Anabolic steroids

Users would benefit from healthcare advice, says Dr Euan Lawson.

Professional athletes account for only a small fraction of total users (Photograph: SPL)
Professional athletes account for only a small fraction of total users (Photograph: SPL)

Anabolic steroids are a group of drugs with similar actions to endogenous testosterone that have performance enhancing effects. Strictly speaking they should be referred to as anabolic-androgenic steroids as they all have androgenic activity to a greater or lesser degree.

Steroids are controlled as a class C drug but personal possession for medical use is not illegal.

Data from the British Crime Survey (BCS) in 2009/10 showed that 0.7 per cent of 16- to 59-year-olds in England and Wales have used anabolic steroids at some point in their life. The BCS showed no upward trend over the past 10 years but needle exchanges have reported a 2,000 per cent increase in the total number of steroid users over the period 1991-2008.

Recognising steroid users
The typical user will be male although some female use can be seen in competitive bodybuilders and sportswomen. Professional athletes might use steroids to enhance their performance but they account for only a small fraction of the total users.

Occupational use can be a reason for those in the security industry, including prison and police officers or door supervisors (bouncers). Many will use steroids simply to increase muscle mass and their own body image satisfaction. It may be useful to consider the possibility of steroid use in anyone with mesomorphic or hyper-mesomorphic body type.

Although some users are reluctant to disclose steroid use to their GP there is evidence many would welcome input from a health professional. However, there are plentiful sources of information on the internet and users will often rely on advice from local gyms. An open and supportive approach is needed to encourage anabolic steroid users to engage with medical services.

Steroid use
The regimens used can be complex but typically will involve cycling, stacking and the use of ancillary drugs.

During cycling the steroids are taken for a short duration (perhaps six to 12 weeks) followed by a period of drug-free training. The rationale being that this will allow the hypothalamic-pituitary-gonadal axis time to resume normal function. The users want to prevent tolerance to the steroids and limit side-effects.

Often steroid users will take two or more anabolic steroids together and this is known as stacking. Every steroid has a slightly different pharmacological profile and the hope is to achieve additional benefits.

There are a number of ancillary drugs that are used to help enhance performance and manage side-effects. These include tamoxifen, clomiphene, growth hormone, clenbuterol, human chorionic gonadotrophin and diuretics, such as spironolactone.

There is also evidence that users are more likely to use recreational drugs, such as cocaine.

Risks of steroid use
One of the biggest dangers with steroids is the risk of counterfeit products. Many are bought over the internet and may not be subject to the good practices in the production of pharmaceuticals. There is a risk of contamination and the strength of medications may vary.

Most steroid users inject and are therefore at risk of bacterial infections at injecting sites. They are also at risk of blood-borne viruses, such as HIV, hepatitis B and hepatitis C.

Most of the harmful effects of steroids are not life threatening and the literature on side-effects is weak and heavily reliant on self-reporting. Acne has been commonly reported and some have noted male pattern baldness and increased body hair.

Steroid use may be associated with a number of psychological and behavioural problems including aggression, violence, depression and hypomania. It remains unclear whether steroids can cause dependence.

Gynaecomastia can occur when excess circulating steroids go through aromatisation to estrogens. It can also be caused by ancillary drugs, such as spironolactone.

Users may self-treat with tamoxifen or clomiphene. Most gynaecomastia will resolve spontaneously but it is recommended that the current steroid cycle is stopped.

There have been a small number of deaths linked to liver damage from long-term steroid use and this is particularly associated with oral anabolic steroids.

Management of users
The key issue is to ensure you establish what the user wants from the consultation. Newer users may be able to achieve their goals through alternative methods - perhaps with advice on exercise and nutrition. However, a long-term user may be seeking professional advice on using safely and minimising risk.

Offer harm reduction advice - ensure they can access sterile injecting equipment and give advice on safe use. Warn of the risk of counterfeit drugs and encourage them to keep 'on-cycles' brief.

Offer examination for physical effects. This might include: pulse, BP, injection site inspection, skin for acne and chest for gynaecomastia. Assess testicles for any atrophy. Assess mental health and screen for depression. Take blood for LFTs and check for hepatitis B, C and HIV.

Key points

  • Consider anabolic steroid use in people with mesomorphic body type.
  • An open and supportive approach is needed to encourage anabolic steroid users to engage with medical services.
  • Give advice on how to access sterile injecting equipment and how to inject safely.
  • Check LFTs, hepatitis B, C and HIV status.
  • Accept that some will not stop and be prepared to offer monitoring of their health.
  • Dr Lawson is a GP in Cumbria and RCGP lead for the Certificate in the Detection, Diagnosis and Management of Hepatitis B and C in Primary Care
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