Hepatic tumours induced by anabolic steroids in an athlete

Androgen-Induced, β-Catenin-Activated Hepatocellular Adenomatosis with Spontaneous External Rupture

Androgens have long been recognized as oncogenic agents. They can induce both benign and malignant hepatocellular neoplasms, including hepatocellular adenoma (HCA) and hepatocellular carcinoma, though the underlying mechanisms remain unclear. Androgen-induced liver tumors are most often solitary and clinically silent. Herein, we reported an androgen-induced HCA complicated by spontaneous rupture. The patient was a 24-year-old male presenting with fatigue, diminished libido, radiology-diagnosed hepatocellular adenomatosis for 3 years, and sudden-onset, severe, sharp, constant abdominal pain for one day. He used Aveed (testosterone undecanoate injection) from age 17 and completely stopped one year before his presentation. A physical exam showed touch pain and voluntary guarding in the right upper quadrant of the abdomen. An abdominal CT angiogram demonstrated multiple probable HCAs, with active hemorrhage of the largest one (6.6 × 6.2 × 5.1 cm) accompanied by large-volume hemoperitoneum. After being stabilized by a massive transfusion protocol and interventional embolization, he underwent a percutaneous liver core biopsy. The biopsy specimen displayed atypical hepatocytes forming dense cords and pseudoglands. The lesional cells diffusely stained β-catenin in nuclei and glutamine synthetase in cytoplasm. Compared to normal hepatocytes from control tissue, the tumor cells were positive for nuclear AR (androgen receptor) expression but had no increased EZH2 (Enhancer of Zeste 2 Polycomb Repressive Complex 2 Subunit) protein expression. The case indicated that androgen-induced hepatocellular neoplasms should be included in the differential diagnosis of acute abdomen.

Role of sex in liver tumor occurrence and clinical outcomes: A comprehensive review

Clinical research on sex-based differences in the manifestations, pathophysiology, and prevalence of several diseases, including those affecting the liver, has expanded considerably in recent years. Increasing evidence suggests that liver diseases develop, progress, and respond to treatment differently depending on the sex. These observations support the concept that the liver is a sexually dimorphic organ in which estrogen and androgen receptors are present, which results in disparities between men and women in liver gene expression patterns, immune responses, and the progression of liver damage, including the propensity to develop liver malignancies. Sex hormones play protective or deleterious roles depending on the patient's sex, the severity of the underlying disease, and the nature of precipitating factors. Moreover, obesity, alcohol consumption, and active smoking, as well as social determinants of liver diseases leading to sex-related inequalities, may interact strongly with hormone-related mechanisms of liver damage. Drug-induced liver injury, viral hepatitis, and metabolic liver diseases are influenced by the status of sex hormones. Available data on the roles of sex hormones and gender differences in liver tumor occurrence and clinical outcomes are conflicting. Here, we critically review the main gender-based differences in the molecular mechanisms associated with liver carcinogenesis and the prevalence, prognosis, and treatment of primary and metastatic liver tumors.

Inflammatory Hepatocellular Adenoma Mimicking Focal Nodular Hyperplasia That Grew during Pregnancy and Changed Its Appearance on Magnetic Resonance Imaging after Delivery

We reported a notable case of inflammatory hepatocellular adenoma that grew during pregnancy, consequently changing its appearance on magnetic resonance imaging remarkably. A 5-months-pregnant 35-year-old woman presented with a 37-mm liver nodule that had been diagnosed as focal nodular hyperplasia 3 years earlier. She had never used oral contraceptives. After 2 months, the nodule grew to 57 mm. The patient delivered a full-term infant without complications. Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging performed after delivery revealed markedly different findings compared with the first images. A liver biopsy was performed, and the tumor was diagnosed as inflammatory hepatocellular adenoma.

Transgender Males on Gender-Affirming Hormone Therapy and Hepatobiliary Neoplasms: A Systematic Review

OBJECTIVE

Behavioral therapy, gender-affirming hormone therapy (GAHT), and surgery are all components of a successful gender transition, but due to a historical lack of access, there is paucity of long-term data in this population. We sought to better characterize the risk of hepatobiliary neoplasms in transgender males undergoing GAHT with testosterone.

METHODS

In addition to the 2 case reports, a systematic literature review of hepatobiliary neoplasms in the setting of testosterone administration or endogenous overproduction across indications was conducted. The medical librarian created search strategies using keywords and controlled vocabulary in Ovid Medline, Embase.com, Scopus, Cochrane Database of Systematic Reviews, and clinicaltrials.gov. A total of 1273 unique citations were included in the project library. All unique abstracts were reviewed, and abstracts were selected for complete review. Inclusion criteria were articles reporting cases of hepatobiliary neoplasm development in patients with exogenous testosterone administration or endogenous overproduction. Non-English language articles were excluded. Cases were collated into tables based on indication.

RESULTS

Forty-nine papers had cases of hepatocellular adenoma, hepatocellular carcinoma, cholangiocarcinoma, or other biliary neoplasm in the setting of testosterone administration or endogenous overproduction. These 49 papers yielded 62 unique cases.

CONCLUSION

Results of this review are not sufficient to conclude that there is an association between GAHT and hepatobiliary neoplasms. This supports current evaluation and screening guidelines for initiation and continuation of GAHT in transgender men. The heterogeneity of testosterone formulations limits the translation of risks of hepatobiliary neoplasms in other indications to GAHT.

Hepatocellular adenoma in men: A nationwide assessment of pathology and correlation with clinical course

BACKGROUND & AIMS

Hepatocellular adenomas (HCA) rarely occur in males, and if so, are frequently associated with malignant transformation. Guidelines are based on small numbers of patients and advise resection of HCA in male patients, irrespective of size or subtype. This nationwide retrospective cohort study is the largest series of HCA in men correlating (immuno)histopathological and molecular findings with the clinical course.

METHODS

Dutch male patients with available histological slides with a (differential) diagnosis of HCA between 2000 and 2017 were identified through the Dutch Pathology Registry (PALGA). Histopathology and immunohistochemistry according to international guidelines were revised by two expert hepatopathologists. Next generation sequencing (NGS) was performed to confirm hepatocellular carcinoma (HCC) and/or subtype HCA. Final pathological diagnosis was correlated with recurrence, metastasis and death.

RESULTS

A total of 66 patients from 26 centres fulfilling the inclusion criteria with a mean (±SD) age of 45.0 ± 21.6 years were included. The diagnosis was changed after expert revision and NGS in 33 of the 66 patients (50%). After a median follow-up of 9.6 years, tumour-related mortality of patients with accessible clinical data was 1/18 (5.6%) in HCA, 5/14 (35.7%) in uncertain HCA/HCC and 4/9 (44.4%) in the HCC groups (P = .031). Four B-catenin mutated HCA were identified using NGS, which were not yet identified by immunohistochemistry and expert revision.

CONCLUSIONS

Expert revision with relevant immunohistochemistry may help the challenging but prognostically relevant distinction between HCA and well-differentiated HCC in male patients. NGS may be more important to subtype HCA than indicated in present guidelines.

Anabolic-Androgenic Steroid Use in the Eastern Mediterranean Region: a Scoping Review of Extant Empirical Literature

The use of image- and performance-enhancing drugs particularly anabolic-androgenic steroids (AAS) is not a new phenomenon. AAS use is not limited to athletes, with mainstream populations using these drugs for aesthetic purposes. Prevalence has been predominantly in Western countries, with some recent studies indicating a rise in popularity in the Eastern Mediterranean region. A scoping review of extant empirical literature from the Eastern Mediterranean region described and mapped what is known about the extent of AAS in the region. Four themes emerged from the review: (1) profile of AAS users; (2) AAS within gymnasium practice; (3) AAS regimes of use; and (4) knowledge and understanding of the AAS concept and related adverse effects. The review highlights a relatively new phenomenon of AAS use in the Eastern Mediterranean. The review underscores the need to carry out further research, particularly qualitative and quantitative studies with both genders, and cognisant of the complexities of culture and religiosity.

The Relationship Between the Big Five Personality Traits, Impulsivity, and Anabolic Steroid Use

BACKGROUND

The increase in the prevalence of anabolic-androgenic steroids (AAS) use has been the subject of study in the last decades. Several studies indicated a strong association between the use of AAS and the performance of risky behaviors mediated by factors such as aggression, impulsivity, depression, and anxiety.

OBJECTIVE

This study aimed to identify differences in personality trait, impulsivity, and the ability to delay gratification between AAS users and non-users that predispose or serve as a buffering mechanism against its usage and whether it is related to an increased likelihood of engaging in infidelity.

METHODS

Two hundred and twelve male volunteers (88 AAS users), aged between 21 and 36 years (M = 28.22), completed self-report measures of personality, impulsivity, delayed gratification, and attitudes toward infidelity. Multivariate analysis of variance and logistic regression were conducted to establish differences between AAS users and non-users.

RESULTS

The results showed that AAS users displayed an inability to delay gratification, a greater impulsivity, and a more benevolent attitude toward infidelity. AAS users obtained higher scores on openness and neuroticism, which was larger "off-cycle," although they presented lower scores on extraversion compared to the non-users group. Regression analysis revealed that neuroticism, impulsivity, and delaying gratification scores were significant predictors of AAS usage. In addition, impulsivity functioned as a partial mediator in the relationship between neuroticism and AAS use.

CONCLUSION

The results of this research highlight a pivotal implication of impulsivity in AAS use in conjunction with neuroticism, openness, and extraversion traits.

Hepatocellular adenoma in a woman who was undergoing testosterone treatment for gender identity disorder

A 32-year-old Japanese woman was admitted to our hospital for the diagnosis and treatment of multiple liver tumors. She had been receiving 125 mg testosterone enanthate every 2 weeks following female-to-male gender identity disorder (GID) diagnosis at 20 years of age. Ultrasonography, computed tomography, and magnetic resonance imaging showed 11 hepatic nodular tumors with a maximum diameter of 28 mm. Liver tumors with hepatocellular adenoma (HCA) were diagnosed with needle biopsy. Segmentectomy of the left lateral lobe including two lesions, subsegmentectomy of S6 including two lesions, enucleation of each tumor in S5 and S7, and open surgical radiofrequency ablation for each tumor in S4 and S7 were performed. Immunohistochemical specimens showed that the tumor cells were diffusely and strongly positive for glutamine synthetase and that the nuclei were ectopically positive for β-catenin. Thus, the tumors were diagnosed as β-catenin-activated HCA (b-HCA). Transcatheter arterial chemoembolization plus subsequent radiofrequency ablation was performed for the 3 residual lesions in S4 and S8. Although testosterone enanthate was being continued for GID, no recurrence was observed until at least 22 months after the intensive treatments. HCA development in such patients receiving testosterone should be closely monitored using image inspection.

Doping and Urologic Tumors

Several substances such as growth hormone (GH), erythropoietin (Epo), and anabolic steroids (AS) are improperly utilized to increase the performance of athletes. Evaluating the potential cancer risk associated with doping agents is difficult since these drugs are often used at very high doses and in combination with other licit or illicit drugs.

The GH, via its mediator, the insulin-like growth factor 1 (IGF-1), is involved in the development and progression of cancer. Animal studies suggested that high levels of GH/IGF-1 increase progression of androgen-independent prostate cancer. Clinical data regarding prostate cancer are mostly based on epidemiological studies or indirect data such as IGF-1 high levels in patients with prostate cancer. Even if experimental studies showed a correlation between Epo and cancer, no clinical data are currently available on cancer development related to Epo as a doping agent. Androgens are involved in prostate carcinogenesis modulating genes that regulate cell proliferation, apoptosis and angiogenesis. Most information on AS is anecdotal (case reports on prostate, kidney and testicular cancers). Prospective epidemiologic studies failed to support the hypothesis that circulating androgens are positively associated with prostate cancer risk.

Currently, clinical and epidemiological studies supporting association between doping and urological neoplasias are not available. Nowadays, exposure to doping agents starts more prematurely with a consequent longer exposition period; drugs are often used at very high doses and in combination with other licit or illicit drugs. Due to all these elements it is impossible to predict all the side effects, including cancer; more detailed studies are therefore necessary.

An FT-Raman, FT-IR, and Quantum Chemical Investigation of Stanozolol and Oxandrolone

We have studied the Fourier Transform Infrared (FT-IR) and the Fourier transform Raman (FT-Raman) spectra of stanozolol and oxandrolone, and we have performed quantum chemical calculations based on the density functional theory (DFT) with a B3LYP/6-31G (d, p) level of theory. The FT-IR and FT-Raman spectra were collected in a solid phase. The consistency between the calculated and experimental FT-IR and FT-Raman data indicates that the B3LYP/6-31G (d, p) can generate reliable geometry and related properties of the title compounds. Selected experimental bands were assigned and characterized on the basis of the scaled theoretical wavenumbers by their total energy distribution. The good agreement between the experimental and theoretical spectra allowed positive assignment of the observed vibrational absorption bands. Finally, the calculation results were applied to simulate the Raman and IR spectra of the title compounds, which show agreement with the observed spectra.

Malignant transformation of hepatocellular adenomas into hepatocellular carcinomas: a systematic review including more than 1600 adenoma cases

BACKGROUND

Malignant transformation of hepatocellular adenomas (HCAs) into hepatocellular carcinomas (HCCs) has been reported repeatedly and is considered to be one of the main reasons for surgical treatment. However, its actual risk is currently unknown.

OBJECTIVE

To provide an estimation of the frequency of malignant transformation of HCAs and to discuss its clinical implications.

METHODS

A systematic literature search was conducted using the following databases: The Cochrane Hepatobiliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, MEDLINE and EMBASE.

RESULTS

One hundred and fifty-seven relevant series and 17 case reports (a total of 1635 HCAs) were retrieved, reporting an overall frequency of malignant transformation of 4.2%. Only three cases (4.4%) of malignant alteration were reported in a tumour smaller than 5 cm in diameter.

DISCUSSION

Malignant transformation of HCAs into HCCs remains a rare phenomenon with a reported frequency of 4.2%. A better selection of exactly those patients presenting with an HCA with an amplified risk of malignant degeneration is advocated in order to reduce the number of liver resections and thus reducing the operative risk for these predominantly young patients. The Bordeaux adenoma tumour markers are a promising method of identifying these high-risk adenomas.

Management of an incidental liver mass

The increased use of sensitive imaging modalities has led to increased identification of the incidental liver mass (ILM). A combination of careful consideration of patient factors and imaging characteristics of the ILM enables clinicians to recommend a safe and efficient course of action. Using an algorithmic approach, this article includes pertinent clinical factors and the specific radiologic criteria of ILMs and discusses the indications for potential procedures. It is the aim of this article to assist with the development of an individualized strategy for each patient with an ILM.

Adverse health effects of anabolic-androgenic steroids

Anabolic-androgenic steroids (AAS) are synthetic drugs derived from testosterone. Illegally, these drugs are regularly self-administered by body builders and power lifters to enhance their sportive performance. Adverse side effects of AAS include sexual dysfunction, alterations of the cardiovascular system, psyche and behavior, and liver toxicity. However, severe side effects appear only following prolonged use of AAS at high dose and their occurrence is limited. Occasionally, AAS abuse may be linked to certain social and psychological traits of the user, like low self-esteem, low self-confidence, suffered hostility, childhood conduct disorder, and tendency to high-risk behavior. The overwhelming stereotype about AAS is that these compounds cause aggressive behavior in males. However, the underlying personality traits of a specific subgroup of the AAS abusers, who show aggression and hostility, may be relevant, as well. Use of AAS in combination with alcohol largely increases the risk of violence and aggression. The dependence liability of AAS is very low, and withdrawal effects are relatively mild. Based on the scores for acute and chronic adverse health effects, the prevalence of use, social harm and criminality, AAS were ranked among 19 illicit drugs as a group of drugs with a relatively low harm.

The effect of long-term danazol prophylaxis on liver function in hereditary angioedema-a longitudinal study

BACKGROUND

Danazol is a drug most widely used for the prophylaxis of hereditary angioedema resulting from the deficiency of the C1-inhibitor. Potential hepatotoxic or liver tumor-inducing side effects of long-term danazol prophylaxis have been investigated during the follow-up of hereditary angioedema patients.

METHODS

Characteristic parameters of liver function (including bilirubin, GOT, GPT, gammaGT, total protein, ALP, LDH), as well as findings of viral serology screens and abdominal ultrasonography-determined during years 0 and 5 of follow-up of patient groups taking/not taking danazol-have been reviewed and analyzed comparatively.

RESULTS

From a population of 126 hereditary angioedema patients, 46 subjects taking danazol and another 46 not taking danazol fulfilled the inclusion criteria. Longitudinal follow-up did not reveal any clinically relevant difference between the liver function parameters determined in years 0 and 5 in the two groups. Abdominal ultrasound did not detect neoplastic or other potentially treatment-related alterations of the liver parenchyma. There were no discontinuations of treatment during the study.

CONCLUSIONS

Our results clearly suggest that, administered at the lowest effective dose, danazol does not induce liver injury in hereditary angioedema patients.

[Liver and sport]

The liver is a vital organ and plays a central role in energy exchange, protein synthesis as well as the elimination of waste products from the body. Acute and chronic injury may disturb a variety of liver functions to different degrees. Over the last three decades, the effects of physical activity and competitive sport on the liver have been described by various investigators. These include viral hepatitis and drug-induced liver disorders. Herein, we review acute and chronic liver diseases potentially caused by sport. Team physicians, trainers and others, responsible for the health of athletes, should be familiar with the risk factors, clinical features, and consequences of liver diseases that occur in sports.

Anabolic-androgenic steroid dependence? Insights from animals and humans

Anabolic-androgenic steroids (AAS) are drugs of abuse. They are taken in large quantities by athletes and others to increase performance, with negative health consequences. As a result, in 1991 testosterone and related AAS were declared controlled substances. However, the relative abuse and dependence liability of AAS have not been fully characterized. In humans, it is difficult to separate the direct psychoactive effects of AAS from reinforcement due to their systemic anabolic effects. However, using conditioned place preference and self-administration, studies in animals have demonstrated that AAS are reinforcing in a context where athletic performance is irrelevant. Furthermore, AAS share brain sites of action and neurotransmitter systems in common with other drugs of abuse. In particular, recent evidence links AAS with opioids. In humans, AAS abuse is associated with prescription opioid use. In animals, AAS overdose produces symptoms resembling opioid overdose, and AAS modify the activity of the endogenous opioid system.

Sports and trauma in amyotrophic lateral sclerosis revisited

An evidence-based review was undertaken of the literature published between 2002 and 2006 about sports, trauma and ALS in order to see if there were new data to modify the conclusions of a previous review (2003). The new data support the previous conclusions that physical activity and trauma are probably ("more likely than not") not risk factors for ALS (Level II conclusions). This review concludes also that the reports of an apparent excess of ALS in Italian soccer players likely reflect incorrect analysis of the data. The appearance of excess relies on accepting as valid estimation methods resulting in improbably low numbers of expected cases. A different method is proposed: it generates more plausible numbers of expected cases, compared to which there is no excess of total cases (Level C conclusion). A theoretical framework is developed to analyze the possible influence of a "healthy worker effect" on incidence of neurodegenerative diseases in cohorts of employed or formerly employed individuals. In lieu of theoretical speculations, data are needed to measure this effect, while controlling for known lifestyle factors and accounting for the effect of loss of competing causes of mortality.

Near-fatal spontaneous hepatic rupture associated with anabolic androgenic steroid use: a case report

Anabolic androgenic steroids are commonly used at high doses by bodybuilders and athletes to enhance physique and improve performance levels. We report a case of spontaneous hepatic rupture with life-threatening haemorrhage associated with a past history of anabolic steroid use.

Liver cell adenoma: A case report with clonal analysis and literature review

We report a case of liver cell adenoma (LCA) in a 33-year-old female patient with special respect to its clonality status, pathogenic factors and differential diagnosis. The case was examined by histopathology, immunohistochemistry and a clonality assay based on X-chromosomal inactivation mosaicism in female somatic tissues and polymorphism at androgen receptor focus. The clinicopathological features of the reported cases from China and other countries were compared. The lesion was spherical, sizing 2 cm in its maximal dimension. Histologically, it was composed of cells arranged in cords, most of which were two-cell-thick and separated by sinusoids. Focal fatty change and excessive glycogen storage were observed. The tumor cells were round or polygonal in shape, resembling the surrounding parenchymal cells. Mitosis was not found. No portal tract, central vein or ductule was found within the lesion. The tumor tissue showed a positive reaction for cytokeratin (CK) 18, but not for CK19, vimentin, estrogen and progesterone receptors. Monoclonality was demonstrated for the lesion, confirming the diagnosis of an LCA. Clonality analysis is helpful for its distinction from focal nodular hyperplasia.

Hepatocellular neoplasms after intrahepatic transplantation of ovarian fragments into ovariectomized rats

Intrahepatic transplantation of ovarian fragments in ovariectomized rats results in morphological abnormalities. The liver acini draining blood from ovarian grafts show alterations resembling chemically induced amphophilic hepatocellular preneoplasias. We investigated the long-term development of these estrogen-induced foci of altered hepatocytes (FAH). We divided 451 Lewis rats into one main group (MG) and 11 (7 female, 4 male) control groups and observed them for up to 30 months. MG animals were ovariectomized and received ovarian transplants into the right liver part. Different combinations of castration, transplantation of ovarian or testicular fragments, and administration of antiestrogenic toremifene were used in controls. In the MG, transplants showed signs of gonadotropic stimulation, and estrogen levels were strongly increased in the downstream liver acini. After 6 and 12 months, FAH developed in hepatocytes downstream of the transplants. After 18 months, 27% of the MG animals showed transformation of FAH into hepatocellular adenomas; this figure increased to 42% after 24 months (8/19), significantly outnumbering four spontaneous adenomas that developed between 18 and 30 months in 258 control animals. Hepatocellular carcinoma (HCC) appeared only in the MG. At 24 and 30 months, 18 HCCs developed; thus, 78% of MG animals showed at least one carcinoma. Administration of toremifene in ovariectomized and transplanted animals completely prevented hepatocarcinogenesis. Testicular grafts showed no influence on liver tissue. In conclusion, initially adaptive but preneoplastic alterations in hepatocytes downstream of intrahepatically transplanted ovarian fragments may transform into HCC, indicating a strong hepatocarcinogenic potential of high local levels of endogenous estrogens in the rat liver.

Psychiatry in orthodontics. Part 2: Substance abuse among adolescents and its relevance to orthodontic practice

Substance abuse by adolescents is a serious problem that will touch every orthodontic practice. Recent data show that 40% of tenth graders in the United States will use an illicit drug at some time, and 18% will do so in a 30-day period. These are significant figures that should impact orthodontic diagnosis and treatment planning. The nature of orthodontic treatment is unique in that the orthodontist will see relatively healthy adolescent patients on a monthly basis over a period of years. The orthodontist is in a prime position to recognize potential substance abuse problems and make referrals. This article discusses various types of substance abuse, diagnosis, options for referral, and orthodontic implications.

Sporadic amyotrophic lateral sclerosis as an infectious disease: A possible role of cyanobacteria?

The available epidemiological data for amyotrophic lateral sclerosis (ALS) support an infectious etiology and lead us to propose a new hypothesis. We examined older epidemiological data concerning categories of the population with increased incidence (aged people, people living in rural areas, farmers, breeders), more recent epidemiological reports regarding Italian soccer players, AIDS patients, people living in highly polluted areas, and reports of cases of conjugal and pregnancy-associated ALS. The toxic and infectious hypotheses lead us to suggest a role for cyanobacteria in the production of endogenous beta-N-methylamino-L-alanine. Infection from a cyanobacterium, or another ubiquitous bacterium having similar characteristics, may be the missing clue to the etiology of ALS. We speculate that ubiquitous bacteria secreting toxic amino acids and "colonizing" tissues and organs in the human body might be the common element linking motor neuron diseases in Guam to sporadic ALS in the rest of the world.

Proportionate mortality of Italian soccer players: is amyotrophic lateral sclerosis an occupational disease?

OBJECTIVES

The objective of the study is to investigate the mortality experience of Italian soccer players and to discuss the findings in the light of possible long term effects of doping.

METHODS

Standardized proportionate mortality ratio (SPMR) and standardized proportionate cancer mortality ratio (SPCMR) were computed for 350 deceased subjects deriving from a list of about 24,000 active Italian soccer players from 1960 to 1996 in the three top leagues (A, B and C).

RESULTS

When considering SPMRs, there is a substantial adherence of observed to expected mortality, with the only exception of mortality for diseases of the nervous system (13 obs. vs. 6 exp.) mainly explained by an excess of amyotrophic lateral sclerosis (8 obs. vs 0.69 exp.). As far as SPCMRs are concerned, some digestive cancers (namely: colon cancer, liver cancer and pancreas cancer) show a doubled risk.

CONCLUSIONS

A high risk for amyotrophic lateral sclerosis is observed among Italian soccer players. Epidemiological data on association between sport and Amyotrophic Lateral Sclerosis (ALS) are contrasting. On the basis of the overall available evidence we suggest a possible connection between dietary supplements or drugs used to enhance sporting performance and ALS pathogenesis. Further epidemiological studies are needed to confirm these specific mortality risks among soccer players.

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.

Hepatocellular adenomas in men: MRI findings in four patients

PURPOSE

To demonstrate both MRI and histopathological findings of hepatocellular adenomas (HCAs) in men.

MATERIALS AND METHODS

HCAs in four men are reported. All patients underwent MR studies at 1.5T including serial gadolinium-enhanced gradient echo imaging.

RESULTS

Three men had solitary non-hemorrhagic adenomas that exhibited a uniform capillary blush with no central scar, and uniform fading of the tumor to near isointensity with the liver parenchyma by one minute. One of the subjects had uniform fat content as shown by uniform low signal on out-of-phase images. One patient had a solitary hemorrhagic adenoma that measured 17 cm in diameter and was heterogeneous on all sequences. Two of the four patients had a history of anabolic steroid use, and in the other two patients no underlying explanation for the tumor was found.

CONCLUSIONS

Although three of the four patients had tumors that exhibited uniform homogeneous tumor blush and rapid fading of enhancement, because HCAs are rare in men and resemble hepatocellular carcinoma (HCC) in appearance, our findings suggest that histological confirmation of HCAs may not be avoidable in men.

Reinforcing aspects of androgens

Are androgens reinforcing? Androgenic-anabolic steroids (AAS) are drugs of abuse. They are taken in large quantities by athletes and others to increase performance, often with negative long-term health consequences. As a result, in 1991, testosterone was declared a controlled substance. Recently, Brower [K.J. Brower, Anabolic steroid abuse and dependence. Curr. Psychiatry Rep. 4 (2002) 377-387.] proposed a two-stage model of AAS dependence. Users initiate steroid use for their anabolic effects on muscle growth. With continued exposure, dependence on the psychoactive effects of AAS develops. However, it is difficult in humans to separate direct psychoactive effects of AAS from the user's psychological dependence on the anabolic effects of AAS. Thus, studies in laboratory animals are useful to explore androgen reinforcement. Testosterone induces a conditioned place preference in rats and mice, and is voluntarily consumed through oral, intravenous, and intracerebroventricular self-administration in hamsters. Active, gonad-intact male and female hamsters will deliver 1 microg/microl testosterone into the lateral ventricles. Indeed, some individuals self-administer testosterone intracerebroventricularly to the point of death. Male rats develop a conditioned place preference to testosterone injections into the nucleus accumbens, an effect blocked by dopamine receptor antagonists. These data suggest that androgen reinforcement is mediated by the brain. Moreover, testosterone appears to act through the mesolimbic dopamine system, a common substrate for drugs of abuse. Nonetheless, androgen reinforcement is not comparable to that of cocaine or heroin. Instead, testosterone resembles other mild reinforcers, such as caffeine, nicotine, or benzodiazepines. The potential for androgen addiction remains to be determined.

Androgens and liver tumors: Fanconi's anemia and non-Fanconi's conditions

The association between anabolic androgenic steroids and liver tumors was first noted in patients with Fanconi's anemia (FA). The hypotheses which led to this review were as follows: (1) androgen-treated individuals who do not have FA are also at risk of liver tumors; (2) parenteral as well as oral androgens may be responsible for liver tumors; (3) FA patients develop liver tumors after smaller and briefer androgen exposure than non-FA individuals; (4) the risk of hepatic neoplasms may depend on the specific androgen. Medline and Web of Science were searched for all cases of liver tumors associated with androgens. Information from individual cases was entered into a spreadsheet and descriptive statistical analyses were performed. Thirty-six FA cases and 97 non-FA cases with both nonhematologic disorders and acquired aplastic anemia (non-FA AA) were identified. The most common androgens were oxymetholone, methyltestosterone, and danazol. Hepatocellular carcinomas (HCC) were more often associated with oxymetholone and methyltestosterone, while adenomas were associated with danazol. Tumors were reported in six patients who received only parenteral and not oral androgens. FA patients were younger than non-FA patients when androgen use was initiated, and the FA patients developed tumors at younger ages. Non-AA patients were treated with androgens for longer periods of time, compared with FA and non-FA AA patients. All patients on anabolic androgenic steroids are at risk of liver tumors, regardless of underlying diagnosis. The magnitude of the risk cannot be determined from currently available data, because the number of patients receiving androgens is unknown.

The anabolic androgenic steroid oxandrolone in the treatment of wasting and catabolic disorders: review of efficacy and safety

There has been increasing interest in the development of effective agents that can be safely used to promote anabolism in the clinical setting for patients with chronic wasting conditions as well as in the prevention and treatment of frailty associated with loss of muscle tissue in aging (sarcopenia). One such agent is the anabolic androgenic steroid (AAS) oxandrolone, which has been used in such clinical situations as HIV-related muscle wasting, severe burn injury, trauma following major surgery, neuromuscular disorders and alcoholic hepatitis for over 30 years. In the US, oxandrolone is the only AAS that is US FDA-approved for restitution of weight loss after severe trauma, major surgery or infections, malnutrition due to alcoholic cirrhosis, and Duchenne's or Becker's muscular dystrophy. Our review of the use of oxandrolone in the treatment of catabolic disorders, HIV and AIDS-related wasting, neuromuscular and other disorders provides strong evidence of its clinical efficacy. Improvements in body composition, muscle strength and function, status of underlying disease or recovery from acute catabolic injury and nutritional status are significant in the vast majority of well designed trials. However, oxandrolone has not yet been studied in sarcopenia.Unlike other orally administered C17alpha-alkylated AASs, the novel chemical configuration of oxandrolone confers a resistance to liver metabolism as well as marked anabolic activity. In addition, oxandrolone appears not to exhibit the serious hepatotoxic effects (jaundice, cholestatic hepatitis, peliosis hepatis, hyperplasias and neoplasms) attributed to the C17alpha-alkylated AASs. Oxandrolone is reported to be generally well tolerated and the most commonly documented adverse effects are transient elevations in transaminase levels and reductions in high density lipoprotein cholesterol level.However, optimal risk:benefit ratios for oxandrolone and other agents in its class will need to be refined before widespread clinical acceptance of AASs as a therapeutic option in sarcopenia and other chronic wasting conditions.

[Liver and sports]

Physical exercise does not have harmful effects on liver, yet it can be an occasional cause of heat stroke in long-distance runners if they do not drink enough. Practicing sports does not have harmful liver effects as long as some risk behaviors are avoided such as consumption of anabolizers, sharing syringes or traveling to hepatitis endemic countries without being vaccinated. In patients with acute or chronic liver diseases, physical activity or practicing sports can be allowed as long as these do not lead to an excessive fatigue.

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.

Hepatatis in growth promoter treated cows

Adult female beef cattle found positive for stanozolol in the urine were investigated for liver pathology. In all the animals toxic hepatitis was found, including cholestasis, periportal fibrosis and inflammation, focal necrosis and blood filled lacunae. As no clinical data of the cows were available, apart from the history of illegal stanozolol abuse, it is not possible to attribute all changes to the illegal hormone treatment. Moreover, the cows have probably been treated with a cocktail, and apart from stanozolol more anabolic steroids may have been used. Management factors, viral and bacterial infections, former caesarean sections and especially feeding regime may also be responsible for the lesions described. Striking similarities with data from hepatotoxicity found in human body builders using similar agents, however, suggest a major role of stanozolol as causative agent.

Pumping iron, risking infection? Exposure to hepatitis C, hepatitis B and HIV among anabolic-androgenic steroid injectors in Victoria, Australia

AIMS

To measure exposure to the hepatitis C and B viruses and HIV among Victorian steroid injectors and evaluate associations between exposure and risk behaviour, and report other characteristics of the study group.

DESIGN

Seroprevalence study using a convenience sample.

SETTING

Victoria, Australia.

PARTICIPANTS

Current injectors of illicit anabolic steroids.

MEASUREMENTS

Prevalences of exposure to HIV and the hepatitis B and C viruses; associations of characteristics and behaviours with exposure; descriptive statistics for the sample.

FINDINGS

Six of 63 blood samples (9.5%) contained hepatitis C virus antibodies; 12.0% tested positive for hepatitis B core antibody; none contained anti-HIV. Hepatitis C virus exposure was associated with heroin injection, imprisonment, sharing needles to inject other drugs, number of tattoos, and hepatitis B virus exposure. No significant differences existed in the steroid-related risk behaviour of exposed and non-exposed individuals. Hepatitis B virus exposure was associated only with hepatitis C virus exposure, past imprisonment and age of first injection.

CONCLUSIONS

Exposure to the hepatitis B and C viruses was detected; hepatitis C virus exposure was at much lower prevalence than normally found among other drug injectors. Factors other than steroid injecting were associated with exposure. Nonetheless, the hepatitis C-exposed reported many steroid-related and other risk behaviours which could spread the virus. Steroid injectors should not be neglected in blood-borne virus prevention efforts.

Differentiation of liver cell adenomas from well-differentiated hepatocellular carcinomas by comparative genomic hybridization

Liver cell adenomas (LCAs) are rare tumours which may be difficult to differentiate from low-grade hepatocellular carcinomas (HCCs). This study used comparative genomic hybridization (CGH) to look for cytogenetic aberrations which would serve to distinguish between these tumours. For this purpose, ten LCAs and six well-differentiated HCCs were analysed and the results were compared with those reported previously for 15 well-differentiated HCCs. Aberrations were seen in 2/10 LCAs: a gain of chromosome 7p was observed in one and gains of 17q and 20 in a second case. In 6/6 well-differentiated HCCs, up to 13 aberrations were detectable, with a mean of 7.2 aberrations per case in chromosome sites 1q, 4p, 4q, 5p, 5q, 6p, 6q, 7p, 7q, 8p, 8q, 10q, 11p, 13q, 14q, 16p, 16q, 17p, 17q, 20p, 20q, and 21q. Aberrations focused on gains or losses of six chromosome sites, 1q, 4q, 8p, 8q, 16p, and 17p; in all HCC samples, at least two of these sites were affected. None of these aberrations occurred in any of the LCAs analysed. CGH is therefore helpful in distinguishing between LCA and well-differentiated HCC. Detection of one or more of the six most frequent aberrations in HCC supports the diagnosis of carcinoma and makes LCA unlikely.

Pigmented liver cell adenoma in two male patients

We report two cases of hepatocyte neoplasia with extensive deposition of Dubin-Johnson-like pigment in men without Dubin-Johnson syndrome. This pigment has previously been described in hepatocellular carcinoma but not in liver cell adenoma. The tumors of both patients showed some atypical cytologic features, but no frank histologic evidence of malignancy. Long-term follow up for several years showed no evidence of recurrence after limited surgical excision. We conclude that tumors with this structure may be cured by limited surgical excision and should be considered as pigmented liver cell adenomas.

Risk factors for anabolic steroid use in college students and the role of expectancy

Anabolic steroids are now recognized as a widespread addictive and dangerous substance, no longer exclusively used as an aid to muscle size and strength in world-class athletes. Psychologists have neglected prevention programs for steroid abuse, in part because of a lack of knowledge of the precipitants of abuse. This study examined demographics, personality factors, and steroid expectancies as risk factors for future steroid use. Older subjects, extraversion, global-positive expectancies for steroid use, and identification with peers who advocated health-risk behaviors predicted higher steroid use, whereas specific social-behavioral negative expectancies for steroid use significantly predicted lowered risk of steroid use. These findings are discussed in the context of past research, and implications for preventive intervention are described.

Associations between physical activity and susceptibility to cancer: possible mechanisms

Physical activity is associated with a reduced risk of all-cause and colonic cancers, and it seems to exert a weaker effect on the risk of breast, lung and reproductive tract tumours. This review examines possible mechanisms behind the observed associations. Restriction of physical activity by pre-existing disease may contribute to the association with lung cancers, but seems a less likely explanation for other types of tumour. Indirect associations through activity-related differences in body build or susceptibility to trauma seem of minor importance. Potential dietary influences include overall energy balance and energy expenditure, the intake and/or bioavailability of minerals, antioxidant vitamins and fibre, and the relative proportions of protein and fat ingested. Links between regular exercise and other facets of lifestyle that influence cancer risks are not very strong, although endurance athletes are not usually smokers, and regular leisure activity is associated with a high socioeconomic status which tends to reduce exposure to airborne carcinogens, both at work and at home. Overall susceptibility to cancer shows a 'U'-shaped relationship to body mass index (mass/height2) reflecting, in part, the adverse influences of cigarette smoking and a tall body build for those with low body mass indices and, in part, the adverse effect of obesity at the opposite end of the body mass index distribution. Obesity seems a major component in the exercise-cancer relationship, with a particular influence on reproductive tract tumours; it alters the pathways of estradiol metabolism, decreases estradiol binding and facilitates the synthesis of estrogens. Among the hormonal influences on cancer risk, insulin-like growth factors promote tumour development and exercise-mediated increases in cortisol and prostaglandin levels may depress cellular components of immune function. However, the most important change is probably the suppression of the gonadotropic axis. Apparent gender differences in the benefits associated with regular exercise reflect gender differences in the hormonal milieu and also a failure to adapt activity questionnaires to traditional patterns of physical activity in females. The immune system is active at various stages of tumour initiation, growth and metastasis. However, acute and chronic changes in immune response induced by moderate exercise are rather small, and their practical importance remains debatable. At present, the oncologist is confronted by a plethora of interesting hypotheses, and further research is needed to decide which are of practical importance.

Sex hormonal preparations and the liver

The long-term use of oral contraceptives (OCs) may be associated with an increased, though quite small, risk of certain types of liver disease: acute intrahepatic canalicular idiosyncratic cholestasis, benign hepatic tumors (hepatic adenoma, focal nodular hyperplasia, hemangiomas), hepatocellular carcinoma, peliosis hepatis, hepatic vein thrombosis, and portal vein thrombosis. Estrogens have lithogenic properties, as shown by a rise in biliary cholesterol secretion and cholesterol saturation index, yet no substantial increase in the risk of gallstones among estrogen users has been found. Hormone replacement therapy (HRT), given after oophorectomy or menopause, is not associated with clinically significant liver injury. Generally speaking, synthetic sex hormones should not be used in patients with acute and chronic liver disease. A trial of a low-dose estrogen can be instituted under close monitoring for adverse reactions and HRT preparations are not contraindicated in patients with chronic liver disease. Moreover, OCs and HRT can be prescribed quite safely following successful liver transplantation. The incidence of hepatic abnormalities in patients taking androgen hormones is very high. Liver adenomas, cholestasis, peliosis, nodular regenerative hyperplasia and, particularly, hepatocellular carcinoma may complicate long-term use of C17-substituted testosterone and anabolic steroids.

Androgen use by athletes: a reevaluation of the health risks

It has been estimated that 1 to 3 million male and female athletes in the United States have used androgens. Androgen use has been associated with liver dysfunction, altered blood lipids, infertility, musculotendinous injury, and psychological abnormalities. Although androgens have been available to athletes for over 50 years, there is little evidence to show that their use will cause any long-term detriment; furthermore, the use of moderate doses of androgens results in side effects that are largely benign and reversible. It is our contention that the incidence of serious health problems associated with the use of androgens by athletes has been overstated.

Hepatocellular carcinoma associated with anabolic steroid therapy: report of a case and review of the Japanese literature

We report herein the case of a 35-year-old woman with aplastic anemia who developed hepatocellular carcinoma after long-term therapy with oxymetholone. She was treated with 60 mg/day of oxymetholone for 3 years (total dose 64.8 g). Alpha-fetoprotein, hepatitis B surface antigen, and hepatitis C antibody were all negative, but serum titers of carcinoembryonic antigen and carbohydrate antigen were elevated. Lateral segmentectomy of the liver was performed. The histopathological findings were compatible with those of multiple hepatocellular carcinoma without liver cirrhosis. Three years since the operation, the patient is doing well and no signs of tumor recurrence have been detected. According to our review of Japanese cases of hepatocellular carcinoma associated with anabolic steroid therapy, in all instances the tumors developed after long-term administration of anabolic steroids for hematologic diseases. In patients under long-term anabolic steroid therapy, routine screening of the liver by ultrasonography and computed tomography should be performed to detect liver tumors in the early stages.

Hepatic neoformations

The aim of the paper is an accurate histologic description and illustration of those liver lesions that are usually summarized under the heading of "hepatic tumors and related subjects". For in some cases it may be unclear or at least controversial, whether the individual lesion is indeed an autonomous neoplasia or a malformation, regeneration or hyperplasia, the indifferent master term of neoformation is introduced, based on the fact that all of them are characterized by a cellular multiplication. According to common definitory practice the survey distinguishes between mesenchymal (angiomatous and non angiomatous) and epithelial neoformations. Among the latter hepatocellular and cholangiocellular types are distinguished, the criterium for differentiation being a phenomenological one, which is by no means identical with a histogenetical statement. The definition of subgroups mostly adheres to current nomenclatory usage; only occasionally--in the group of endothelial tumors--a novel term is employed, in view of brevity and coordination with the overall system of neoformations.

Exercise in the prevention and treatment of cancer. An update

Physical activity potentially encourages a healthy lifestyle and it could have a more direct preventive effect on certain forms of carcinogenesis (for instance, by speeding gastrointestinal transit, or by moderating sex hormone levels). However, there are also potential negative effects, particularly an excessive exposure to ultraviolet light in certain water sports. The many types of neoplasm and the equally varied sources of physical activity militate against finding any simple relationship between the risk of malignancy and the individual's physical activity history. Nevertheless, evidence that physical activity protects against certain forms of cancer can be deduced from studies of experimental animals, former athletes, people employed in active occupations, and those with an active recreational lifestyle. Many occupational surveys and a number of studies of recreational activity show an association between sedentary living and a risk of colon cancer, both in men and in women. Moreover, an application of Bradford Hill's criteria gives some support to the causal nature of the association. More limited data suggest that a history of active leisure is associated with a reduced risk of all-cause cancer and in women of breast and reproductive system cancers. The last observation must still be reconciled with an apparent increase in the risk of prostatic cancer in active men. Since moderate exercise elevates mood and helps to conserve lean tissue, it may finally be a helpful component of treatment after a neoplasm has been diagnosed.

The efficacy of ergogenic agents in athletic competition. Part I: Androgenic-anabolic steroids

OBJECTIVE

To summarize the literature describing the epidemiology, pharmacology, efficacy, and adverse effects associated with androgenic-anabolic steroid (AAS) use among athletes.

DATA SOURCES

Relevant articles were identified from a MEDLINE search using the search terms "Doping in Sports," "Anabolic Steroids (exploded)," and "Androgens (exploded)." Additional references were found in the bibliographies of these articles.

STUDY SELECTION/DATA EXTRACTION

We reviewed studies of AAS use among professional athletes. Interpretation of these studies is difficult because of poor research design. The efficacy studies lacked adequate placebo control. Much of the literature describing adverse effects consists of anecdotal reports. All of this literature was considered for review.

DATA SYNTHESIS

Of all ergogenic drugs, AASs are the most widely abused. Abuse of AASs among high school students is estimated at five to ten percent. AASs are hypothesized to produce ergogenic effects during periods of concomitant positive nitrogen balance via antagonism of the catabolic effect of glucocorticoids released during intense exercise. Despite years of study, the extent of the ergogenic effects associated with AASs remains unclear. This may be because most studies have failed to approximate athletes' AAS usage patterns. The primary toxic effects of AASs are divided into four areas: hepatic, reproductive, cardiovascular, and psychiatric. Athletes do not consider these effects severe enough to refrain from using these drugs.

CONCLUSIONS

Athletes view AASs as an essential component for success. Without adequate intervention measures, AAS abuse is likely to continue unchecked.