Anabolic steroid abuse and cardiac death

Cardiac autonomic dysfunction in rats chronically treated with anabolic steroid

To date no published data exist regarding the effects of chronic high-dose anabolic-androgenic steroid administration on tonic cardiac autonomic control. The aim of this study was to evaluate, by power spectral analysis of heart rate variability (HRV), the effects of chronic treatment with supraphysiological doses of nandrolone decanoate (DECA) on tonic cardiac autonomic regulation in sedentary rats. Male Wistar rats were treated weekly with 10 mg kg(-1) of DECA (n=7) or vehicle (CONTROL, n=7) for 10 weeks. At the 8th week of treatment, electrocardiogram was recorded in the conscious state, for time- and frequency-domain HRV analysis. Parasympathetic indexes were reduced in DECA group: high-frequency power (CONTROL=11.1+/-3.0 ms2 vs. DECA=3.8+/-0.6 ms2, P<0.05), RMSSD (CONTROL=5.9+/-0.9 ms vs. DECA 3.5+/-0.3 ms; P<0.05) and pNN5 (CONTROL=31.5+/-7.5 ms vs. DECA=13.2+/-2.6 ms; P<0.05). The sympathetic index LF/HF tended to be higher in DECA group (CONTROL=0.65+/-0.15 vs. DECA=1.17+/-0.26, P=0.0546). In conclusion, chronic treatment with DECA, in rats, impairs tonic cardiac autonomic regulation, which may provide a key mechanism for anabolic steroid-induced arrhythmia and sudden cardiac death.

Prevention and treatment of cancer cachexia: new insights into an old problem

Cancer cachexia (CC) is a multifactorial paraneoplastic syndrome characterized by anorexia, body weight loss, loss of adipose tissue and skeletal muscle, accounting for at least 20% of deaths in neoplastic patients. CC significantly impairs quality of life and response to anti-neoplastic therapies, increasing morbidity and mortality of cancer patients. Muscle wasting is the most important phenotypic feature of CC and the principal cause of function impairment, fatigue and respiratory complications, mainly related to a hyperactivation of muscle proteolytic pathways. Most therapeutic strategies to CC have proven to be only partially effective . The inhibition of catabolic processes in muscle has been attempted pharmacologically with encouraging results in animal models. However, data in the clinical setting are still scanty and contradictory. Stimulation of muscle anabolism could represent a promising and valid therapeutic alternative for cancer-related muscle wasting. This goal may be currently achieved with the conventional, short-acting and adverse side effect-rich anabolic steroids. Insulin-like growth factor-1 (IGF-1) plays a critical role in muscle homeostasis, hypertrophy and regeneration. IGF-1 overexpression at the muscular level by gene therapy reverses muscle hypotrophy secondary to catabolic conditions and induces muscle hypertrophy increasing muscle mass and strength. This allows the speculation that this approach could also prove effective in modulating cancer-induced muscle wasting, while avoiding the potentially hazardous side effects of systemic IGF-1 administration. The present review will focus on the potential biochemical and molecular targets of CC therapy, and will define the rationale for a novel, gene therapy-based approach.

Current perspectives on anabolic steroids

Steroids are used outside the realm of competitive athletics in Australia among a wide variety of groups with different motivations and goals. This paper provides an overview of the reasons for use; rates of usage; physical and psychological side effects; and sources of steroids. Issues associated with injecting steroids; their current legal status; and drug education and prevention programmes are reviewed briefly. Research involving identified sub-populations is needed to determine user profiles and prevalence rates of users and potential users. Studies of Australian users are also needed to obtain baseline information on areas of potential harm associated with steroids use, e.g. aggressive behaviour, needle-sharing behaviour, physical side effects and potential for dependency. It is concluded that future deterrence strategies should focus more on demand reduction, rather than supply.

Cardiovascular toxicities of performance-enhancing substances in sports

Athletes commonly use drugs and dietary supplements to improve athletic performance or to assist with weight loss. Some of these substances are obtainable by prescription or by illegal means; others are marketed as supplements, vitamins, or minerals. Nutritional supplements are protected from Food and Drug Administration regulation by the 1994 US Dietary Supplement Health and Education Act, and manufacturers are not required to demonstrate proof of efficacy or safety. Furthermore, the Food and Drug Administration lacks a regulatory body to evaluate such products for purity. Existing scientific data, which consist of case reports and clinical observations, describe serious cardiovascular adverse effects from use of performance-enhancing substances, including sudden death. Although mounting evidence led to the recent ban of ephedra (ma huang), other performance-enhancing substances continue to be used frequently at all levels, from elementary school children to professional athletes. Thus, although the potential for cardiovascular injury is great, few appropriately designed studies have been conducted to assess the benefits and risks of using performance-enhancing substances. We performed an exhaustive OVID MEDLINE search to Identify all existing scientific data, review articles, case reports, and clinical observations that address this subject. In this review, we examine the current evidence regarding cardiovascular risk for persons using anabolic-androgenic steroids including 2 synthetic substances, tetrahydrogestrinone and androstenedione (andro), stimulants such as ephedra, and nonsteroidal agents such as recombinant human erythropoietin, human growth hormone, creatine, and beta-hydroxy-beta-methylbutyrate.

Behavioural manifestations of anabolic steroid use

The use of anabolic androgenic steroids (AAS) for gains in strength and muscle mass is relatively common among certain subpopulations, including athletes, bodybuilders, adolescents and young adults. Adverse physical effects associated with steroid abuse are well documented, but more recently, increased attention has been given to the adverse psychiatric effects of these compounds. Steroids may be used in oral, 17alpha-alkylated, or intramuscular, 17beta-esterified, preparations. Commonly, steroid users employ these agents at levels 10- to 100-fold in excess of therapeutic doses and use multiple steroids simultaneously, a practice known as 'stacking'. Significant psychiatric symptoms including aggression and violence, mania, and less frequently psychosis and suicide have been associated with steroid abuse. Long-term steroid abusers may develop symptoms of dependence and withdrawal on discontinuation of AAS. Treatment of AAS abusers should address both acute physical and behavioural symptoms as well as long-term abstinence and recovery. To date, limited information is available regarding specific pharmacological treatments for individuals recovering from steroid abuse. This paper reviews the published literature concerning the recognition and treatment of behavioural manifestations of AAS abuse.

Anabolic steroid abuse: physiological and anaesthetic considerations

This review summarises the physiological and pharmacological effects of the anabolic steroids used to enhance performance in sports. The anabolic steroids promote muscle growth and protein synthesis. Side-effects of anabolic steroids include cardiomyopathy, atherosclerosis, hypercoagulopathy, hepatic dysfunction, and psychiatric and behavioural disturbances. It is therefore appropriate that the anaesthetist be familiar with the abuse of anabolic steroids, their potential adverse effects, and the peri-operative risk associated with the use of these drugs.

Pharmacoepidemiology of anabolic androgenic steroids: a review

Non-prescribed use of anabolic androgenic steroids (AAS) has been associated with a number of physical and psychiatric/behavioural complications, some of which are potentially lethal. Here, we review both observational and experimental studies on human subjects concerned with such side-effects. The only physical complication of AAS use that receives definitive support from such investigations is unfavourable changes in blood lipid profiles. Support for various psychiatric complications has also been provided by a number of cross-sectional studies, most involving comparisons between weight-training individuals who use or do not use AAS. Certain of these complications, in particular hypomania and increased aggressiveness, have been confirmed in some, but not all, randomized controlled studies. Epidemiological attempts to determine whether AAS use triggers violent behaviour have failed, primarily because of high rates of non-participation. Studies regarding the prevalence of AAS use in different populations typically report life-time prevalences of 1-5% among adolescents. However, the life-time prevalence (i.e. use on at least one occasion) is of doubtful relevance in attempting to estimate the number of individuals at risk for side-effects, as most of these complications appear to develop during prolonged use of AAS. Furthermore, it is reasonable to assume that the symptoms and signs of AAS use are often overlooked by healthcare professionals, so that the number of cases of possible AAS-related complications is virtually unknown. These limitations, together with an apparently low prevalence of prolonged AAS use among the general population, indicate that future epidemiological research in this area should focus on retrospective case-control studies and, perhaps, also on prospective cohort studies of populations selected for a high prevalence of AAS use, rather than attempting to perform large-scale population-based studies.

Androgen dependence in hamsters: overdose, tolerance, and potential opioidergic mechanisms

Anabolic steroids are drugs of abuse. However, the potential for steroid reward and addiction remains largely unexplored. This study used i.c.v. testosterone self-administration and controlled infusions of testosterone or vehicle in hamsters to explore central mechanisms of androgen overdose. Forty-two hamsters used nose-pokes to self-administer 1 microg/microl testosterone i.c.v. 4 h/day in an operant chamber. During 1-56 days of androgen self-administration, 10 (24%) hamsters died. Deaths correlated with peak daily intake of testosterone. Of the hamsters that self-administered a peak intake of <20 microg/day, there was 100% survival (10/10). Survival decreased to 86% (19/22) when daily testosterone intake peaked at 20-60 microg/day. Only 30% (three of 10) survived when daily testosterone intake exceeded 60 microg/day. Deaths are not due to volume or vehicle because i.c.v. infusions of 80 mul vehicle had no effect. Testosterone overdose resembles opiate intoxication. When male hamsters received infusions of 40 microg testosterone, locomotion (25.1+/-18.8 grid-crossings/10 min), respiration (72.7+/-5.4 breaths/min) and body temperature (33.5+/-0.4 degrees C) were significantly reduced, compared with males receiving vehicle infusions (186.1+/-8.1 crossings/10 min, 117.6+/-1.0 breaths/min, 35.9+/-0.1 degrees C, P<0.05). However, males developed tolerance to continued daily testosterone infusion. After 15 days, locomotion (170.2+/-6.3 crossings), respiration (118.4+/-1.3 breaths/min), and body temperature (35.3+/-0.3 degrees C) in testosterone-infused males were equivalent to that in vehicle controls (P>0.05). The depressive effects of testosterone infusion are blocked by the opioid antagonist, naltrexone. With naltrexone pre-treatment (10 mg/kg s.c.), locomotion (183.7+/-1.8 crossings/10 min), respiration (116.9+/-0.3 breaths/min), and body temperature (36.1+/-0.4 degrees C) during testosterone infusion were equivalent to vehicle controls. Likewise, naltrexone prevents the reinforcing effects of i.c.v. testosterone self-administration. These results indicate that testosterone at high doses causes central autonomic depression, which may be a factor in deaths during self-administration. As well, the depressive effects of large quantities of testosterone may be mediated, at least in part, by an opioidergic mechanism.

Adolescent anabolic steroid use, gender, physical activity, and other problem behaviors*

To test the comparative value of strain theory and problem behavior theory as explanations of adolescent anabolic steroid use, this study examined gender-specific relationships among steroid use, physical activity, and other problem behaviors. Based on the United States Centers for Disease Control and Prevention's 1997 Youth Risk Behavior Survey, a nationally representative sample of over 16,000 U.S. public and private high school students, binge drinking, cocaine use, fighting, and sexual risk-taking were associated with higher odds of lifetime steroid use. In gender-specific analyses, steroid use was strongly associated with female fighting and smokeless tobacco use as well as male sexual risk. Neither athletic participation nor strength conditioning predicted odds of steroid use after controlling for problem behaviors, nor did steroid-using athletes report more frequent use than steroid-using nonathletes. The study's limitations and policy implications were noted. These data suggest that other problem behaviors such as substance use, fighting, and sexual risk are better predictors of adolescent steroid use than physical activity. Interventions to prevent steroid use should not be limited to male participants in organized sports programs, but should also target adolescents identified as at risk for other problem behaviors.

Therapy of muscle wasting in cancer: what is the future?

PURPOSE OF REVIEW

The aim of the present review is to provide insights into the future therapeutic approaches to cancer-related muscle wasting that flow from the progressive knowledge of mechanisms regulating muscle mass in health and disease.

RECENT FINDINGS

Cancer cachexia is a severely debilitating and life-threatening paraneoplastic syndrome accounting for approximately 20% of cancer deaths. The prominent clinical feature of cancer cachexia is the progressive loss of muscle mass, which is substantially not reversible with any of the currently available nutritional, metabolic or pharmacological approaches. Cancer cachexia has long been considered a late event in the natural history of cancer patients, thus condemning them to merely palliative interventions. The accumulating evidence that the metabolic and molecular derangements ultimately leading to muscle wasting are operating early after tumour onset, even when weight loss is minimal or absent, is strengthening the view that cancer cachexia should be considered an early phenomenon.

SUMMARY

Currently, despite scientific and economic efforts, the therapy of cancer-related muscle wasting has a poor success rate. Present knowledge of the intracellular mechanisms involved in muscle homeoastasis is prompting continuous research aimed at developing more effective and selective therapeutic tools for the prevention and treatment of muscle loss in cancer.

The effects of anabolic-androgenic steroids upon resting and peak exercise left ventricular heart wall motion kinetics in male strength and power athletes

Previous investigations reported alterations in myocardial fibres and systolic function associated with anabolic-androgenic steroid consumption by athletes. Advances in bio-medical technology have allowed further investigation in assessing the possible effects of anabolic-androgenic steroids on gross left ventricular kinetics. Twenty-three male strength and power athletes with a past and current history of anabolic-androgenic steroid consumption (x 46 days, range 28 days to 70 days), were compared to 23 controls. Testing consisted of resting and immediate post-exercise transthoracic left ventricular wall cardiokymograms. Statistical results identified no difference over time between groups or condition. Cardiokymographic waveform analysis found 32.61% of all (n =184) waveforms to be abnormal (Type II, n = 56 or Type III, n = 4). There were 14 treatment subjects (60.87%) who demonstrated an abnormal waveform as compared to 9 controls (39.13%). A significant difference (p < or = 0.01) in the overall proportions of waveform types was identified where the treatment group exhibited 41.30% abnormal waveforms, compared to 23.91% by controls. Additionally, two athletes (1 treatment, 1 control) demonstrated abnormal left ventricular wall motions (Type III) analogous to impaired left ventricular performance. The results indicated: (a) highly strength trained athletes with no history of anabolic-androgenic steroid usage exhibited an unexpected high incidence of Type II waveforms (28.26% pre/23.91% post); (b) a comparable group of strength trained athletes using anabolic-androgenic steroids exhibited a significantly higher percentage of abnormal waveforms as compared to controls (34.78% pre/37.21% post). Based on these results, high intensity strength training with and without anabolic-androgenic steroid supplementation induced alterations in the left ventricular wall motion.

Effects of Androgenic-Anabolic Steroids in Athletes

Androgenic-anabolic steroids (AAS) are synthetic derivatives of the male hormone testosterone. They can exert strong effects on the human body that may be beneficial for athletic performance. A review of the literature revealed that most laboratory studies did not investigate the actual doses of AAS currently abused in the field. Therefore, those studies may not reflect the actual (adverse) effects of steroids. The available scientific literature describes that short-term administration of these drugs by athletes can increase strength and bodyweight. Strength gains of about 5-20% of the initial strength and increments of 2-5 kg bodyweight, that may be attributed to an increase of the lean body mass, have been observed. A reduction of fat mass does not seem to occur. Although AAS administration may affect erythropoiesis and blood haemoglobin concentrations, no effect on endurance performance was observed. Little data about the effects of AAS on metabolic responses during exercise training and recovery are available and, therefore, do not allow firm conclusions. The main untoward effects of short- and long-term AAS abuse that male athletes most often self-report are an increase in sexual drive, the occurrence of acne vulgaris, increased body hair and increment of aggressive behaviour. AAS administration will disturb the regular endogenous production of testosterone and gonadotrophins that may persist for months after drug withdrawal. Cardiovascular risk factors may undergo deleterious alterations, including elevation of blood pressure and depression of serum high-density lipoprotein (HDL)-, HDL2- and HDL3-cholesterol levels. In echocardiographic studies in male athletes, AAS did not seem to affect cardiac structure and function, although in animal studies these drugs have been observed to exert hazardous effects on heart structure and function. In studies of athletes, AAS were not found to damage the liver. Psyche and behaviour seem to be strongly affected by AAS. Generally, AAS seem to induce increments of aggression and hostility. Mood disturbances (e.g. depression, [hypo-]mania, psychotic features) are likely to be dose and drug dependent. AAS dependence or withdrawal effects (such as depression) seem to occur only in a small number of AAS users. Dissatisfaction with the body and low self-esteem may lead to the so-called 'reverse anorexia syndrome' that predisposes to the start of AAS use. Many other adverse effects have been associated with AAS misuse, including disturbance of endocrine and immune function, alterations of sebaceous system and skin, changes of haemostatic system and urogenital tract. One has to keep in mind that the scientific data may underestimate the actual untoward effects because of the relatively low doses administered in those studies, since they do not approximate doses used by illicit steroid users. The mechanism of action of AAS may differ between compounds because of variations in the steroid molecule and affinity to androgen receptors. Several pathways of action have been recognised. The enzyme 5-alpha-reductase seems to play an important role by converting AAS into dihydrotestosterone (androstanolone) that acts in the cell nucleus of target organs, such as male accessory glands, skin and prostate. Other mechanisms comprises mediation by the enzyme aromatase that converts AAS in female sex hormones (estradiol and estrone), antagonistic action to estrogens and a competitive antagonism to the glucocorticoid receptors. Furthermore, AAS stimulate erythropoietin synthesis and red cell production as well as bone formation but counteract bone breakdown. The effects on the cardiovascular system are proposed to be mediated by the occurrence of AAS-induced atherosclerosis (due to unfavourable influence on serum lipids and lipoproteins), thrombosis, vasospasm or direct injury to vessel walls, or may be ascribed to a combination of the different mechanisms. AAS-induced increment of muscle tissue can be attributed to hypertrophy and the formation of new muscle fibres, in which key roles are played by satellite cell number and ultrastructure, androgen receptors and myonuclei.

[Body-building, steroid use, and risk perception among young body-builders from a low-income neighborhood in the city of Salvador, Bahia State, Brazil]

Recent studies in different countries have shown an increase in anabolic steroid consumption among young people and the harm caused by indiscriminate use. In Brazil, research on steroid abuse is scarce. The present study examines the risk perception of health problems associated with anabolic steroid consumption among young working-class adults engaged in body-building practices in a poor neighborhood in the city of Salvador, Bahia. The methodology involved an anthropological approach based on qualitative research techniques consisting of ethnography, in-depth interviews, and a focus group with steroid users. The data describe the most common substances consumed and highlight the lack of information among interviewees concerning potential related health hazards, showing that for many steroid consumers the quest for muscle-mass development to achieve an idealized body supersedes the risk of harmful side effects. The results indicate the need for culturally sensitive measures to prevent steroid abuse among youth.

Sports doping in the adolescent athlete the hope, hype, and hyperbole

A well-balanced diet with appropriate training is the key to maximizing athletic performance. Nutritional counseling should be an essential part of anticipatory guidance, especially for certain teens, such as those who are vegetarians or those with low-calorie intakes. Other considerations for anticipatory guidance are listed in Box 8. Adequate hydration before, during, and after practice or a game is important to maintain hemodynamic balance, prevent heat disorders, and optimize performance. Cool water is adequate for short-duration activities, while carbohydrate-electrolyte fluids are more desirable for long-term activities, especially those lasting more than an hour. Such drinks are also more palatable and the athlete is more likely to consume them. Carbohydrates (meaning hydrates of carbon) are an important part of the athlete's diet; carbohydrates are rapidly broken down and their energy is quickly supplied to the body. The body stores only a small amount of carbohydrates in the form of glycogen in the liver, while muscle glycogen is an immediate source of energy. Thus, carbohydrate loading has been used to increase glycogen stores and aid the athlete involved in endurance events.

Anabolic-androgenic steroids induce apoptotic cell death in adult rat ventricular myocytes

We tested whether exposure to anabolic-androgenic steroids (AASs) would induce apoptosis in adult rat ventricular myocytes in vitro. Myocytes were exposed to stanozolol (STZ), testosterone enanthate (TE) and testosterone (T) (0.1 micromol/L, 1 micromol/L, 10 micromol/L, and 100 micromol/L) for 20 h. The percentage of myocytes undergoing apoptosis was determined by terminal deoxynucleotidyl transferase-mediated nick end labeling (TUNEL) and was found to be increased when compared to control myocytes at STZ 10 micromol/L 12 +/- 2% (mean +/- SD), STZ 100 micromol/L 42 +/- 3%; TE 1 micromol/L 11 +/- 2%, TE 10 micromol/L 21 +/- 3%, TE 100 micromol/L 62 +/- 2%; T 10 micromol/L 11 +/- 2%, T 100 micromol/L 40 +/- 3% (P < 0.001 vs. CTL 2 +/- 2%). The STZ-, TE- and T-induced dose-dependent apoptotic cell death was corroborated by a significantly increased DNA laddering in myocytes exposed to STZ and T > or = 10 micromol/L and TE > or = 1 micromol/L. Notably, STZ, TE, and T exposure markedly increased the expression of the pro-apoptotic oncogene Bax-alpha, as assessed by reverse transcription-polymerase chain reaction. Taken together, these results clearly show for the first time that AASs induce apoptotic cell death in a dose-dependent manner. This finding may have important implications in understanding the pathogenesis of ventricular remodeling, cardiomyopathy, and sudden cardiac death associated with AAS abuse.

Anabolic steroid abuse and cardiac sudden death: a pathologic study

CONTEXT

Androgenic anabolic steroids (AAS) used for improving physical performance have been considered responsible for acute myocardial infarction and sudden cardiac death.

OBJECTIVE

To establish the relationship between AAS and cardiac death.

DESIGN

Case report.

PATIENTS

Two young, healthy, male bodybuilders using AAS.

MAIN OUTCOME MEASURES

Pathologic cardiac findings associated with AAS ingestion.

RESULTS

The autopsy revealed normal coronary arteries. In one case, we documented a typical infarct with a histologic age of 2 weeks. A segmentation of myocardial cells at the intercalated disc level was observed in the noninfarcted region. This segmentation was the only anomaly detected in the second case. No other pathologic findings in the heart or other organs were found. Urine in both subjects contained the metabolites of nortestosterone and stanozolol.

COMMENT

A myocardial infarct without vascular lesions is rare. To our knowledge, its association with AAS use, bodybuilding, or both lacks any evidence of a cause-effect relationship. The histologic findings in our 2 cases and in the few others reported in medical literature are nonspecific and do not prove the cardiac toxicity of AAS. A better understanding of AAS action on the neurogenic control of the cardiac function in relation to regional myocardial contraction and vascular regulation is required.

Combined cardiac effects of cocaine and the anabolic steroid, nandrolone, in the rat

Despite reports of an increase in the incidence of simultaneous cocaine and anabolic steroid abuse, potential adverse interactions between these two drugs on the cardiovascular system are largely unquantified. Cocaine has been reported to induce coronary vasoconstriction, cardiac arrhythmias and conduction delays. Anabolic steroids have been associated with cardiac hypertrophy and hypertension. Utilising both in vivo (radiotelemetry) and in vitro (isolated Langendorff-perfused heart) techniques, our aim was to determine whether anabolic steroids cause cardiac hypertrophy and alter cardiac function, and consequently alter the response of the heart to cocaine. It was found that 15 days of treatment of rats with nandrolone decanoate (20 mg/kg, s.c.) was not sufficient to cause hypertrophy, alter cardiac function or the spread of electrical activity through the heart. However, nandrolone pretreatment was found to significantly potentiate the heart rate response to cocaine (45 mg/kg, i.p.) in vivo. This study indicates that nandrolone significantly elevates the heart rate response to high dose cocaine without changing heart morphology. The mechanism of this interaction remains uncertain.

Atrial fibrillation and anabolic steroids

A young male bodybuilder, consuming large doses of anabolic steroids (AS), presented to the Emergency Department (ED) with symptomatic rapid atrial fibrillation (AF). Echocardiogram revealed significant septal hypokinesis, and posterior and septal wall thickness at the upper limit of normal for highly trained athletes. The atrial fibrillation had not recurred at 10 weeks after discontinuation of AS use. Consumption of these agents in athletes has been associated with hypertension, ischemic heart disease, hypertrophic cardiomyopathy, and sudden death.

The cardiac toxicity of anabolic steroids

Anabolic steroids are synthetic derivatives of testosterone that were developed as adjunct therapy for a variety of medical conditions. Today they are most commonly used to enhance athletic performance and muscular development. Both illicit and medically indicated anabolic steroid use have been temporally associated with many subsequent defects within each of the body systems. Testosterone is the preferred ligand of the human androgen receptor in the myocardium and directly modulates transcription, translation, and enzyme function. Consequent alterations of cellular pathology and organ physiology are similar to those seen with heart failure and cardiomyopathy. Hypertension, ventricular remodeling, myocardial ischemia, and sudden cardiac death have each been temporally and causally associated with anabolic steroid use in humans. These effects persist long after use has been discontinued and have significant impact on subsequent morbidity and mortality. The mechanisms of cardiac disease as a result of anabolic steroid use are discussed in this review.

Anabolic agents

This article provides a comprehensive but practical discussion of four anabolic agents used by athletes. Anabolic-androgenic steroids, dehydroepiandrosterone, human growth hormone, and insulin-like growth factor are discussed. A thorough review of available literature on the basic chemistry and physiology, epidemiology, reasons for use, and performance and side effects of each agent are also presented.

Medico-legal aspects of doping

Abuse of anabolic steroids is an increasing problem not only among athletes but also body-builders and teenagers. A fast-developing black market has been established since the opening of the borders to eastern Europe. Medico-legal aspects of doping are addressed with particular reference to toxicology and pathology. Constituents of anabolic steroids bought on the black market were identified using gas chromatography/mass spectrometry; the products did not contain the expected ingredients in 35% of cases. Long-term effects and fatalities because of anabolic steroid abuse are reported here based on our own case material and a literature review. In our own cases, severe cardiovascular side-effects developed after long-term abuse of Dianabol (methandrostenolone) and Oral-Turinabol (chlordehydromethyltestosterone), i.e. myocardial infarction, stroke, organomegaly and/or severe atherosclerosis. The pathogenesis of cardiovascular complications (cardiotoxic effect, risk of atherosclerosis, thrombogenic risk) is discussed based on the available literature reports following fatal outcome after the abuse of anabolic steroids.

Gym and tonic: a profile of 100 male steroid users

OBJECTIVE

To identify unsupervised anabolic steroid regimens used by athletes.

METHODS

100 athletes attending four gymnasia were surveyed using an anonymous self administered questionnaire.

RESULTS

Anabolic steroid doses ranged from 250 to 3200 mg per week and users combined different drugs to achieve these doses. Injectable and oral preparations were used in cycles lasting four to 12 weeks. Eighty six per cent of users admitted to the regular use of drugs other than steroids for various reasons, including additional anabolic effects, the minimisation of steroid related side effects, and withdrawal symptoms. Acne, striae, and gynaecomastia were the most commonly reported subjective side effects.

CONCLUSIONS

Multiple steroids are combined in megadoses and self administered in a cyclical fashion. Polypharmacy is practised by over 80% of steroid users. Skeletal muscle hypertrophy along with acne, striae, and gynaecomastia are frequent physical signs associated with steroid use.

Anabolic steroid users identified by needle and syringe exchange contact

The increasing prevalence in the extent of misuse of anabolic-androgenic steroids has been well recognised in the United States and more recently in Great Britain. The injecting misuse of steroids carries with it considerable risks in relation to liver damage, lipid metabolism disturbance and the potential of HIV and viral hepatitis transmission. This study of 21 steroid users contacted at a needle and syringe exchange showed that 42.8% had abnormal liver function tests and 28.5% had lowered high-density lipoprotein concentrations. None of this group reported engaging in high risk behaviour through sharing injecting equipment. The group did contain a bisexual and a previous injecting amphetamine user. Needle and syringe exchanges offering health examination facilities will provide a valuable role in contacting steroid users who will then be in a position to make informed decisions about their own drug use and the potential harm from steroids.