Prevalence of anabolic steroid users seeking support from physicians: a systematic review and meta-analysis

Off-label use of clomiphene citrate to treat anabolic androgenic steroid induced hypogonadism upon cessation among men (CloTASH) - A pilot study protocol

Background

Non-prescribed anabolic androgenic steroid (AAS) use is associated with AAS-induced hypogonadism (ASIH), and metabolic, cardiovascular, and mental health risks. Symptoms of ASIH (fatigue, depression, anxiety, sexual dysfunction) are hard to endure following cessation, but there is no consensus on whether endocrine treatment should be used to treat ASIH. This proof-of-concept study aims to explore safety of off-label clomiphene citrate therapy, whether the treatment will reduce the symptoms of androgen deficiency, and to study changes in health risks after cessation.

Methods

In this open-labeled non-randomized off-label hormone intervention pilot study, we shall include males with AAS dependence intending to cease use. The 16-week intervention included clomiphene citrate, transdermal testosterone gel for the first four weeks and optional human chorionic gonadotropin (hCG) from week 4 if low treatment response. Measures of physical and mental health will be examined from ongoing AAS use, during the intervention, and at 6- and 12 months post cessation. Change in self-reported symptoms of hypogonadism and other withdrawal symptoms will be compared with data from a group of men who ended AAS use temporarily without the medical intervention. The study may provide valuable clinical insights and may be used to inform the design of future intervention studies.

The relationship between anabolic androgenic steroid use and body image, eating behavior, and physical activity by gender: A systematic review

The prevalence of anabolic androgenic steroids (AAS) is rising, especially in recreational sports and the general population. While body image significantly influences AAS use, gender differences remain unclear. We examined gender-related connections between AAS use, body image, eating behavior, and physical activity. Following PRISMA guidelines, we analyzed 22 studies: 14 with male-only samples, 5 mixed-gender, 2 with sexual and gender minorities, and 1 with a female-only sample. FINDINGS: confirm body image as a key predictor of AAS use. Though AAS use correlates with eating disorders, outcomes vary by context; for instance, no discernible difference in eating behavior was observed between AAS users and non-users in bodybuilding. Physical activity findings varied, with some studies showing no significant differences between AAS users and non-users. Due to limited gender-comparison studies, conclusive gender-related differences cannot be drawn. This systematic review underscores the complex interplay between AAS use, body image, eating behavior, and physical activity, emphasizing the necessity for further research to develop targeted interventions for diverse populations, addressing AAS-related concerns and promoting overall well-being.

The health effects of non-prescribed anabolic-androgenic steroid use: Findings from The Performance and image-enhancing drugs UseRS' Health (PUSH) audit

INTRODUCTION

To ascertain the adverse health outcomes experienced by those using prescribed testosterone and non-prescribed anabolic-androgenic steroids presenting to general practitioner (GP) clinics.

METHODS

Retrospective clinical audit from nine GP clinics in major metropolitan areas across three Australian states. Data included demographic and individual characteristics (age, sexuality, body mass index, smoking status and HIV status); performance and image-enhancing drug use (type, reasons for use, patient-reported adverse effects); and blood biochemistry measurements (lipid profiles, liver function tests and red blood cell tests). Adverse health outcomes included evidence of polycythaemia, hypertension, liver abnormalities and hypercholesterolemia.

RESULTS

Three hundred men were identified as either using prescribed testosterone (66%; n = 197) or non-prescribed anabolic-androgenic steroids (AAS) (34%; n = 103). Individuals in the prescribed group were more likely to be older (p < 0.001), gay or bisexual (p < 0.001) and living with diagnosed HIV (p < 0.001) compared to individuals in the non-prescribed group. Abnormal liver function, polycythemia and gynecomastia were the top three adverse events experienced. When adjusting for age, sexuality, HIV status and smoking status, those who used non-prescribed AAS were more likely to experience any adverse event (aPR = 1.28; 95% CI 1.01-1.60; p = 0.038), hypertension (aPR = 1.86; 95% CI 1.19-2.91; p = 0.006) and liver abnormalities (aPR = 1.51; 95% CI 1.04-2.20; p = 0.030) compared to those using prescribed testosterone.

DISCUSSION AND CONCLUSION

For GPs who have clients who may be using, or who they suspect of using, AAS, these findings highlight the importance of not only exploring a patient's history of the adverse effects they have experienced, but that measuring for these other conditions may provide a more accurate clinical picture.

Assessment of Anabolic Androgenic Steroids Use Among Professional CrossFit® Athletes: Motives, Perception, and Safety

BACKGROUND

Anabolic androgenic steroids (AAS) are traditionally used for the treatment/control of various diseases; however, they are being used for non-therapeutic and indiscriminate purposes to enhance sports performance and physical appearance. This study aimed to assess the prevalence and associated factors of AAS use among professional CrossFit® competitors.

METHODS

We conducted an observational cross-sectional survey in which an anonymous questionnaire was applied to professional CrossFit® athletes.

RESULTS

The prevalence of AAS usage was 33.3%. Most users were male (74.2%), aged between 30 and 39 years (51.6%), with completed higher education (83.9%), and had been training for more than 5 years (77.4%); the primary motivation for AAS use was performance enhancement (77.4%). Individuals who were older (p < 0.05) and more experienced in competitions (p < 0.01) are more likely to use AAS. Testosterone was the most employed AAS (71.0%); CrossFit® athletes typically used an average of 2 different AAS. The majority of users had notably sought advice from a physician (74.2%), and AAS were acquired from either drugstores (80.6%) or through illicit channels (29.0%). Moreover, 61.3% of AAS users reported experiencing adverse effects.

CONCLUSIONS

Our results demonstrated a higher prevalence of AAS users among professional competitors in CrossFit® compared to the general population; older age and greater experience in official competitions were decisive factors for a greater inclination toward AAS use. A significant percentage of athletes seek drugs through illegal channels. Despite the majority of users experiencing adverse effects, athletes report satisfaction with use, believing that the benefits still outweigh the drawbacks.

Treatment-seeking behavior and cardiovascular morbidity among men with anabolic-androgenic steroid use: A cross-sectional study

AIMS

To determine associations between anabolic-androgenic steroid (AAS) use-related morbidity including cardiovascular disease (CVD) and engagement to health services.

METHODS

In this cross-sectional study, 90 males with at least 12 months cumulative current or former use of AAS were included. The participants were divided into a treatment-seeking group (TSG) and a non-treatment seeking group (non-TSG) based on their responses to a self-report web questionnaire. All participants were screened for symptoms that could be indicative of CVD through a clinical interview, and examined with blood samples, blood pressure measurements and transthoracic echocardiography.

RESULTS

In the total sample (n = 90), mean age was 39 ± 11 years with cumulative AAS use of 12 ± 9 years. Among men in the TSG with current use there were higher prevalence of dyspnoea (50% vs 7%) and reduced left ventricular ejection fraction (LVEF) in conjunction with left ventricular hypertrophy (LVH) (36 vs. 9%) and/or high blood pressure (55% vs. 19%) compared to men in the non-TSG. Among men with current AAS use and established LVEF <50% (n = 25) or LVH (n = 21), 44% (11) and 43% (9) respectively, had never engaged health services due to AAS-related adverse effects. Deviant liver- and kidney parameters were frequently observed in the total sample but without between-group differences.

CONCLUSIONS

Treatment-seeking behavior among current AAS users may be associated with increased levels of dyspnoea and established CVD. Despite objective signs of severe CVD among a substantial amount of study participants, it is of great concern that the majority had never sought treatment for AAS-related concerns.

The Uses of Anabolic Androgenic Steroids Among Athletes; Its Positive and Negative Aspects- A Literature Review

The use of anabolic androgenic steroids (AAS) for strength training and muscle building is a widespread practice among athletes and young individuals. Athletes and bodybuilders are using these substances for various purposes, such as enhancing muscle mass, strengthening their bodies, and enhancing their performances. AAS exert a wide range of physiological effects that result in the activation of central signaling, resulting in adverse effects. Moreover, excessive use of AAS which can be categorized as AAS abuse; is linked to biological and psychological pathologies, which can lead to mortality. Complications arising from steroid abuse involve both cellular and physiological complications. Cellular complications arise when activation of signaling proteins like mTOR, Akt, etc. leads to alteration in protein synthesis pathways, cell cycle, oxidative stress, and apoptosis, contributing to damage at the cellular level. Physiological complications are evident with cardiovascular pathologies, including an altered lipid profile, cardiac hypertrophy, hypogonadism after discontinuation of AAS, and modulation of GABA receptors in the brain, all contributed by the androgen receptor signaling. Clinical complications budding from these altered physiological processes lead to clinical effects like testicular dysfunction, acne, gynecomastia, and neuropsychiatric disorders. Despite potential therapeutic benefits, AAS use is prohibited by the World Anti-Doping Agency (WADA) due to concerns over adverse health effects. This review highlights the molecular mechanisms, physiological processes, and clinical complications arising from the excessive use of AAS among athletes.

Systematic reviews and meta-analyses on androgen administration in humans: an umbrella review

PURPOSE OF REVIEW

The present umbrella review systematically searches and synthesizes recent (2021-2023) systematic reviews and meta-analyses (SRMA) on androgen administration in humans.

RECENT FINDINGS

Results from 19 SRMA are synthesized. Four themes were identified: market for androgens, prevalence of androgen abuse, psychological effects of androgens, and clinical/therapeutic effects of androgens. One of three androgens on the illicit market are fake or substandard. Whereas one of three androgen users experiences dependence and various serious disorders, only one of three androgen users seeks physician support. Additionally, androgen administration increases self-reported aggression in healthy male individuals, and abuse positively correlates with interpersonal violence. Furthermore, androgen therapy is beneficial in treating persons suffering from various chronic diseases.

SUMMARY

In this umbrella review, we identified 19 SRMA on androgen use and abuse. Results show a high prevalence of fake androgens on the illicit market, a high prevalence of androgen abuse and dependence, and that a huge proportion of androgen users tend to avoid seeking support from clinicians. Also, androgen administration increases self-reported aggression among healthy male, and there is a positive correlation between androgen abuse and violent behavior. Finally, androgens have multiple therapeutic effects on various pathology.

A review of recent evidence on androgen abuse from interviews with users

PURPOSE OF REVIEW

Androgens (also known as anabolic-androgenic steroids; AAS) are increasingly being abused worldwide to enhance body physique or athletic performance. Qualitative studies including interviews provide a wider understanding of androgen abuse and focus specific support needs to this group. This narrative review summarizes recent studies (2021-2023) using interviews with individuals abusing androgens.

RECENT FINDINGS

Motivations for androgen abuse in men include desires to achieve certain physicality, enhance self-confidence and improve libido. The risks of androgen abuse are justified to achieve these outcomes and men may use other illicit substances as postcycle-therapy to lessen the risks. Some adverse effects may be more pronounced with certain substances. The therapeutic relationship with healthcare professionals is often described negatively by androgen abusers due to stigma and a perceived lack of knowledge. Both healthcare professionals and androgen abusers agree that development of guidelines are needed. Androgen abuse in women is rare however body dissatisfaction and desires for improve appearance and strength are motivators.

SUMMARY

Recent qualitative studies have helped further our understanding of men and women who abuse androgens, however the small number of recently published studies confirms there is still a paucity of evidence in the literature. Further research is needed to develop specific harm minimization strategies in those abusing androgens.

The use of post-cycle therapy is associated with reduced withdrawal symptoms from anabolic-androgenic steroid use: a survey of 470 men

BACKGROUND

Anabolic-androgenic steroids (AAS) mimic the effects of testosterone and may include testosterone itself; they are used for body enhancement within the general population. AAS use has been linked with increased mortality, cardiovascular disease, mental health disorders, and infertility. AAS-induced hypogonadism can persist for an uncertain time period despite cessation, during which men may report physical and neuropsychiatric symptoms. In an attempt to mitigate these symptoms and expedite testicular recovery, many men self-administer post-cycle-therapy (PCT), typically involving human chorionic gonadotrophin (hCG) and selective oestrogen receptor modulators (SERMs), which are known to potently stimulate testicular function. However, this practice has no objective evidence of effectiveness to lessen the severity or duration of hypogonadal symptoms.

METHODS

An anonymous survey of four-hundred-and-seventy men using AAS explored the symptoms they experienced when ceasing AAS use; the effect of PCT on relieving their symptoms, and their perceived role for health service support.

RESULTS

The majority of respondents were white, aged 18-30 years old, and working in skilled manual work. 51.7% (n = 243) reported no issues with AAS use, but 35.3% reported increased aggression. 65.1% (n = 306) of respondents had attempted AAS cessation and 95.1% of these experienced at least one symptom upon AAS cessation. Low mood, tiredness and reduced libido were reported in 72.9%, 58.5% and 57.0% of men stopping AAS use, respectively, with only 4.9% reporting no symptoms. PCT had been used by 56.5% of respondents with AAS cessation and mitigated cravings to restart AAS use, withdrawal symptoms and suicidal thoughts by 60%, 60% and 50%, respectively. The effect of stopping AAS on body composition and recovery of testosterone or fertility was a concern in 60.5% and 52.4%, respectively. Most respondents felt PCT should be prescribed under medical supervision in the community.

CONCLUSIONS

Our survey suggests that the majority of men stopping AAS use are using some form of PCT. Some self-reported symptoms of AAS-induced hypogonadism such as cravings to restart AAS use reduce by 60% and suicidal thoughts reduce by 50%. These individuals are concerned about the negative effect of AAS use and cessation. This study provides crucial information for planning future research to evaluate the effects of PCT on symptoms when men stop AAS use.

The awareness and experience of healthcare providers with the use of anabolic androgenic steroids by gym users

OBJECTIVES

This study aims to evaluate healthcare providers' awareness and experience with anabolic androgenic steroid (AAS) use among gym users in Jordan and their role in mitigating AAS misuse.

METHODS

A cross-sectional study was conducted between November 2022 and Feb 2023. During the study period, 158 physicians involved in prescribing AAS or treating adverse effects associated with these agents were invited to participate. A questionnaire was created and uploaded on Google Forms and distributed through social media platforms to reach physicians from different medical subspecialties.

RESULTS

Of the 158 physicians surveyed, 30.4% were general practitioners, and 63.3% reported having formal education about the risks of bodybuilding with AAS. Among the participants, 48.7% had encountered gym users who were using AAS, with the main reason for referral being the management of side effects associated with AAS use. The median knowledge score regarding AAS and their complications was 10.0 out of 14 (IQR = 7.0), indicating adequate knowledge about most AAS side effects. Around 46% of the physicians (n = 73, 46.2%) believed that gym users might struggle to disclose AAS because they lack trust in them. Finally, the most common advice to gym users was informing them about the health-associated consequences of AAS use, with 92.2% of physicians providing this advice.

CONCLUSION

Although healthcare professionals in Jordan had adequate knowledge about AAS, they needed more to make them confident in dealing with AAS use. This highlights the necessity for specialized teaching and training programs to enhance their knowledge and skills in providing accurate information to AAS users.

Evidence of use and users of image- and performance-enhancing drugs in sports in Switzerland: a scoping literature review and implications for Swiss drug policy

BACKGROUND

"Image- and performance-enhancing drugs" are widely used in sports worldwide to improve body image and performance goals. In view of the growing research interest and use of these substances, and the paucity of data on the situation in Switzerland, we conducted a scoping literature review on evidence of the use and users of these substances in Switzerland.

METHODS

A scoping review was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) statement. We searched PubMed/Medline, Embase and Google Scholar for articles published before August 2022. Primary outcomes were evidence of the use and users of image- and performance enhancing drugs in Switzerland. We used a narrative synthesis approach for data analysis.

RESULTS

Overall, 18 studies were reviewed, which in total comprised 11,401 survey participants, 140 interviews and 1368 toxicologically analysed substances. Articles were mostly peer-reviewed (83%) and mostly included evidence from professional athletes (43%). The mean publication year was 2011. In most articles both outcomes (78%) were evaluated simultaneously. We demonstrate that image- and performance-enhancing drugs appear to be prevalent among athletes and non-athletes in Switzerland. A wide variety of substances exist, and the type of substances used varied by age, motivation, sex and sports discipline. The main motivations for using these substances were, among others, image- and performance enhancement. The main route of acquisition of these substances was the Internet. Furthermore, we demonstrated that substantial proportions of these substances, as well as supplements, may be counterfeit. Information on image- and performance-enhancing drug use was acquired from different sources.

CONCLUSIONS

Although evidence of image- and performance-enhancing drug use and its users in Switzerland is scarce and there are major gaps, we demonstrate that these substances are also prevalent among athletes and non-athletes in Switzerland. Furthermore, high proportions of substances acquired from unregulated drug markets are counterfeit, which puts users in a situation of unpredictable risk when consuming them. Overall, the use of these substances may pose a substantial risk to individual and public health in this possibly growing and often insufficiently informed and medically neglected user community in Switzerland. There is a great need for future research, as well as prevention, harm-reduction and treatment programmes for this hard-to-reach user community. Doping policies in Switzerland should be critically reviewed as simple medical care and evidence-based treatment for non-athlete image- and performance-enhancing drug users is excessively criminalized under the current legislature, leaving possibly over 200,000 image- and performance-enhancing drug users in Switzerland with inadequate medical care.

Female doping: observations from a data lake study in the Hospital District of Helsinki and Uusimaa, Finland

BACKGROUND

Doping is a well-recognized risk factor for several potentially severe health effects. Scientific literature concerning the need for medical treatment for such adversities is still sparse. This is especially true for women, due to lower doping use prevalence compared to men. Our study explored the nature of medical contacts and deviance in red blood cell parameters of female patients with doping use in Finnish specialized health care.

METHODS

This was a retrospective register study. The study sample was gathered from the Hospital District of Helsinki and Uusimaa, Finland (HUS) Datalake. An exhaustive search for doping related terms was performed to find patients with doping use documentation within free-text patient records. Medical record data was supplemented with laboratory data and medical diagnoses covering a total observation time of two decades. Statistical analysis included Fisher's Exact Test and one-way ANOVA.

RESULTS

We found 39 female patients with history of doping use and specialized health care contacts in the HUS-area between 2002-2020. At initial contact (i.e., the first documentation of doping use), the mean age of these patients was 33.6 years (min 18.1, max 63.5, SD 10.6). The most frequently used doping agents were anabolic androgenic steroids (AAS). The initial contacts were significantly more often acute in nature among patients with active doping use than among patients with only previous use (no use within one year; p = 0.002). Psychiatric and substance use disorder (SUD) morbidity was high (46.2% and 30.8%, respectively). Eight patients (20.5%) had received specialized health care for acute poisoning with alcohol or drugs, and nine (23.1%) for bacterial skin infections. Less than 45% of patients with active AAS use presented with off-range red blood cell parameters.

CONCLUSIONS

Our findings suggest that female patients with a history of doping use encountered in specialized health care may exhibit high psychiatric and SUD related morbidity. Also, majority of patients with AAS use had red blood cell parameters within-range. Further studies are required to assess the generalizability of these findings to patients within primary health care services, and to determine the usefulness of hematological parameters as indicators of AAS use in female patients.

Health service engagement, side effects and concerns among men with anabolic-androgenic steroid use: a cross-sectional Norwegian study

BACKGROUND

Recreational use of anabolic-androgenic steroids (AAS) is a public health concern world-wide associated with a range of physical and psychological side effects. Still, people who use AAS tend to be reluctant to seek treatment. This study aims to explore use characteristics, treatment-seeking behaviour, side effects and associated health concerns among men with AAS use.

METHODS

The study includes cross-sectional self-report data from 90 men with a current or previous use of AAS exceeding 12 months, where 41 (45.6%) had sought treatment at least once during their lifetime, and 49 (54.4%) had not. Health service engagement was examined with descriptive statistics on reasons for contacting health services, transparency about AAS use, satisfaction with health services and reasons for not seeking treatment. Furthermore, experienced side effects and health concerns were compared between the treatment seeking and the non-treatment seeking group, using two-sample t-tests and Chi² or Fisher exact tests for numerical and categorical variables, respectively.

RESULTS

All 90 AAS-using men reported side effects from AAS use. Treatment seekers were significantly younger, experienced more side effects including gynecomastia, excessive sweating, fatigue, depression and anxiety, and expressed more concern for testosterone deficiency. Preventive health check-up was the most common reason for seeking treatment (n = 22, 53.7%), and 38 men (93%) were transparent about AAS use during consultations with health professionals. The main reported reasons for not seeking healthcare services were that the experienced side effects were not considered to be of treatment demanding nature (n = 39, 79.6%) and the belief that healthcare providers had scarce knowledge about AAS use and its health impacts (n = 12, 24.5%).

CONCLUSIONS

Reluctance to seek treatment among people who use AAS, despite having associated side effects and health concerns, may contribute to continued health risks. It is important to fill the knowledge gap on how to reach and treat this new patient group, and policy makers and treatment providers need to be educated on how to meet their treatment needs.