids can be aromatized to estrogen, leading to the development of gynecomastia in boys (athletes take human chorionic gonadotropin to prevent this). Liposuction may be necessary to fix this.
For women, many steroid effects are visible—hirsutism, acne, male-pattern balding. These effects can usually be reversed but if abuse persists, virilization can cause lasting physical changes. Some of the East German swimmers who used steroids in the 1970s eventually had to undergo sex-change surgery.