Anabolic Steroids

Naturally occurring testosterone has:

• Androgenic effects - maintains male sexual and secondary-sexual characteristics
• Anabolic effects - builds and maintains muscle mass

Synthetically produced chemicals mimic these effects and can be divided broadly into androgenic steroids (testosterone salts and esters, mesterolone) and anabolic steroids (nandrolone, danazol). Anabolic steroids are less virilising than androgens when taken by women but there is considerable overlap of androgenic and anabolic properties.

The medical uses of anabolic steroids are very limited and are more often encountered as abused drugs in practice. In common parlance “anabolic steroids” or “roids” can refer to both androgenic and anabolic steroids. Relatively few preparations are now licensed as medicines in the UK but many are available via the “underground” market or internet.

• Treatment of some aplastic anaemias .
• Endometriosis (danazol) not responding to other treatments.¹
• Benign fibrocystic breast disease (danazol) not responding to other treatments.¹
• Androgen deficiency in male hypogonadism.²
• Treatment of weight loss in HIV-related muscle wasting, severe burns and trauma or following major surgery and infection. (Note, no anabolic steroids are currently licensed for this indication in the UK but oxyandralone is FDA approved in the US.³ A Cochrane Review of anabolic steroids for the treatment of weight loss in individuals with HIV was suggestive of benefit but cautious in view of inconsistent results.)⁴

The use of anabolic steroids for osteoporosis in women is no longer recommended.

• Anabolic steroids are class C drugs to be sold only by pharmacists with a doctor's prescription. However, it is legal to possess or import steroids for personal use. Intent to supply can carry a prison sentence.
• Anabolic steroids are popular with body builders and power and endurance athletes because of their perceived performance-enhancing effects. They are felt to enable sports people to train harder, build muscle mass quicker and recover from strenuous exercise faster. Actual evidence for benefit is equivocal particularly in view of common and potentially serious side-effects.⁵
• UK questionnaire studies in the 1990s suggested that 6% of male gym attendees were current androgenic steroid users and 1-2% of female attenders⁶ suggesting that doctors should be alert to anabolic steroid abuse and enquire further regarding presenting symptoms and signs that may be due to side-effects of these drugs (see below). The misuse of performance-enhancing drugs extends beyond the super-athlete elite and now they are widely used by men for solely cosmetic reasons.⁷
• Illegal steroids are bought as tablets or injectables. Counterfeiting is common and purity/safety is frequently poor.
• Doses greatly exceed therapeutic doses and in complicated regimes: different steroids may be used together (stacking) or varied sequentially (cycling).
• Other drugs may be used concurrently to minimise unwanted side-effects (e.g. tamoxifen to prevent gynaecomastia). Polypharmacy is normal amongst abusers of these drugs.⁷
• Sharing needles to inject steroids increases the risk of blood borne infections and injection techniques are frequently risky.⁷
• Doctors prescribing or colluding in provision of drugs or treatment with the intent to enhance an individual's sporting performance can be struck off the GMC register.

• Pregnancy and breastfeeding - female fetuses may become virilised^1,8
• Prostate or male breast cancer
• Skeletal metastases - risk of hypercalcaemia
• Avoid in children and young adults - risk of premature epiphyseal fusion
• Use with caution in those with increased risk of cardiovascular disease
• Hepatic and renal impairment
• Epilepsy and migraine

• In females, virilisation (oily hair, acne, amenorrhoea, hirsutism, clitoral enlargement) and irreversible voice deepening can occur.^8,9
• In males, inhibition of spermatogenesis, testicular atrophy, baldness, impotence and gynaecomastia can occur. Recovery of fertility is unpredictable.
• Premature epiphyseal closure with subsequent growth retardation.
• Abnormal LFTs, cholestatic jaundice and liver tumours occur with prolonged treatment. The risk of hepatotoxicity is greatest with chronic administration of large doses of orally active C-17α alkylated steroids.
• Sodium retention, oedema, raised BP and cholesterol adversely increase the risk of stroke and heart disease.
• Varied psychological side-effects - increased risk of mood swings and depression, paranoia and insomnia. Links to increased aggression and violence are also suggested.¹⁰ Risks increase with dose.¹¹
• Dependence can occur with reports of fatigue, anorexia, headache and depression on withdrawal.

• Monitor growth in children on these drugs carefully.
• Monitor BP closely and assess and treat cardiovascular risk factors where appropriate.

• Try to advise non-judgementally regarding the risks and potential benefits (mostly unproven) of illicit use to try to dissuade patients from use.
• In those who are determined to continue despite medical advice, adopt a harm reduction approach and offer advice regarding issues such as avoiding needle sharing and multi-dose vials, needle-exchange schemes, discouraging reckless dosing practices and providing relevant monitoring.
• Help for those using anabolic steroids illegally is difficult as users are not the typical client group of drug and alcohol teams and motivations for using, such as the desire for sporting achievement and body self-image, are very strong. Seek expert help where available.

Some advocate a stronger programme to try to limit the growing abuse of anabolic steroids including:¹²

• More widespread random dope testing in sport
• Medical follow up of athletes
• Educational interventions
• Tougher legislation against possession
• Disqualification of athletes found to have abused anabolic steroids