Anabolic steroids, acute myocardial infarction and polycythemia: a case report and review of the literature

Sports Endocrinology

Sports endocrinology holds a unique importance in understanding and optimizing an active and healthy lifestyle. Active patients with diabetes will need to consider modifying medications, especially insulin. The use of the dual energy x-ray absorptiometry and Fracture Risk Assessment Tool scores is important as both initiate and monitor bone health treatment. Menstrual disorders and energy imbalances are some special concerns when treating female athletes, calling for a multidisciplinary treatment team. Performance agents are popular and have made their way into recreational sports.

Androgen abuse: Risks and adverse effects in men

Androgens, formerly known as anabolic-androgenic steroids, mimic the effects of testosterone and are being increasingly abused for nonmedical purposes such as body and performance enhancement. Androgen abuse is associated with increased mortality, and multisystem adverse effects have been reported, including cardiovascular toxicity, infertility, hypogonadism, hepatotoxicity, and mental health disorders. Men may present with the negative health consequences of androgen abuse even despite cessation for a number of years. There is frequently a reluctance to disclose androgen abuse, and substances are often sourced from the black market, which is not regulated and where the products sold may be counterfeit. All men should be encouraged to stop androgen abuse. Managing associated adverse effects will be organ-specific and is complex due to physical and neuropsychiatric symptoms, substance dependence, and high rates of relapse. Given the broad reach and prolonged adverse effects of androgen abuse, clinicians across medical specialties should have an awareness of androgen abuse, its increasing prevalence, and the harms it poses to men and their families. This narrative review aims to summarize the adverse effects and risks associated with androgen abuse.

Pulmonary haemorrhage and extensive arterial thrombosis with anabolic steroid abuse

Anabolic-androgenic steroids (AASs) are commonly implicated in thromboembolic events but rarely cause diffuse alveolar haemorrhage. We report the case of a Caucasian man in his late 40s who was consuming supratherapeutic doses of AAS and presented with shortness of breath and haemoptysis. Chest imaging showed bilateral patchy infiltrates in the lungs with diffuse blood throughout the airways on bronchoscopy. Extensive infectious and autoimmune workup were unremarkable. The patient then developed right foot ischaemia and was found to have extensive aortic and bilateral lower extremity arterial thrombosis. Anticoagulation was attempted despite haemoptysis. Thrombectomy procedures were unsuccessful and the patient eventually developed worsening rhabdomyolysis requiring intubation and bilateral amputation. His clinical condition continued to worsen and he passed away 10 days after admission. This case highlights the rare synchronous occurrence of two life-threatening complications secondary to anabolic steroid abuse which can pose a significant diagnostic and therapeutic challenge for clinicians.

Doping and sports endocrinology: anabolic-androgenic steroids

The use of anabolic steroids affects not only professional athletes but also the general population (bodybuilders, gym clients, and adolescents). In the first case, its use is prohibited and sanctioned by the World Anti-Doping Agency and Olympic committees. For the other users, it is difficult to establish its prevalence since many obtain the products via the internet. The reasons for its use are varied and different forms of use and other types of users have been described. Among the side effects of steroid use, hypogonadism is the most frequent cause for endocrinological consultation. After a general introduction to doping, this review describes the historical background of anabolic-androgenic steroids, their classification, forms of use, physiological effects, adverse effects on different organs and systems, treatment of hypogonadism, as well as detection methods.

Testosterone Replacement Therapy in the Treatment of Depression

BACKGROUND

Depression is a common disorder that affects millions globally and is linked to reduced quality of life and mortality. Its pathophysiology is complex and there are several forms of treatment proposed in the literature with differing side effect profiles. Many patients do not respond to treatment which warrants augmentation with other treatments and the investigation of novel treatments. One of these treatments includes testosterone therapy which evidence suggests might improve depressed mood in older patients with low levels of testosterone and helps restore physical impairments caused by age-related hormonal changes.

OBJECTIVE

The objective of this review is to synthesize information regarding clinical depression, its treatment options, and the efficacy and safety of testosterone treatment for the treatment of depression.

METHODS

This review utilized comprehensive secondary and tertiary data analysis across many academic databases and published work pertaining to the topic of interest.

RESULTS

Within some subpopulations such as men with dysthymic disorder, treatment resistant depression, or low testosterone levels, testosterone administration yielded positive results in the treatment of depression. Additionally, rodent models have shown that administering testosterone to gonadectomized male animals reduces symptoms of depression. Conversely, some studies have found no difference in depressive symptoms after treatment with testosterone when compared with placebo. It was also noted that over administration of testosterone is associated with multiple adverse effects and complications.

CONCLUSION

The current evidence provides mixed conclusions on the effectiveness of testosterone therapy for treating depression. More research is needed in adult men to see if declining testosterone levels directly influence the development of depression.

ARDS, Diffuse Alveolar Hemorrhage and Pericardial Effusion due to Anabolic-Androgenic Steroids Consumption: Legal and Ethical Policy in Medical Education

Anabolic-androgenic steroids (AAS) are one of the ingredients of herbal and dietary supplements that are popular among sports trainers. AAS abuse predisposes everyone to several complications. Reviews of the literature on AAS users have shown mainly skin, renal, and hepatic complications. In this case report, we presented a case with simultaneous complications, including diffuse alveolar hemorrhage (DAH), acute respiratory distress syndrome (ARDS), pericardial effusion, gastrointestinal bleeding (GIB), and acute kidney injury (AKI). Given the potential for lethal complications and the consequences of ethical, civil, and criminal law, it seems that specific policies will be considered for the use of bodybuilding drugs. It is also suggested that this approach be added as a new part of the medical curriculum. Also, ARDS and DAH are unreported side effects in other studies, which is suggested to be considered by specialists.

Use, Misuse and Abuse of Testosterone and Other Androgens

INTRODUCTION

For several decades, testosterone and its synthetic derivatives have been used for anabolic and androgenic purposes. Initially restricted to professional bodybuilders, these substances gradually became more popular with recreational weightlifters. Considering its increasing prevalence, the consumption of anabolic androgenic steroids (AAS) has become a matter of great concern. Although most side effects are mild and reversible, some of them can cause permanent damage or can be potentially life threatening.

OBJECTIVES

To review and summarize medical literature regarding misuse and abuse of testosterone and other androgens, in order to provide evidence-based information on the main topics related to this subject, such as how to identify and how to deal with these patients, and to elucidate the multiple possible adverse effects secondary to this practice.

METHODS

Key studies were retrieved from PubMed (1989-2021) with reference searches from relevant articles. Search terms included "hypogonadism", "anabolic androgenic steroids", "androgens", "misuse AND testosterone", "abuse AND testosterone", and "side effects AND testosterone".

RESULTS

There is a significant lack of information in the peer-reviewed literature describing demographic data, implications for different organ systems and the management of current or former AAS users; however, androgen abuse has been already linked to a wide variety of cardiovascular diseases, metabolic, endocrine, neurological, psychiatric and liver disorders. Despite all this, most physicians still feel uncomfortable and hesitate to discuss the issue with patients.

CONCLUSIONS

The chronic use of high doses of AAS is associated with adverse effects in several organ systems; however, there are still many gaps in our knowledge about the long-term consequences of this practice and how to deal with these patients. Healthcare professionals have a crucial role in combating this public health problem, recognizing and preventing the spread of androgen abuse. Linhares BL, Miranda EP, Cintra AR, et al. Use, Misuse and Abuse of Testosterone and Other Androgens. Sex Med Rev 2021;XX:XXX-XXX.

Severe Cardiac and Metabolic Pathology Induced by Steroid Abuse in a Young Individual

Androgenic-Anabolic Steroids (AAS) abuse is known to play an important role in causing the systemic inflammatory response and multiple-organ dysfunction in healthy individuals. Although many of the undesirable effects of steroid abuse have been reported, at present, little is known about the effect of anabolic supplements and the correlation between cardiac and metabolic pathology. This paper presents a case of a 25 year old patient with a complex medical history after 6 months of steroid administration. Myocardial infraction, dyslipidemia, obesity, hyperuricemia, secondary diabetes, and chronic renal disease were identified after clinical and para-clinical examinations. The particularities of this case were interpreted in the context of a literature review, highlighting the effect of multi-organ damage as a result of the uncontrolled use of anabolic steroid supplements.

Influence of different training methods on cardiovascular disease risk markers after cessation of anabolic steroids abuse in bodybuilders at risk

Evidence suggests that anabolic-androgenic steroid (AAS) abuse induces adverse effects on cardiovascular disease (CVD). However, it is unclear whether different training methods are effective in reducing these consequences. This study aims to compare the effects of aerobic training (AT), resistance training (RT), and combined training (CT) on CVD risk markers in professional bodybuilders at risk after cessation of AAS abuse. Forty bodybuilders were randomly assigned to one of four groups: control (n=10), AT (n=10), RT (RT, n=10), and CT (n=10) groups. Before and after eight weeks of training, the high sensitivity C-reactive protein (hs-CRP), haematocrit (HCT), homocysteine (HCY), N-terminal prohormone of brain natriuretic peptide (NT-proBNP), and blood pressure (BP) were measured. Significant decreases within groups in HCY and CRP were observed (P<0.05). However, decreases were greater in training groups, and there was a significant difference between control and training groups (P<0.05). Increase in NT-proBNP, and decreases in systolic blood pressure (SBP), and diastolic blood pressure (DBP) levels were significant only in training groups (P<0.005). The increase of NT-proBNP was significant in the CT when compared to the RT (P<0.05). The present study found that discontinuing AAS consumption can improve some CVD risk markers in professional bodybuilders, but this effect could be improved if various modalities of training were performed. Accompanying AT with RT was also discovered to have a greater impact on some markers (including NT-proBNP).

How the love of muscle can break a heart: Impact of anabolic androgenic steroids on skeletal muscle hypertrophy, metabolic and cardiovascular health

It is estimated 6.4% of males and 1.6% of females globally use anabolic-androgenic steroids (AAS), mostly for appearance and performance enhancing reasons. In combination with resistance exercise, AAS use increases muscle protein synthesis resulting in skeletal muscle hypertrophy and increased performance. Primarily through binding to the androgen receptor, AAS exert their hypertrophic effects via genomic, non-genomic and anti-catabolic mechanisms. However, chronic AAS use also has a detrimental effect on metabolism ultimately increasing the risk of cardiovascular disease (CVD). Much research has focused on AAS effects on blood lipids and lipoproteins, with abnormal concentrations of these associated with insulin resistance, hypertension and increased visceral adipose tissue (VAT). This clustering of interconnected abnormalities is often referred as metabolic syndrome (MetS). Therefore, the aim of this review is to explore the impact of AAS use on mechanisms of muscle hypertrophy and markers of MetS. AAS use markedly decreases high-density lipoprotein cholesterol (HDL-C) and increases low-density lipoprotein cholesterol (LDL-C). Chronic AAS use also appears to cause higher fasting insulin levels and impaired glucose tolerance and possibly higher levels of VAT; however, research is currently lacking on the effects of AAS use on glucose metabolism. While cessation of AAS use can restore normal lipid levels, it may lead to withdrawal symptoms such as depression and hypogonadism that can increase CVD risk. Research is currently lacking on effective treatments for withdrawal symptoms and further long-term research is warranted on the effects of AAS use on metabolic health in males and females.

Anabolic steroid use and ischaemic stroke in a young fitness enthusiast

We report a case of ischaemic stroke in a 34-year-old male recreational bodybuilder following a 3-month period of anabolic androgenic steroid (AAS) use and 1-month period of 'post-cycle therapy' (tamoxifen and clomiphene citrate), the latter treatments aimed at restoring normal endogenous testosterone production after initial AAS use. We hypothesise a transient drug-related prothrombotic state with paradoxical embolisation via an atrial septal defect which was later found on bubble echocardiogram. We highlight a rare but important cause of stroke in younger patients which is relevant given the increasing use of AAS misuse among casual fitness enthusiasts. We explore the various possible mechanisms by which AAS use can increase ischaemic stroke risk in such patients.

Effects of Exogenous Androgens on Platelet Activity and Their Thrombogenic Potential in Supraphysiological Administration: A Literature Review

Anabolic androgenic steroids (AAS), simply called “androgens”, represent the most widespread drugs used to enhance performance and appearance in a sporting environment. High-dosage and/or long-term AAS administration has been associated frequently with significant alterations in the cardiovascular system, some of these with severe endpoints. The induction of a prothrombotic state is probably the most life-threatening consequence, suggested by numerous case reports in AAS-abusing athletes, and by a considerable number of human and animal studies assessing the influence of exogenous androgens on hemostasis. Despite over fifty years of research, data regarding the thrombogenic potential of exogenous androgens are still scarce. The main reason is the limited possibility of conducting human prospective studies. However, human observational studies conducted in athletes or patients, in vitro human studies, and animal experiments have pointed out that androgens in supraphysiological doses induce enhanced platelet activity and thrombopoiesis, leading to increased platelet aggregation. If this tendency overlaps previously existing coagulation and/or fibrinolysis dysfunctions, it may lead to a thrombotic diathesis, which could explain the multitude of thromboembolic events reported in the AAS-abusing population. The influence of androgen excess on the platelet activity and fluid–coagulant balance remains a subject of debate, urging for supplementary studies in order to clarify the effects on hemostasis, and to provide new compelling evidence for their claimed thrombogenic potential.

Anabolic Steroid Use and Aortic Dissection in Athletes: A Case Series

The use of anabolic steroids in supraphysiologic doses has grown in the last decade as doping drugs in athletes. The high dose of anabolic-androgenic steroids (AAS) causes cardiomyopathy, hypertension, thrombosis, myocardial infarction (MI), weakness of connective tissue, and its sequelae such as tendon injury and aortic dissection. Dissection of the ascending aorta is an uncommon injury that has been recognized with increasing frequency in bodybuilders in recent years. It has been proposed that such cases commonly accompany the weakening of connective tissue and must be actively evaluated in the presence of anabolic steroid usage. We present a case series of isolated ascending aorta dissection in athletes who were bodybuilders. All cases were evaluated by transthoracic echocardiography (TTE) and laboratory exams. These cases also served as a reminder of the risks of ascending aorta dissection with AAS, especially in strength athletes who place high demands on their musculoskeletal structures. The results of the current study suggested that anabolic steroid abuse may be associated with detrimental effects on the myocardium represented as cardiomyopathy or atherosclerotic changes in the coronary artery as MI. These findings also strongly suggest that anabolic steroid treatment predisposes the individual to aortic dissection, especially when the patients are exercised.

Acute myocardial infarction with cardiogenic shock in a young physically active physician concurrently using the anabolic steroid sustanon: A case report

The association between ischemic heart disease (IHD) and the concurrent use of anabolic androgenic steroids (AASs) is underestimated in clinical settings. The tendency of patients to not disclose AASs use may explain this underestimation. In the present case report, the clinical case of a 26-year-old physically active male, who was a physician, without any classical coronary risk factors, who presented with chest pain that was misdiagnosed by the peripheral care unit as skeletal muscle pain is described. Later, the patient was brought to our central hospital (King Abdullah University Hospital) suffering from a massive acute myocardial infarction with marked ECG changes and cardiogenic shock. Following stabilization of his condition, a detailed history of the patient was taken, during which the patient admitted that he was a chronic user of the anabolic steroid sustanon (250 mg, once/week for 6 months) and amino acid supplements (whey protein isolate, 6 tabs every day for 1 year). Specific cardiac markers were increased and the patient exhibited dynamic ischemic changes in his electrocardiogram. Notably, the coronary angiogram of the patient demonstrated ostial occlusion of the left anterior descending artery, which was associated with mid-right coronary artery embolic obstruction. Other than the anabolic steroids and protein supplementation use, the patient history, examination and lab evaluation were normal. During follow up, the patient continued to suffer heart failure with low ejection fraction. In addition, he developed apical thrombus 2 months after primary admission. The patient developed tachycardia in spite of optimal medical treatment and finally received an implantable cardioverter defibrillator. Physicians should always be aware of the possibility of AASs use in young physically active patients. IHD should always be suspected and investigated with typical chest pain in healthy young patients, even if regular risk factors are not present. Medical professionals should not be excluded as potential AASs users/abusers.

Therapeutic Phlebotomy for Testosterone-Induced Polycythemia

OBJECTIVES

To evaluate therapeutic phlebotomy (TP) requests for testosterone replacement therapy (TRT) and to highlight the impact to a blood center (BC) or service that provides TP for individuals on TRT.

METHODS

Review of TP requests for individuals on TRT at our BC over a 3-year period from 2014 through 2016, as well as the total number of TP collections.

RESULTS

Total TPs during 2014, 2015, and 2016 were 475, 500, and 569, respectively. Annual TP collections for patients on TRT were 193, 212, and 239, respectively. TRT patients with TP orders increased 71.4% during this period. After discontinuation of TP services for TRT at our BC, 32% continued to donate as volunteer blood donors at our BC.

CONCLUSIONS

Our BC observed increased TP requests for patients on TRT from 2014 through 2016. Our findings suggest that individuals on TRT may be presenting to BCs as volunteer blood donors to avoid charges for TP.

Treatments for people who use anabolic androgenic steroids: a scoping review

BACKGROUND

A growing body of evidence suggests that anabolic androgenic steroids (AAS) are used globally by a diverse population with varying motivations. Evidence has increased greatly in recent years to support understanding of this form of substance use and the associated health harms, but there remains little evidence regarding interventions to support cessation and treat the consequences of use. In this scoping review, we identify and describe what is known about interventions that aim to support and achieve cessation of AAS, and treat and prevent associated health problems.

METHODS

A comprehensive search strategy was developed in four bibliographic databases, supported by an iterative citation searching process to identify eligible studies. Studies of any psychological or medical treatment interventions delivered in response to non-prescribed use of AAS or an associated harm in any setting were eligible.

RESULTS

In total, 109 eligible studies were identified, which included case reports representing a diverse range of disciplines and sources. Studies predominantly focussed on treatments for harms associated with AAS use, with scant evidence on interventions to support cessation of AAS use or responding to dependence. The types of conditions requiring treatment included psychiatric, neuroendocrine, hepatic, kidney, cardiovascular, musculoskeletal and infectious. There was limited evidence of engagement with users or delivery of psychosocial interventions as part of treatment for any condition, and of harm reduction interventions initiated alongside, or following, treatment. Findings were limited throughout by the case report study designs and limited information was provided.

CONCLUSION

This scoping review indicates that while a range of case reports describe treatments provided to AAS users, there is scarce evidence on treating dependence, managing withdrawal, or initiating behaviour change in users in any settings. Evidence is urgently required to support the development of effective services for users and of evidence-based guidance and interventions to respond to users in a range of healthcare settings. More consistent reporting in articles of whether engagement or assessment relating to AAS was initiated, and publication within broader health- or drug-related journals, will support development of the evidence base.

Gerstmann syndrome complicating polycythemia secondary to anabolic steroid use

Anabolic steroid use is prevalent among athletes and bodybuilders. There are known cardiovascular, reproductive, musculoskeletal and neuropsychiatric risks associated with their prolonged use. Although there have been very few documented cases of strokes associated with anabolic steroid use, cardiomyopathy and secondary erythropoiesis can increase the risk of strokes in users with no other risk factors. We present a 49-year-old man with left parietal ischaemic stroke with haemorrhagic conversion resulting in Gerstmann syndrome secondary to a hypercoagulable state from chronic anabolic steroid use.

Testosterone, myocardial function, and mortality

The cardiovascular system is particularly sensitive to androgens, but some controversies exist regarding the effect of testosterone on the heart. While among anabolic abusers, cases of sudden cardiac death have been described, recently it was reported that low serum level of testosterone was correlated with increased risk of cardiovascular diseases (CVD) and mortality rate. This review aims to evaluate the effect of testosterone on myocardial tissue function, coronary artery disease (CAD), and death. Low testosterone level is associated with increased incidence of CAD and mortality. Testosterone administration in hypogonadal elderly men and women has a positive effect on cardiovascular function and improved clinical outcomes and survival time. Although at supraphysiologic doses, androgen may have a toxic effect, and at physiological levels, testosterone is safe and exerts a beneficial effect on myocardial function including mechanisms at cellular and mitochondrial level. The interaction with free testosterone and estradiol should be considered. Further studies are necessary to better understand the interaction mechanisms for an optimal androgen therapy in CVD.

Determination of boldenone in postmortem specimens including blood and urine samples using LC-MS/MS

Boldenone (BOLD), one of androgenic anabolic steroids (AAS), although banned in humans, is still available illegally. AAS abuse has previously been associated with various cardiovascular adverse events including acute myocardial infarction, arrhythmia, and sudden death. In this study, the concentration of BOLD was determined in postmortem specimens from the corpse of a human male who intentionally injected BOLD undecylenate into his shoulder muscle. In addition, the endogenous levels of BOLD in the blood and urine samples of young human males have been reported. A liquid chromatography-tandem mass spectrometry (LC-MS/MS) method with solid-phase extraction (SPE) was developed and validated for the analysis of BOLD in blood, muscular tissue and urine samples. The validation parameters including linearity, accuracy, precision, matrix effect, and recovery were satisfactory. The concentrations of BOLD in the blood of 20 young human males who didn't take BOLD were under the limit of quantitation (LOQ, 0.5 ng/mL). Additionally, the mean level of BOLD in the urine samples was 3.19 ± 1.65 ng/mL (range: 0.37˜6.02 ng/mL). The concentrations of BOLD in the victim's blood from the femoral vein and heart were 140.44 and 25.74 ng/mL, respectively. On the other hand, those in the muscular tissue from the injection site and the urine sample were 142.3 ng/g and 3474 ng/mL, respectively.

Left ventricular assist device for ventricular recovery of anabolic steroid-induced cardiomyopathy

Herein we report a case of a 26-year-old gentleman with severe cardiomyopathy likely secondary to anabolic-androgenic steroid (AAS) abuse who received a HeartMate II (Abbott Laboratories, Abbott Park, IL) left ventricular assist device (LVAD) for rapidly deteriorating heart failure with hemodynamic compromise. Following 18 months on LVAD support, excellent recovery of ventricular function was achieved to allow for LVAD discontinuation. Given that active substance abuse is a contraindication to heart transplantation, few options remain for patients with AAS induced heart failure. Our case demonstrates that LVAD therapy can be an important intervention for bridging to candidacy, recovery or destination therapy.

Cardiomyopathy induced by anabolic-androgenic steroid abuse

Bodybuilders use anabolic-androgenic steroids to increase muscle mass, but abuse of these hormones has been related to cardiomyopathy in the past. A 60-year-old Caucasian male bodybuilder with medical history of male hypogonadism and on testosterone replacement therapy, allegedly preparing for a weightlifting competition and receiving stem cell infusions from his trainer, is transferred to the intensive care unit for worsening shortness of breath after failing treatment for community-acquired pneumonia. Chest X-ray on transfer was suggestive of pulmonary oedema, and transthoracic echocardiography showed an ejection fraction of 25%-30%. The patient was taken for cardiac catheterisation, which yielded non-ischaemic cardiomyopathy. His testosterone levels were supratherapeutic. Anabolic-androgenic steroid abuse can be a cause of cardiomyopathy in patients who have no other risk factor for such disease.

Comprehensive review of cardiovascular toxicity of drugs and related agents

Cardiovascular diseases are a leading cause of morbidity and mortality in most developed countries of the world. Pharmaceuticals, illicit drugs, and toxins can significantly contribute to the overall cardiovascular burden and thus deserve attention. The present article is a systematic overview of drugs that may induce distinct cardiovascular toxicity. The compounds are classified into agents that have significant effects on the heart, blood vessels, or both. The mechanism(s) of toxic action are discussed and treatment modalities are briefly mentioned in relevant cases. Due to the large number of clinically relevant compounds discussed, this article could be of interest to a broad audience including pharmacologists and toxicologists, pharmacists, physicians, and medicinal chemists. Particular emphasis is given to clinically relevant topics including the cardiovascular toxicity of illicit sympathomimetic drugs (e.g., cocaine, amphetamines, cathinones), drugs that prolong the QT interval, antidysrhythmic drugs, digoxin and other cardioactive steroids, beta-blockers, calcium channel blockers, female hormones, nonsteroidal anti-inflammatory, and anticancer compounds encompassing anthracyclines and novel targeted therapy interfering with the HER2 or the vascular endothelial growth factor pathway.

Effects of stanozolol on apoptosis mechanisms and oxidative stress in rat cardiac tissue

Stanozolol is a widely used 17α-alkylated anabolic androgenic steroid (AAS) derivative. Despite stanozolol's adverse effects, its effect on oxidative stress parameters and mitochondrial apoptosis pathway is not clearly defined. In our study, thirty four male Sprague-Dawley rats were divided into 5 groups as control (C), vehicle control (VC), steroid (ST), vehicle control-exercise (VCE), and steroid-exercise (STE). Animals were subcutaneously administered stanozolol 5 mg/kg in steroid groups and propylene glycol 1 ml/kg in the vehicle-control groups. On the 28th day-after sacrification, oxidative stress (MDA, GSH, PC, SOD, CAT) and apoptosis parameters (TUNEL, Cytochrome-c) in cardiac tissue were evaluated. Also, blood vessel morphology of cardiac tissue was evaluated with Verhoeff-van Giesen staining. It has been demonstrated that stanozolol administration triggers apoptosis by using TUNEL assay and cytochrome-c immunohistochemical staining intensity, while this effect is significantly reduced in the presence of exercise. In conclusion, the present study demonstrated that stanozolol administration induces apoptosis with increasing PC and CAT levels, while GSH, MDA and SOD parameters do not reveal any significant change. Exercise has a protective role in stanozolol induced oxidative stress and apoptosis. According to Verhoeff-van Giesen staining results for blood vessel morphology assessment, it has been seen that exercise has a protective role on cardiac blood vessels. This mechanism needs further investigations with long term exposure studies for clarifying possible pathways.

Effects of testosterone enanthate and resistance training on myocardium in Wistar rats; clinical and anatomical pathology

This study was performed to determine the effects of 8 weeks testosterone enanthate (TE) injection and resistance training (RT) on cardiac muscle in male Wistar rats. A total of 28 male adult Wistar rats were randomly divided into 4 groups; control + placebo, RT + placebo, TE and TE + RT. Testosterone enanthate (20 mg/kg BW, IM) and placebo (olive oil; 0.2 ml, IM) were injected twice a week for 2 months. The RT consisted of climbing (5 reps/3 sets) a ladder carrying a load suspended from the tail. The serum activities of aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH) and creatine kinase MB (CK-MB) and serum level of creatinine, urea and cardiac troponin I (CTnI) were evaluated. After sacrifice, samples from myocardial muscle were collected for histopathology evaluation. The serum concentration of CTnI and CK-MB activity significantly increased in group RT compared with control (p < .05). In group RT + TE, all biomarkers of muscle damage (CTnI, CK-MB, AST, LDH) were significantly more than those in control (p < .05). Also, mild myocardial hypertrophy was observed in RT and RT + TE groups. The higher level of all heart damage biomarkers in the RT + TE group rather than control may indicate the synergistic effects of medication and exercise.

Administration of anabolic steroid during adolescence induces long-term cardiac hypertrophy and increases susceptibility to ischemia/reperfusion injury in adult Wistar rats

Chronic administration of anabolic androgenic steroids (AAS) in adult rats results in cardiac hypertrophy and increased susceptibility to myocardial ischemia/reperfusion (IR) injury. Molecular analyses demonstrated that hyperactivation of type 1 angiotensin II (AT1) receptor mediates cardiac hypertrophy induced by AAS and also induces down-regulation of myocardial ATP-sensitive potassium channel (K_ATP), resulting in loss of exercise-induced cardioprotection. Exposure to AAS during adolescence promoted long-term cardiovascular dysfunctions, such as dysautonomia. We tested the hypothesis that chronic AAS exposure in the pre/pubertal phase increases the susceptibility to myocardial ischemia/reperfusion (IR) injury in adult rats. Male Wistar rats (26day old) were treated with vehicle (Control, n=12) or testosterone propionate (TP) (AAS, 5mgkg^-1 n=12) 5 times/week during 5 weeks. At the end of AAS exposure, rats underwent 23days of washout period and were submitted to euthanasia. Langendorff-perfused hearts were submitted to IR injury and evaluated for mechanical dysfunctions and infarct size. Molecular analysis was performed by mRNA levels of α-myosin heavy chain (MHC), βMHC and brain-derived natriuretic peptide (BNP), ryanodine receptor (RyR2) and sarcoplasmic reticulum calcium ATPase 2a (SERCA2a) by quantitative RT-PCR (qRT-PCR). The expression of AT1 receptor and K_ATP channel subunits (Kir6.1 and SURa) was analyzed by qRT-PCR and Western Blot. NADPH oxidase (Nox)-related reactive oxygen species generation was assessed by spectrofluorimetry. The expression of antioxidant enzymes was measured by qRT-PCR in order to address a potential role of redox unbalance. AAS exposure promoted long-term cardiac hypertrophy characterized by increased expression of βMHC and βMHC/αMHC ratio. Baseline derivative of pressure (dP/dt) was impaired by AAS exposure. Postischemic recovery of mechanical properties was impaired (decreased left ventricle [LV] developed pressure and maximal dP/dt; increased LV end-diastolic pressure and minimal dP/dt) and infarct size was larger in the AAS group. Catalase mRNA expression was significantly decreased in the AAS group. In conclusion, chronic administration of AAS during adolescence promoted long-term pathological cardiac hypertrophy and persistent increase in the susceptibility to myocardial IR injury possible due to disturbances on catalase expression.

Ameliorative Effects of Endurance Exercise with Two Different Intensities on Nandrolone Decanoate-Induced Neurodegeneration in Rats: Involving Redox and Apoptotic Systems

Despite the importance of this issue, less has been paid to the influence of exercise on the neural side effects of anabolic androgenic steroids and mechanisms. We investigated the effects of two levels of endurance exercise on neurodegeneration side effects of nandrolone. The study period was 8 weeks. Wistar rats were divided into nine groups including the control (CTL) group, mild exercise (mEx) group, and vehicle (Arach) group which received arachis oil intramuscularly, nandrolone (Nan) group which received nandrolone decanoate 5 mg/kg two times weekly, mEx+Arach group which treated with arachis oil along with mild exercise, mEx+Nan group which treated with nandrolone along with mild exercise, severe exercise (sEx) group, sEx+Arach, and sEx+Nan groups. Finally, brain samples were taken for histopathological, biochemical, and western blot analysis. Nandrolone significantly decreased the intact cells of the hippocampus, total antioxidant capacity (TAC) (P < 0.05 versus CTL and Arach groups), TAC to malondialdehyde ratio (TAC/MDA), and Bcl-2. Nandrolone increased the Bax/Bcl-2 ratio of the brain tissue (P < 0.01 versus CTL and Arach groups). Combination of mild exercise and nandrolone rescued the intact cells to some extent, and this effect was associated with the improvement of Bcl-2 level and Bax/Bcl-2 ratio of brain tissue. Combination of severe exercise and nandrolone rescued the intact cells and improved the TAC, TAC/MDA, and Bax/Bcl-2 ratios. The findings suggest that low- and high-intensity endurance exercise decreased the risk of neurodegeneration effect of nandrolone in the hippocampus of rats. This effect can be explained by the regulation of the redox system and cell homeostasis.

The Effects of Nandrolone Decanoate Along with Prolonged Low-Intensity Exercise on Susceptibility to Ventricular Arrhythmias

We examined the influence of chronic administration of nandrolone decanoate with low-intensity endurance swimming exercise on susceptibility to lethal ventricular arrhythmias in rat. The animal groups included the control group, exercise group (EX), nandrolone group (Nan), vehicle group (Arach), trained vehicle group (Arach + Ex) and trained nandrolone group (Nan + Ex) that treated for 8 weeks. Then, arrhythmia induction was performed by intravenous infusion of aconitine and electrocardiogram recorded. Then, malondialdehyde (MDA), hydroxyproline (HYP) and glutathione peroxidase of heart tissue were measured. Chronic administration of nandrolone with low-intensity endurance swimming exercise had no significant effect on blood pressure, heart rate and basal ECG parameters except RR interval that showed increase (P < 0.05). Low-intensity exercise could prevent the incremental effect of nandrolone on MDA and HYP significantly. It also increased the heart hypertrophy index (P < 0.05) and reduced the abating effect of nandrolone on animal weighting. Nandrolone along with exercise significantly increased the duration of VF (P < 0.05) and reduced the VF latency (P < 0.05). The findings suggest that chronic co-administration of nandrolone with low-intensity endurance swimming exercise to some extent facilitates the occurrence of ventricular fibrillation in rat. Complementary studies are needed to elucidate the involved mechanisms of this abnormality.

Acute myocardial infarction in a young bodybuilder taking anabolic androgenic steroids: A case report and critical review of the literature

We describe a case report of a 30-year-old bodybuilder suffering acute myocardial infarction (AMI). He had been taking stanozolol and testosterone for two months. The coronary angiogram showed high thrombotic burden in the left anterior descending artery without underlying atherosclerosis. Few case reports of AMI in athletes taking anabolic androgenic steroids (AASs) have been reported so far. AAS-related AMI is possibly underreported in the medical literature due to the desire of the affected individuals to hide AAS use. Physicians should always consider the possibility of AAS abuse in the context of a young athlete suffering AMI. AASs can predispose to AMI through the acceleration of coronary atherosclerosis. Additionally, thrombosis without underlying atherosclerosis or vasospasm is highly possible to cause AMI in AAS users. Complications after AMI may be more frequent in AAS users.

The risk of life-threatening ventricular arrhythmias in presence of high-intensity endurance exercise along with chronic administration of nandrolone decanoate

Anabolic steroids used to improve muscular strength and performance in athletics. Its long-term consumption may induce cardiovascular adverse effects. We assessed the risk of ventricular arrhythmias in rats which subjected to chronic nandrolone plus high-intensity endurance exercise. Animals were grouped as; control (CTL), exercise (Ex): 8 weeks under exercise, vehicle group (Arach): received arachis oil, and Nan group: received nandrolone decanoate 5 mg/kg twice a week for 8 weeks, Arach+Ex group, and Nan+Ex. Finally, under anesthesia, arrhythmia was induced by infusion of 1.5 μg/0.1 mL/min of aconitine IV and ventricular arrhythmias were recorded for 15 min. Then, animals' hearts were excised and tissue samples were taken. Nandrolone plus exercise had no significant effect on blood pressure but decreased the heart rate (P<0.01) and increased the RR (P<0.01) and JT intervals (P<0.05) of electrocardiogram. Nandrolone+exercise significantly increased the ventricular fibrillation (VF) frequency and also decreased the VF latency (P<0.05 versus CTL group). Combination of exercise and nandrolone could not recover the decreasing effects of nandrolone on animals weight gain but, it enhanced the heart hypertrophy index (P<0.05). In addition, nandrolone increased the level of hydroxyproline (HYP) and malondialdehyde (MDA) but had not significant effect on glutathione peroxidase of heart. Exercise only prevented the effect of nandrolone on HYP. Nandrolone plus severe exercise increases the risk of VF that cannot be explained only by the changes in redox system. The intensification of cardiac hypertrophy and prolongation of JT interval may be a part of involved mechanisms.

Acute unilateral sensorineural hearing loss associated with anabolic steroids and polycythaemia: case report

Background:

Unilateral sudden sensorineural hearing loss due to an infarct in the vertebrobasilar system has been widely reported. Most patients have a background of traditional coronary risk factors related to these cerebrovascular episodes.

Case report:

A 32-year-old male, a regular user of anabolic steroids, presented to the emergency department with unilateral sensorineural hearing loss and symptoms suggestive of an infarct of the anterior inferior cerebellar artery but in the absence of risk factors for ischaemic stroke.

Results:

Magnetic resonance imaging confirmed the presence of infarction in the region supplied by the anterior inferior cerebellar artery. Polycythaemia was found on haematological analysis, which we believe was secondary to the use of anabolic steroids. The patient was commenced on aspirin as per the stroke management protocol. There was resolution of neurological symptomatology six weeks after the episode, but no improvement in hearing.

Conclusion:

To our knowledge, this is the first case report of unilateral sensorineural hearing loss secondary to the use of anabolic steroids causing polycythaemia. This cause should be considered in the differential diagnosis of patients presenting with sensorineural hearing loss, especially in young males, when no other risk factors can be identified.

Multiple Intussusceptions Associated with Polycythemia in an Anabolic Steroid Abuser, A Case Report and Literature Review

Intussusceptions are generally associated with mechanical lead points or localized inflammation that function as foci for intestinal telescoping. We present the case of a patient whose abuse of anabolic steroids resulted in the development of multiple simultaneous intussusceptions. Our patient had no additional identifiable risk factors for intussusception. Consistent with previous reports, corticosteroid induced polycythemia and its consequent hyperviscosity led to intravascular sludging and mesenteric ischemia with associated bowel wall thickening. The localized intestinal induration then served as mechanical foci for intussusception. Due to the illicit nature of anabolic androgenic steroid (AAS) abuse, the physiologic effects of supraphysiologic doses are sparsely reported and poorly understood. The scope of AAS abuse and its consequences are likely under-reported and under-recognized within the medical community. Our case presented a unique diagnostic and therapeutic challenge with which we aim to increasing awareness and clinical suspicion for AAS among healthcare personnel.

Doping in sport and exercise: anabolic, ergogenic, health and clinical issues

The use of doping agents is evident within competitive sport in senior and junior age groups, where they are taken by non-elite as well as elite participants. They are also taken in non-sporting contexts by individuals seeking to ‘improve’ their physique through an increase in muscle and/or decrease in fat mass. While attaining accurate data on the prevalence of their use has limitations, studies suggest the illicit use of doping agents by athletes and non-athletes may be 1–5% in the population and greater than 50% in some groups; with the prevalence being higher in males. There is conclusive evidence that some doping agents are anabolic and ergogenic. There is also evidence that the use of doping agents such as anabolic androgenic steroids, growth hormone and other anabolic agents, erythropoietin and stimulants conveys considerable health risks that include, but are not limited to: cardiovascular disease, diabetes, cancer, mental health issues, virilisation in females and the suppression of naturally produced androgens in males. This review will outline the anabolic, ergogenic and health impacts of selected doping agents and methods that may be used in both the sporting and physique development contexts. It also provides a brief tabulated overview of the history of doping and how doping agents may impact upon the analyses of clinical samples.

Doping with anabolic androgenic steroids (AAS): Adverse effects on non-reproductive organs and functions

Since the 1970s anabolic androgenic steroids (AAS) have been abused at ever increasing rates in competitive athletics, in recreational sports and in bodybuilding. Exceedingly high doses are often consumed over long periods, in particular by bodybuilders, causing acute or chronic adverse side effects frequently complicated by additional polypharmacy. This review summarizes side effects on non-reproductive organs and functions; effects on male and female reproduction have been recently reviewed in a parallel paper. Among the most striking AAS side effects are increases in haematocrit and coagulation causing thromboembolism, intracardiac thrombosis and stroke as well as other cardiac disturbances including arrhythmias, cardiomyopathies and possibly sudden death. 17α-alkylated AAS are liver toxic leading to cholestasis, peliosis, adenomas and carcinomas. Hyperbilirubinaemia can cause cholemic nephrosis and kidney failure. AAS abuse may induce exaggerated self-confidence, reckless behavior, aggressiveness and psychotic symptoms. AAS withdrawal may be accompanied by depression and suicidal intentions. Since AAS abuse is not or only reluctantly admitted physicians should be aware of the multitude of serious side effects when confronted with unclear symptoms.

Roles of Testosterone Replacement in Cardiac Ischemia-Reperfusion Injury

Testosterone is an anabolic steroid hormone, which is the major circulating androgen hormone in males. Testosterone levels decreasing below the normal physiological levels lead to a status known as androgen deficiency. Androgen deficiency has been shown to be a major risk factor in the development of several disorders, including obesity, metabolic syndrome, and ischemic heart disease. In the past decades, although several studies from animal models as well as clinical studies demonstrated that testosterone exerted cardioprotection, particularly during ischemia-reperfusion (I/R) injury, other preclinical and clinical studies have shown an inverse relationship between testosterone levels and cardioprotective effects. As a result, the effects of testosterone replacement on the heart remain controversial. In this review, reports regarding the roles of testosterone replacement in the heart following I/R injury are comprehensively summarized and discussed. At present, it may be concluded that chronic testosterone replacement at a physiological dose demonstrated cardioprotective effects, whereas acute testosterone replacement can cause adverse effects in the I/R heart.

Nandrolone Plus Moderate Exercise Increases the Susceptibility to Lethal Arrhythmias

Background:

Until now, no experimental study has directly assessed the arrhythmogenesis of chronic consumption of anabolic androgenic steroids along with moderate-intensity endurance exercise.

Objectives:

We evaluated the influence of integration of anabolic androgenic steroids along with moderate-intensity endurance exercise on susceptibility to lethal ventricular arrhythmias in rat.

Materials and Methods:

The animal groups were as follows: control group (CTL); exercise group (EX) which were under 6 weeks of treadmill exercise; nandrolone group (Nan) which received 5 mg/kg of nandrolone decanoate twice a week; vehicle group (Arach) which received Arachis oil (solvent of nandrolone); trained vehicle group (Arach + Ex); and trained nandrolone group (Nan + Ex). One day after ending of the intervention period, arrhythmia was inducted by intravenous infusion of aconitine and ventricular arrhythmias were recorded. Then malondialdehyde (MDA) and glutathione peroxidase (GPX) of heart tissue were measured.

Results:

Nandrolone, exercise, and their combination were associated with heart hypertrophy. Exercise could prevent the incremental effect of nandrolone on MDA/GPX ratio. Chronic administration of nandrolone with moderate-intensity endurance exercise had no significant effect on blood pressure, heart rate, and basal electrocardiographic parameters. Combination of nandrolone and exercise significantly increased the incidence of ventricular fibrillation (VF) and reduced the VF latency (P < 0.05).

Conclusions:

The findings suggest that chronic coadministration of nandrolone with moderate-intensity endurance exercise facilitates the VF occurrence in rat. Complementary studies are needed to elucidate the involved mechanisms of this abnormality.

Anabolic steroid-induced hypogonadism: diagnosis and treatment

OBJECTIVE

To develop an understanding of hypogonadal men with a history of anabolic-androgenic steroid (AAS) use and to outline recommendations for management.

DESIGN

Review of published literature and expert opinions. Intended as a meta-analysis, but no quality studies met the inclusion criteria.

SETTING

Not applicable.

PATIENT(S)

Men seeking treatment for symptomatic hypogonadism who have used nonprescribed AAS.

INTERVENTION(S)

History and physical examination followed by medical intervention if necessary.

MAIN OUTCOME MEASURES(S)

Serum testosterone and gonadotropin levels, symptoms, and fertility restoration.

RESULT(S)

Symptomatic hypogonadism is a potential consequence of AAS use and may depend on dose, duration, and type of AAS used. Complete endocrine and metabolic assessment should be conducted. Management strategies for anabolic steroid-associated hypogonadism (ASIH) include judicious use of testosterone replacement therapy, hCG, and selective estrogen receptor modulators.

CONCLUSION(S)

Although complications of AAS use are variable and patient specific, they can be successfully managed. Treatment of ASIH depends on the type and duration of AAS use. Specific details regarding a patient's AAS cycle are important in medical management.

Influence of chronic administration of anabolic androgenic steroids and taurine on haemostasis profile in rats: a thrombelastographic study

Anabolic androgenic steroids (AAS) are synthetic derivatives of testosterone with thrombogenic potential in high doses and long-term administration. Taurine, a widely distributed amino-sulfonic acid, is known for its beneficial effects in hypercoagulable states. In order to assess the impact of chronic administration of high doses of AAS and taurine upon haemostasis process in rats, 40 male Wistar rats were divided into four equal groups: control group (group C) - no treatment; androgen group (group A) - received 10 mg/kg per week of nandrolone decanoate (DECA); taurine (group T) - received oral supplementation of 2% taurine in drinking water; androgen and taurine group (group AT) - concomitant administration of DECA and taurine. After 12 weeks, blood samples were collected and haemostasis parameters were assessed with the thrombelastographic (TEG) analysis system: reaction time, clot kinetics (K, α), final clot strength, coagulation index and the clot lysis (Ly30). Nandrolone significantly decreased reaction time in group A compared with control (P<0.001), whereas taurine significantly increase reaction time (P=0.01), and this effect was maintained in group AT compared with group A (P=0.009). Similar differences between groups have been recorded for the clot kinetics parameters K, α. The final clot strength and coagulation index were significantly increased in group A versus group C (P=0.04, respectively P<0.001), but not in group AT versus group C (P>0.05). There were no differences in clot lysis, as shown by Ly30. Nandrolone produces an accelerated clot development and an increased clot firmness in Wistar rats. Taurine association ensures a protective effect against this hypercoagulable state, partially restoring the altered parameters of the coagulation profile.

Effect of testosterone undecanoate on hematological profiles, blood lipid and viscosity and plasma testosterone level in castrated rabbits

OBJECTIVE

The association between testosterone replacement therapy and cardiovascular risk remains controversial. Blood viscosity is a known individual risk factor for cardiovascular disease mortality. The objective of the present study was to investigate the effects of the long-acting injectable testosterone undecanoate (TU) on risk factors of cardiovascular disease.

METHODS

In total, 24 male New Zealand white rabbits (2.5 kg) were randomly divided into 3 groups of 8. Group 1 was used as control. Group 2 was castrated bilaterally and Group 3 was administrated with 6 mg/kg of TU at day 1 and 6 weeks after castration. Whole blood viscosity, total plasma testosterone, hemoglobin (Hb), hematocrit (Hct), fibrinogen (FBN), total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) levels were measured at baseline, 6 weeks and 18 weeks.

RESULTS

In the control group, whole blood viscosity and FBN were significantly increased at 6 and 18 weeks. Castration significantly increased the levels of TC, TG, HDL-C and LDL-C, but decreased Hct and Hb. In the TU injection group, whole blood viscosity was markedly decreased in all share rates, whereas the FBN level was increased. Hb and Hct showed a tendency for higher concentration at 6 weeks.

CONCLUSIONS

Long-acting injectable TU provides another reliable treatment option for testosterone replacement therapy. Moreover, the patients may receive additional beneficial effect in lowered whole blood viscosity.

Echocardiographic findings in power athletes abusing anabolic androgenic steroids

PURPOSE

Anabolic androgenic steroids (AAS) abuse for improving physical appearance and performance in body builders is common and has been considered responsible for serious cardiovascular effects. Due to disagreement about cardiovascular side effects of these drugs in published articles, this case control study was designed to evaluate the echocardiographic findings in body builder athletes who are current and chronic abusers of these drugs.

METHODS

Body builder athletes with continuous practice for the preceding two years and were training at least twice weekly were selected and divided into AAS abuser and non user and compared with age and BMI matched non athletic healthy volunteers (15 cases in each group).

RESULTS

There was no significant difference in left ventricular size or function either systolic or diastolic in comparison to cases and control groups. The only difference was in diastolic size of septum and free wall but observed differences were only significant (P = 0.05) between first (athletic with AAS abuser) and third group (non athletic and nonuser). The difference between the above-mentioned indexes were not significant between two groups of athletes.

CONCLUSION

Observed differences in diastolic size of septum and free wall is in favor of that long term abuse of anabolic steroid results in accentuation of physiologic hypertrophy due to long term sport most probably due to higher rate pressure product. Furthermore long term abuse and supra pharmacologic doses do not have significant effect in size and left ventricular function.