Anabolic steroid use

Examination

Look for signs associated with steroid use or long term complications:

• Body composition (height, weight, body mass index), particularly rapid increase in lean body mass, and for ongoing monitoring

• Skin (acne, male pattern baldness, needle marks, hirsutism, gynaecomastia, striae or keloids)

• Breasts (lactation, gynaecomastia)

• Genitourinary (testicular atrophy, clitoromegaly, enlarged prostate)

• Systemic signs of cardiac or liver disease

• Depression screening and mood assessment.

Consider steroid use in patients presenting with suggestive signs or symptoms: regular weight trainers with a rapid increase in muscle mass, those suspected of violent crime,3 and polydrug users. Ask non-judgemental questions (“Have you ever been offered steroids?”) and consider other diagnoses, including ovarian carcinoma, polycystic ovarian syndrome, adrenal neoplasm, Cushing’s syndrome, drug induced jaundice, hepatitis, and cirrhosis.

Investigations

Table 1⇓ lists the investigations to consider in cases of suspected or confirmed use of anabolic steroids.

Consider longer term risks

The magnitude of health risks is not known. Side effects and risks are potentially higher with oral ingestion,13 although injection risks HIV infection, hepatitis, and local infections. Refer patients to appropriate specialists if you suspect long term complications.

• Cardiac complications and premature death with double the morbidity and mortality risk being reported14: the underlying cause is unclear.8

• Hepatic complications—Cholestasis and chronic vascular injury to the liver. Hepatocellular carcinoma and hepatic adenomas have been reported 2-15 years after initial use.13

• Psychiatric—Obsessive compulsive disorder, body dysmorphic disorder, mood instability, and anxiety in persistent use. Patients may develop anabolic-androgenic steroid dependence2 due to muscle dysmorphia. Increased aggression (“roid rage”) has been reported in up to 44% of users. It is not clear if users of anabolic steroids are predisposed to aggression or if the substance increases aggressive behaviour.15

• Tendon rupture 16

• Reproductive—Testicular atrophy, impotence and infertility.

Management

Assess the patient’s understanding and outline the potential short and long term risks. Strongly encourage cessation; no tapering is required. A loss of muscle tone may trigger relapse of steroid use, but continued resistance and endurance exercise may limit these losses. Consider psychological services for body dysmorphia and any withdrawal depression. Continued exercise can help alleviate depressive symptoms.17 Reassure patients that many side effects are reversible, including changes in lipid profile, hormones, blood pressure, and electrolytes. Expert opinion suggests lifelong monitoring for complications. Consider annual monitoring initially, which can be reduced if examination and biochemical results remain normal.

For patients continuing to use anabolic steroids, aim for harm reduction:

• A minimum of annual monitoring for complications, advice about not sharing needles, provision of clean needles, and advice about avoiding multiple agents and reducing doses.

• Advise of legal and probably safe alternatives to improve muscle mass and performance such as regular resistance exercise, eating a balanced diet, creatine18 or hydroxymethylbutyrate (HMB) supplementation,19 and caffeine use.

• Advise that anabolic steroids are banned by sports governing bodies.6

• Document discussions about the risk of serious long term damage to the heart and liver.