Steroid doping

Essentials

• Remember the possibility of anabolic steroid use when a young competitive athlete or a recreational power athlete seeks medical treatment for acne, infertility, loss of sexual desire, cardiac symptoms, depression, uncontrolled outbursts of rage or sleep disturbances.
• The physician should be particularly alert if the patient has in addition a strong musculature, and other effects of anabolic steroids (e.g. high haemoglobin level) are apparent.
• Rule out the use of anabolic steroids before starting therapy for acne.
• Be alert to the possibility of heart diseases and even acute myocardial infarction in a steroid user.

Preparations

• All steroids used for doping have both androgenic and anabolic properties. The range of non-medically used anabolic substances on the black market includes, for example, the following:
• Nandrolone
  After testosterone the most widely used injectable anabolic steroid
  • The names of methandrostenolone preparations sold on the black market include Silabolin, Deca-Durabolin, Retabolin and Laurobolin.
  • Detectable for long periods in doping tests
• Methandrostenolone
  • The most widely used peroral anabolic steroid
  • Sold as 5, 10 or 50 mg tablets on the black market with names such as Dianabol, Anabol, Anabolin, Methandrostenolon and Metabolin.
• Testosterone and derivatives
  • The most frequently confiscated anabolic substance
  • There are several preparations of East European origin on sale on the street. Commercial injectable preparations include Androxon, Estandron Prolongatum, Omnadren, Primodian-Depot, Primoteston-Depot, Restandol, Sustanon, Panteston, Testen, Testoviron depot and Undestor. The most popular preparation is Sustanon 250 of which there is a wide range of bogus products.
  • Testosterone undecanoate (Panteston) is an orally administered testosterone derivative. Panteston is popular mainly among competing athletes because it is not detectable in doping tests for very long.
• Trenbolone
  • An injectable derivative of nandrolone, sold on the street as Parabolan and Finajet. Trenbolone does not aromatize and thus causes gynaecomastia less often than, e.g., testosterone.
• Stanozolol
  • Is used both as injectable and as tablets.
  • The most well-known trade names are Stromba and Winstrol.
• Boldenone
  • Injectable
  • Most well-known trade name is Equipose
• Oxymetholone
  • Used as tablets
  • The most well-known trade names are Anapolon, Anadrol and Androlic.
  • Like other anabolic steroids used as tablets, oxymetholone has a stronger effect on liver than anabolic steroids that are used as injections.
• Oxandrolone
  • Only as tablets; mostly under the trade name Anavar
• Fluoxymesterone
  • Used as tablets
  • The most well-known trade name is Halotestin.
• Tamoxifen, clomifen, anastrozole and letrozole
  • Oestrogen receptor antagonists that are used to prevent gynaecomastia during use of anabolic steroids.
  • Trade names e.g. Novaldex, Tadex, Clomifen, Arimidex and Femar
• Human chorionic gonadotropin
  • Is used to induce the body's own testosterone production at the end or near the end of abuse period.
  • The best know trade names are Pregnyl, Profas, HCG and Ovitrelle.
• Insulin
  • Insulin is used in association with steroid doping in order to achieve anabolic effects and to reduce the insulin resistance caused by anabolic steroids and growth hormone use. Insulin overdose leads very rapidly to hypoglycaemia and unconsciousness.
• Clenbuterol
  • Oral beta-2 agonist used for treating asthma in horses. The most common names trade names are Ventipulmin, Spiropent, and Clenbuterol.
  • Increases the protein content in striated muscles and enhances the use of muscle glycogen and body fat stores. The size of the muscle cells is increased while their number remains the same.
• Growth hormone
  • Anabolic effect. Most common trade names, produces by DNA recombination technique, are Genotropin, Norditropin, Humatrope and Saizen. The most often confiscated product is the Chinese Jintropin.
  • Growth hormone preparations of human origin are still occasionally encountered on the black market. Their long-term use is linked to the risk of Creutzfeldt-Jacob disease.
  • Causes arthralgia, oedema and cardiomyopathy.
• IGF-1 and LR3IGF-1
  • The use of these substances has increased as IGF-1 has been licensed for the treatment of short stature (mekasermin; Increlex) and LR3IGF-1, which is in the experimental stage, has found its way to the assortment of companies specialized in black market sales in the Internet (e.g. Omega Laboratories and various Chinese companies).
  • The effects are similar to growth hormone and insulin. Potentially acutely life-threatening (hypoglycaemia).
• Other substances used in association with steroid doping
  • Ephedrine and its derivatives for burning fat
  • Thyroid hormones for burning fat
  • Among the various dietary supplements especially the so-called ”testosterone boosters” (which often contain precursors of testosterone and nandrolone) as well as dinitrophenol (DNP). DNP used as fat burner blocks cell respiration and is acutely life-threatening.

Common adverse effects

Subjective

• Increased aggressiveness
• Mood fluctuations
  • Euphoria (omnipotence)
  • Depression (mostly after the abuse period)
  • Delusions
  • Sleep disturbances (mostly after the abuse period)
• Increased libido, later impotence
• Spasticity
• Headache
• Dizziness
• Nausea

Urogenital

• In men
  • Hypogonadism (almost always)
  • Dysuria
  • Testicular pain, testicular atrophy
  • Decreased sperm motility, oligozoospermia or azoospermia
  • Prostatic hypertrophy
  • Prostatic cancer
  • Gynaecomastia
• In women
  • Diminished size of breasts
  • Deepening of voice
  • Menstrual irregularities, amenorrhoea
  • Clitoral enlargement (may remain as a permanent change)
  • Uterine atrophy
  • Teratogenic effects (pseudohermaphroditism, foetal death)

Hepatic

Increased aminotransferase concentrations
• Cholestasis
• Increase in LDL-cholesterol concentration
• Decrease in HDL-cholesterol concentration
• Peliosis hepatis (blood-filled cysts in the liver)
• Benign tumours
• Ruptures of hepatic tumours
• Cancers
• Hepatic coma

Musculoskeletal

• Increased susceptibility to injuries
• Premature epiphyseal closure

Cardiovascular and vascular

• Increased blood pressure
• Cardiomyopathy
• Direct toxic effect (cardiovascular events )
• Atherosclerotic heart disease
• Arrhythmias

Endocrine

• Impaired glucose tolerance and insulin resistance
• Changes of thyroid function

Dermatological

• Seborrhoea, greasy skin and hair
• Comedones, sebaceous cysts
• Papulopustular or cystic acne (picture ) or rosacea
• Furunculosis, folliculitis, pyoderma, abscesses (from contaminated needles)
• Male-type alopecia (permanent in women; picture )
• Hirsutism of face and body (in women; pictures )
• Striae (pictures )

Immunological

• Reduced immunoglobulin A concentration can lead to increased susceptibility to infections.

Investigations

• Plasma ALT, AST
• Plasma cholesterol, HDL-cholesterol
• Plasma triglycerides
• Liver ultrasound
• Semen analysis
• Serum testosterone, follicle stimulating hormone, luteinizing hormone, sex hormone binding globulin
• Echocardiography
• ECG, chest x-ray
• Standardized questionnaires e.g. to assess depression

Withdrawal

• Warning about the risks of steroid abuse
• The patient should be informed that giving up steroids after many weeks of use may cause tiredness, depression and impotence, but that the natural hormone production will resume to its earlier level within 3–12 months.
• Human chorionic gonadotropin may provide some help.

Follow-up

• Serum sex hormone binding globulin, serum luteinizing hormone
• Monitoring of liver function as required
• Referral to a sports physician

Related resources

• Literature

Ədəbiyyat

1. Pope HG Jr, Wood RI, Rogol A et al. Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement. Endocr Rev 2014;35(3):341-75.
2. Rahnema CD, Lipshultz LI, Crosnoe LE et al. Anabolic steroid-induced hypogonadism: diagnosis and treatment. Fertil Steril 2014;101(5):1271-9.