Anabolic Steroids and Athletic Performance

Anabolic Steroids and Athletic Performance

At a time when we are talking about the Olympics, I wanted to write about anabolic steroids (Anabolic Steroids), which were once used for doping purposes, and which may cause significant health problems, although their use has relatively decreased today due to increased awareness of their negative effects. Anabolic-androgenic steroids are synthetic testosterone derivatives that increase skeletal muscle development with their anabolic effects and cause the development of male sex characteristics with their androgenic effects, regardless of the gender of the user.1

History

Historically, the use of performance enhancing substances dates back to ancient Greece. Anabolic steroids entered our lives with the synthesis of testosterone in 1935 and were used to treat depression at that time. Its use became increasingly widespread and abuse among professional athletes began; it is known that testosterone was given to Russian weightlifters at the 1954 Olympics. Tests to detect AS use were only developed in 1974 and its use was banned in 19761.  After the 1980s, its use began to increase in the general population, often for personal image enhancement rather than athletic performance.

Epidemiology

Most anabolic steroid users are men in the 20-30 age group. Those with body perception disorders such as muscle dysmorphia, those involved in competitive sports and bodybuilders constitute the risk group2. Although AS use has declined since the early 2000s, it is estimated that there are more than 3 million active users in Europe.

Patterns of Use

Anabolic steroids are known on the market by names such as “roids” or “juice”. They are available for oral or intramuscular use. Oral administration is usually preferred because of faster clearance from the body. The pattern of use may vary. Generally, multiple doses of AS are used “cyclically” by taking it for a certain period, then stopping it for a period and then restarting it. In “stacking” use, two or more AS are used together, combining oral and IM forms, sometimes even veterinary forms. In this pattern of use, the user believes that the drugs have a synergistic effect and are more effective than when used individually3.

In another pattern of use, “pyramiding”, the user gradually increases the dose of AS from the beginning of the cycle and then decreases it again after the middle of the cycle, bringing the dose down to zero. This cycle is usually followed by a cycle in which the athlete continues training without using AS. In this pattern, it is believed that the body adapts to the high dose of AS during the pyramiding period, while the normal hormonal cycle is restored during the drug-free period. In the “plateau” technique, different types of steroids are used together to prevent the development of tolerance. None of these methods have been scientifically proven to be effective. The doses taken in AS abuse are 10-100 times higher than the doses used clinically for therapeutic purposes.

Side effects of Anabolic Steroids

Cardiovascular system: Hypertension, coagulopathy, acute coronary syndrome, stroke, arterial damage

Endocrine system: In men; decreased sperm production, gynecomastia, testicular shrinkage, male pattern baldness, testicular cancer.

Endocrine system: In women; thickening of the voice, breast shrinkage, rough skin, male pattern baldness, increased body hair growth

Infections HIV, hepaptitis

Liver Pleosis hepatis (a disease in which blood-filled cysts form in the liver), tumors

Musculoskeletal system: Short stature, tendon damage due to use in adolescence

Skin Skin acne and cysts, oily skin, jaundice, abscess at injection site

Psychiatric effects: aggression, mania, delusions, anxiety

Some of these side effects are reversible and resolve with AS withdrawal. Reversible side effects include mood changes, increased appetite, acne, edema, changes in libido, menstrual irregularities. Some side effects do not improve even when the drug is stopped. These irreversible effects include hirsutism, voice tone changes, male pattern baldness, receding hairline, short stature due to adolescent use and premature masculinization or feminization.

When evaluating these individuals, it is also necessary to question other medications they may be taking to prevent AS side effects. Concomitant use of tamoxifen for gynecomastia, human chorionic gonodotropin for testicular atrophy, diuretics for edema and opioid derivatives for pain is common.

Addiction of Anabolic Steroids

Anabolic steroids regulate cellular function and gene expression by acting through androgen receptors. They also increase intracellular calcium levels in skeletal muscle, heart and brain, where calcium plays an important role in neuronal transmission. Some studies have shown that they trigger anxiety by acting on GABAa receptors and also alter dopamine and serotonin levels in the brain3.

Most users develop abuse, meaning that they continue to use AS despite serious health-threatening side effects. If tolerance develops, meaning that the person needs more steroids to produce the same effect, and withdrawal symptoms occur when the person tries to stop using AS, then addiction has developed. One study showed that 1/3 of users develop dependence.  Withdrawal symptoms include restlessness, fatigue, loss of appetite, insomnia and decreased sexual desire. However, the most feared withdrawal symptom is depression, which can result in suicide.

Assessment of the patient using Anabolic Steroids

When evaluating these patients, the physical examination should look for signs of long-term effects of steroid use. Height, weight, body mass index, skin findings (male pattern baldness, hair growth, acne), breast examination (in terms of lactation and gynecomastia), genitourinary system examination, systemic cardiac findings and mood assessment should be performed. Judgmental questions should be avoided when questioning the patient. Ovarian carcinomas, polycystic ovary syndrome, adrenal neoplasia, Cushing’s syndrome and hepatitis should be considered in the differential diagnosis.

When the laboratory values of these patients are analyzed, testosterone/epitestosterone ratio is >4, LH and FSH are suppressed and IGF-1 is increased. As a result of steroid-induced side effects, increased platelets and erythropoiesis in complete blood count, increased blood sugar and liver enzymes, increased LDL cholesterol, decreased HDL and increased prolactin may be detected. These patients should also be evaluated from a cardiac point of view and ECG and ECHO should be performed. Signs of ischemic heart disease and cardiomegaly may be detected.

Management of Anabolic Steroid abuse

The management goal in these patients should be to address the underlying cause of anabolic steroid use. Body perception disorders such as muscle dysmorphia require psychiatric evaluation. Underlying endocrine disorders such as hypogonadism should be treated. In patients who develop addiction, depression should be intervened with antidepressant treatments, the patient should be encouraged that this condition is temporary and should be encouraged to continue sports.

The long-term side effects of anabolic steroids should be explained in detail and relatively safer alternatives for increasing muscle mass, diet and exercise should be offered. Follow-up at least once a year is recommended for those who continue to use despite everything.

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