Androgen Abuse

Written by Ben Bunting: BA(Hons), PGCert. Sport & Exercise Nutrition. British Army Physical Training Instructor.

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Androgen abuse epidemiology is an understudied area of research. Huge numbers of males worldwide misuse supraphysiologic doses of androgens to enhance personal appearance or improve athletic performance.

Androgen use is a significant public health concern. This is primarily due to the long-term adverse effects of androgen use, including cardiomyopathy, atherosclerotic disease, prolonged androgen withdrawal hypogonadism, and numerous neurotoxic effects.

Prevalence

The lifetime prevalence of anabolic-androgenic steroid (AAS) use is estimated at 2.9-4 million Americans. Using AAS is associated with significant adverse outcomes including polycythemia, dyslipidemia, infertility, hypertension, left ventricular hypertrophy and multiple behavioral disorders. Men who discontinue AAS use often experience withdrawal syndrome, including depression and sexual dysfunction. The clinical resources available to physicians to manage patients who are using AAS are limited.

A population-based study was conducted to assess the prevalence of androgen abuse among adolescents aged 17-19 years. A total of 10,259 individuals were surveyed. They answered questions about their mental health, lifestyle and substance use. The results showed that anabolic androgen steroid users had more anger issues, anxiety, depression and lower self-esteem than non-users.

Those who used anabolic androgen steroids were more likely to participate in non-organised sports, be more angry, have more body image problems, have increased substance use and have higher rates of attempted suicide than those who did not use anabolic androgen steroids. This study was the first to examine these risk factors in young adolescents and provide a basis for future prevention programs.

Androgen abuse is primarily an intractable problem among younger men, who are typically affluent and have access to social media and other support groups for bodybuilding and performance-enhancing drug (PED) use. This is a socially and economically damaging epidemic that demands urgent attention by authorities, healthcare professionals and parents.

Physicians may be able to identify androgen abuse in men who readily acknowledge intense, obsessive gym and exercise patterns. They should also consider persistent suppression of blood luteinising hormone and follicle-stimulating hormone. A low serum testosterone level is another indicator of exogenous use.

Adverse effects

The adverse effects of anabolic-androgenic steroids (AAS) are numerous and range from short-term effects such as sexual dysfunction to long-term complications like liver toxicity. AAS also affect psychiatric functioning and behavior.

Male abusers can develop a variety of psychological and social problems as a result of their use. Some common examples of these are a decrease in self-esteem, low confidence and suffered hostility. Others include a distorted view of reality and a propensity for risk-taking behaviour.

Some abusers become physically dependent on AAS and can experience severe side effects when they stop using them. Withdrawal treatment is often necessary and should be monitored by medical professionals.

During the abuse of steroids, a person's body will become depleted of natural hormones. This can lead to a reduction in muscle mass and strength. This can be difficult to reverse, especially if the person has been using steroids for a long time.

Teenage girls can develop a feminine or masculine appearance depending on the amount of steroids they are taking. Males can suffer from reduced sperm counts and testicular atrophy, as well as a change in their voice. They may also develop breast tissue, a condition known as gynecomastia.

Gynecomastia can persist after stopping AAS use and can be treated with anti-estrogens such as tamoxifen. It can also be prevented by avoiding estrogen-progestin cycles.

The effects of AAS on the cardiovascular system are not completely understood, but some evidence suggests that this can have a negative impact on heart function and cholesterol levels. This is likely due to a disruption in the body's hormonal balance that inhibits testosterone production and leads to structural changes in the heart.

An increase in blood pressure and a higher circulating lipid concentration may lead to premature atherosclerosis or cardiomyopathy, both of which can be fatal if not treated immediately. 

Treatment

Testosterone is the primary circulating androgen in men, which plays a critical role in bone mass, sperm production, fat distribution and mood and cognition. Nevertheless, excessive use of exogenous testosterone in supraphysiological doses can produce adverse effects. This is particularly true for patients who are unaware of the risks of using androgens, or those seeking them without medical supervision.

For this reason, a comprehensive assessment of androgen abuse should be carried out by healthcare professionals. This should include screening for mental health disorders such as depression, body image disturbance and other comorbid conditions such as substance misuse and sexual dysfunction. Clinicians should also consider screening for gynecomastia in males and hirsutism in females.

The most common symptoms associated with androgen abuse are alopecia, erectile dysfunction, impotence, increased blood pressure, hepatic steatosis and acne. These can be detected by clinical examination or blood tests and are usually transient.

Androgen abuse is also often associated with a number of psychiatric and neurological complications. In addition to the usual behavioural problems and psychoneuroendocrine disturbances, these may involve changes in the structure of the brain. These changes are known as “reinforcement” or “hedonic” effects and can be induced by both intra-cerebral injections of testosterone and self-administration.

In recent years, there has been an increase in research on the neurobiological consequences of androgen use, which suggests that this can lead to a spectrum of behaviours, including hedonic effects. For example, some studies suggest that androgens can produce conditioned place preference in humans.

Similarly, androgens have been shown to stimulate sebum production, which can be associated with acne in some users. Likewise, some studies suggest that androgens may exacerbate depression in some users.

However, these findings are not entirely clear. Despite the fact that androgen abuse has become a significant problem globally, there are no definitive measures to reduce the incidence of this condition. In addition, the availability of a full range of effective treatment options for androgen abuse is still limited. In order to overcome this challenge, the development of effective intervention methods should be considered. Specifically, clinicians should consider providing ongoing patient education about the risk of androgen abuse and its adverse effects.

Prevention

The prevention of androgen abuse is a multifaceted undertaking. First of all, anti-doping agencies like WADA and the International Olympic Committee (IOC) take a lead role in reducing the risk of steroid use amongst elite athletes. Secondly, physicians should be on the lookout for the telltale signs of steroid misuse and be ready with the right prescription at the right time.

A few of the top notch medical researchers in the field have even gone as far as to publish their findings in peer-reviewed journals. One such study found that a few of the most popular and widely available testosterone compounds were prone to abuse by athletes.

Conclusion

Testosterone and synthetic analogues are among the oldest drugs in medicine, with a long record of safe use in pharmacological androgen therapy (PAT) to replace a deficient or absent testosterone level. They have also been used pharmacologically to produce specific anabolic effects on marrow, muscle or bone in non-androgen deficient men with chronic diseases, including cancer.

The increasing misuse of testosterone and other PIEDs is an emerging public health concern. The pharmacological properties of androgens are well known to produce a wide range of adverse outcomes, and abusers face an increased risk of death and hospital admissions.

AAS are commonly abused at supraphysiological doses, 10-100 times the body's natural production of androgens. This results in a decrease in endogenous testosterone production that lasts after discontinuation of use and may result in hypogonadism and symptoms such as low libido, fatigue and depression.

Acne and gynecomastia are other common side effects associated with AAS use. Moreover, AAS use is often linked to an increased risk of cardiovascular disease.

Cardiovascular risk factors in AAS users include coronary artery disease, hypertension, cardiac arrhythmias, congestive heart failure, pulmonary embolism and sudden death. Prolonged AAS use also increases lipid levels, lowers HDL cholesterol and elevates LDL cholesterol.

Behavioral and mental health problems are often observed in AAS users, including aggressive and delinquent behaviors. Anxiety, depression and suicidal ideation are also reported in AAS users.

A harm reduction approach is recommended for active AAS users, with a strong emphasis on cardiovascular risk reduction. Other treatment considerations include clomiphene citrate and hCG therapies for the management of hypogonadism, antidepressants and cognitive-behavioral therapy for depression.