STEROIDS

OFFICIAL NAMES: Anabolic-androgenic steroids, ergogenic drugs

STREET NAMES: Rhoids, juice, gear, stuff, junk, and ragers, D-bol or D-ball (Dianabol); Depo-T (Depo-Testosterone); test or t (testosterone); Andro (androstenedione); Deca or Deca-D (Deca-Durabolin)

DRUG CLASSIFICATIONS: Schedule III, hallucinogen

OVERVIEW

Anabolic steroids is the familiar term for the synthetic versions of the male sex hormone testosterone. One of the body's many chemical messengers, testosterone promotes the growth of skeletal muscle and the development of male sexual characteristics in puberty, such as enlargement of the penis, growth of facial and pubic hair, a deepening voice, and greater muscular development in boys. The average adult male naturally produces less than 10 milligrams (mg) of testosterone each day. In contrast, the average steroid user takes more than 100 mg daily. The proper term for these compounds is anabolic-androgenic steroids (AAS) because they have bodybuilding (anabolic) effects as well as masculinizing (androgenic) effects. Commonly referred to as steroids, AAS should not be confused with a different group of steroids called corticosteroids. Corticosteroids such as prednisone and cortisone are used to treat illnesses such as rheumatoid arthritis, asthma, and inflammatory diseases.

AASs are used nonmedically to improve athletic performance, physical appearance, and fighting ability. AAS-using bodybuilders believe that AASs enhance their physical strength, boost their confidence and assertiveness, and improve feelings of sexuality. Teens who use AAS tend to use them to improve their physical appearance, and are more likely to use other drugs, tobacco, or alcohol. Three types of nonmedical AAS users have been identified. The first group are athletes who desire to win at any cost, often believing that their competitors are also using AASs. The second group are often bodybuilders or aspiring models whose aim is to create a beautiful body. They display their bodies to obtain financial rewards and respect. The third group use AASs to become more intimidating and to improve their fighting ability. These may include body or prison guards, police, or gang members whose survival depends on their readiness to fight.

History

The first synthetic versions of testosterone were created by European researchers soon after 1935, the year testosterone was first isolated in laboratories. Intended for medical reasons, AASs were devised to help people rebuild body tissue lost through disease. In fact, after World War II ended in 1945, AASs were given to many starving concentration camp survivors to help them add skeletal muscle and gain body weight. Overall, the medical use of AASs has been rare. For example, in the 1960s AASs were used to treat the reduced height (also called short stature) that occurs in a condition called Turner syndrome. Then human growth hormone became available and replaced the use of AASs for this condition. The primary medical use of AASs has been to treat hypogonadism, a condition in which the testes do not produce sufficient testosterone.

While bodybuilders and weightlifters may have started using AASs in the 1940s, Olympic athlete usage began in the 1950s. Until the 1970s, when drug testing technology advances could detect AASs in the urine, their usage went undetected. In 1975 AASs were added to the International Olympic Committee's list of banned substances. However, testing was spotty. For example, at some of the 1984 Olympic sporting events, unplanned detection tests were given to athletes. The results? About half the tested athletes had taken steroids. International awareness of steroid abuse increased in 1988 when Canadian sprinter Ben Johnson tested positive for AASs in the Seoul Olympic games and had to forfeit his gold medal to the second-place finisher, American Carl Lewis. Also that year, a survey showed that 6.6% of American male high school seniors had tried AASs. These two events jumpstarted efforts to include AASs in the Schedule III of Controlled Substances Act, which occurred in 1991. Today the use among teenagers does not appear to be decreasing. Also, because the testing of athletes for AAS use varies widely among countries and competitive events, many athletes continue to take AASs without detection.

Scientists have developed hundreds of different AASs, which require a prescription to be used legally in the United States. Those obtained illegally are smuggled in from other countries, diverted from U.S. pharmacies, or synthesized in illegitimate laboratories. Most illicit AASs are sold at gyms, during competitive events, or through illegal mail operations. It is estimated that illegal steroid sales top more than $500 million each year.

In addition, dietary supplements that have steroidal properties can be purchased legally; common ones are dehydroeiandrosteroine (DHEA) and androstenedione. As of 2002, the effects of these dietary supplements are being researched for possible inclusion as an banned substance.

CHEMICAL/ORGANIC COMPOSITION

Testosterone contains 19 carbon atoms in a four-ring structure, with each numbered from one to 19. Modifications in the carbon atoms creates the hundreds of synthetic AASs that exist today. For example, many common synthetic forms of testosterone have alterations on their seventeenth carbon. AASs created in pill form have an added alkyl group, which is a chain of carbon and hydrogen atoms. These 17-alkylated AAS compounds are more toxic to the liver and more likely to cause cholesterol abnormalities. Common 17-aldylated AASs include Dianabol, Android, and Winstrol. When the addition to the seventeenth carbon is an ester, which is an acidic chain of carbon and hydrogen, the synthetic form is an injectable form that is less toxic on the liver and cholesterol levels. Depo-Testosterone is an example of the injectable testosterone ester. AAS abusers also use veterinary products, such as Finajet and Equipoise, that have been devised for animal usage.

Why were all these derivatives of testosterone initially developed? Researchers had several goals. They sought to make derivatives that were oral medications, that prolonged its biologic activity, and that are more anabolic (particularly, muscle-building) and less androgenic (masculine characteristics) than the parent testosterone. Unfortunately many of the illegal steroids are manufactured under unsupervised conditions, and may be contaminated, or contain unexpected or fake ingredients. A European study analyzed 40 AASs obtained on the illegal market and found over one-third did not contain ingredients indicated on the label. One report estimates that one-third to one-half of the illegal steroids that teens buy are fake.

INGESTION METHODS

Steroids are taken orally, by injection, through skin patches, or as gels or creams rubbed on the skin. Injections are taken in the large muscle groups such as buttocks, thigh, or shoulder; or under the skin. The doses taken are often 10 to 100 times higher than the doses prescribed for medical conditions.

Steroid abusers often "stack," "cycle," and "pyramid." Stacking is the term used when different AASs are combined, such as taking two or more different anabolic steroids; or mixing oral, injectable, and even veterinary products, because of the belief that different steroids produce a greater effect than each drug individually. Cycling is six to 12 weeks on the drug followed by the same time period off. Pyramid doses are often used, which is when the dosage of the drugs is increased during the first half of the cycle and then slowly decreased the second half. Abusers believe pyramiding gives the body time to adjust to the high doses. No scientific research exists that backs the perceived benefits of stacking, cycling, or pyramiding.

The most common illegal AASs include: boldenone (Equipoise), ethlestrenol (Maxibolin), fluxoymesterone (Halotestin), methandriol, methandrostenolone (Dianabol), methyltestosterone, nandrolone (Durabolin, DecaDurabolin), oxandrolone (Anavar), oxymetholone (Anadrol), stanozolol (Winstrol), testosterone, and trenbolone (Finajet).

THERAPEUTIC USE

Physicians most commonly prescribe AASs for hypogonadism or testosterone deficiency, a condition where boys and men produce deficient levels of testosterone. AAS has also been prescribed to treat body-wasting diseases such as advanced human immunodeficiency virus (HIV) infection, when the loss of lean body mass is common. Additionally, men with the advanced disease often have low testosterone levels. Studies have shown that HIV patients given AASs experience significant increases in muscle and lean body mass, as well as improved quality of life, appearance, and well-being. AASs also increase muscle in other muscle-wasting conditions, such as chronic obstructive pulmonary disease (COPD), severe burn injuries, alcoholic hepatitis, and most recently in patients with chronic renal failure. The loss of lean body mass is associated with a higher death rate in many of these conditions. Also, AASs have been medically used in bone marrow failure syndromes, in a rare skin condition called hereditary angioedema, and certain forms of anemia and impotence. In women, AASs have been used in advanced breast cancer, endometriosis, a condition of abnormal uterine tissue growth, and have been combined with female hormones to treat menopausal symptoms. While all these uses are uncommon, AASs do provide a valuable treatment option.

Use of AASs as a therapy for cardiovascular disease, particularly to increase skeletal muscle strength in patients who have congestive heart failure, a condition in which fluid congestion occurs as a result of heart failure, is also being studied. AASs have been proposed for treatment in the cachexia, or wasting that accompanies certain cancers, as well.

USAGE TRENDS

Scope and severity

AAS usage has increased substantially over the past decade. In the United States, the typical AAS user is male, but usage is growing among females. Although adults make up a majority of AAS users, the estimated use among teens ranges from 2.5% up to 6%, depending on the study and age group. According to the 2001 National Institute on Drug Abuses' Monitoring the Future study, which tracks drug use and attitudes in adolescents, an estimated 2.8% of eighth, 3.5% of tenth graders and 3.7% of twelfth graders have taken AASs at least once in their lives. This represents a significant1.2% increase for seniors, and a plateau for tenth graders. Lifetime usage for eighth graders had decreased slightly compared to the prior year (3% in2000). Not surprisingly, recent use also increased for seniors. Seniors' use of AASs during the prior year had increased from 1.7% in 2000 to 2.4% in 2001. Other surveys of middle school students and college students in the United States and among Canadian middle and high school students found overall prevalence rates of2.7% to 2.8%. Higher figures are often found in youth participating in sports. Obtaining anabolic steroids is not difficult. Almost half (44%) of twelfth grade students reported that it is "fairly easy" or "very easy" to get steroids. In an 1992 investigation by U.S. News and World Report, over half of teen AAS users said they were influenced to use the drugs by reading muscle magazines. Four of 10 were influenced because they thought famous athletes were taking them.

It is known that adult bodybuilders and weight-lifters are big users of AASs. Less data exists on the extent of steroid abuse among adults, however, the percentage of adults who have tried AASs appears to be lower than adolescents. In a 2000 Monitoring the Future study that surveyed Americans aged 19–40, 1.4% of young adults (ages 19–28) surveyed reported using steroids at least one time during their lives, and 0.4% reported past year usage. Still AAS use is fairly common in society. About 19% of 19–22 year-olds reported having a friend who was a current AAS user. In addition, experts think the usage figures for both teens and adults are probably considerably higher, because many people hide AAS use.

Age, ethnic, and gender trends

Use in adolescents. Teenage males are most likely to use anabolic steroids; about three times as many male teens use anabolic steroids compared to female teens. The average age of starting AASs is 14, which alarms the medical community because of the stunting of height that can occur. One leading AAS researcher, who bases his estimates on regional and national data, believes that 4–6% of high school boys have taken steroids, and 1–2% of high school girls. This means at least a half million American teenagers have used AASs. Among high school seniors surveyed in 2000,2.5% of males reported steroid use in the past year compared to 0.9% of females. For tenth graders it was 3.7% of males compared to 0.8% of females. A 1998 Pennsylvania State University study found 175,000 high school girls nationwide had taken steroids at least once in their lifetime. According to the study, more than half have tried AASs before age 16, but some start as young as age 10. In the United States, these adolescents are more likely to use other illicit drugs (particularly

cocaine, amphetamines, and heroin), as well as alcohol and tobacco.

Student athletes are more likely than non-athletes to use AASs. Football players, wrestlers, weightlifters, and bodybuilders have significantly higher usage rates than students not engaged in these activities. In one 1999 study of 873 Indiana high school football players6.3% were current or former AAS users, with the average age at first use being 14 years. Fifteen percent had begun taking AASs before age 10. Almost half the respondents said they could easily obtain steroids and listed athletes, physicians, and coaches as sources. Usage was higher in the South and Midwest than the West and Northeast.

Fewer studies outside the United States are available, but prevalence rates in countries such as Canada, Australia, Great Britain, and Sweden appear to be similar. Primary users in other countries are also male adolescents. One Swedish study showed a higher usage(3.7% prevalence) among 16 year-olds than 17 year-olds(2.8%). These male users tended to strength train but also exhibited self-esteem or school achievement problems and used tobacco, alcohol, and other drugs, such as narcotics. Usage among female adolescents in Sweden was nil. Among 13,355 Australian high school students,3.2% of males and 1.2% of females reported using AASs sometime in their lives. In other countries, such as South Africa, prevalence appears to be less.

Use in adults and ethnic use. Usage among professional athletes is also high, although exact figures are not known. Fifteen U.S. powerlifters who competed internationally participated in a survey that involved an anonymous questionnaire. Of these 15, 10 reported using AASs and five admitted they avoided detection during the International Olympic Committee's doping control procedures. In a 2000 study, 25 of 75 women athletes from Boston gyms reported current or previous use of AASs, and also reported using many other performance-enhancing drugs.

One interesting finding in women users is the history of rape. One 1999 study of 75 female weightlifters found nine women began or greatly increased weight lifting activities after being raped as a teenager or adult. Five began abusing anabolic steroids and two others began to use another illegal substance called clenbuterol to gain muscle mass after their rape.

Little data exists on ethnic breakdown of AAS usage in teens and adults. In one study, African American and Hispanic girls were less likely than Caucasians to diet and exercise, but were more likely to report behaviors aimed at weight gain.

MENTAL EFFECTS

AASs typically do not have any immediate psychological effect, but men and women often experience both negative and positive effects. Psychological effects reported by over half of users in one study included a mild state of mania and increased irritability. Probably the most significant behavioral effect is increased aggressive behavior, which was reported by 40% of those surveyed. Steroid users have reported aggressive acts, such as fighting, using force, and armed robbery, while others have committed property crimes, such as stealing, damaging property, or breaking into houses or buildings. "Roid rage" is a slang term for describing the aggressive feelings and behaviors from AAS use. What is uncertain is whether the steroids' direct effects on the brain triggered the aggression or whether the perceived link between steroids and aggression is an excuse to commit the acts. To test this, four studies have been conducted that compared high steroid doses or placebo to reported behavioral symptoms. Three of the four studies showed high steroid doses produced greater feelings of irritability and aggression than placebo. Some researchers believe many, but not all, anabolic steroids increase irritability and aggression.

Tolerance, needing more of a drug to get the same effect, was first demonstrated in AAS use among animals in the 1950s. In two 2000 studies, 12% to 18% of AAS users reported tolerance. Other behavioral effects reported are euphoria, increased energy, sexual arousal, mood swings, distractibility, forgetfulness, and confusion. A minority of volunteers that were given high steroid doses developed extreme behavioral symptoms that affected their jobs and personal lives. There are also the following reported behavior effects when steroid use is stopped: depression, mood swings, fatigue, restlessness, loss of appetite, and reduced sex drive. Overall, the prevalence of extreme cases of violence and behavioral disorders is small, but incidents may be underreported.

In a 2000 study of female athletes from gymnasiums, 40% reported symptoms of depression during withdrawal from AASs. Another finding was both AAS-using and nonusing women reported several unusual psychiatric syndromes, such as eating disorders, nontraditional gender roles, and chronic preoccupation with their physiques.

PHYSIOLOGICAL EFFECTS

Oral AASs are rapidly absorbed and result in an increased AAS concentration in the bloodstream within a few hours, although it is several days before the AAS completely passes through the system. Intravenous AAS solutions are absorbed more slowly. Athletes who use large doses of AASs and strength train do get larger and stronger muscles. One study involving 21 male weight trainers showed greater strength and body weight and increased muscle girth when compared to the group without AAS. Another study showed the trunk and legs of 16 bodybuilders on AASs experienced the most significant increase. While the composition of the muscle fibers does not differ, it appears that AAS users form new and larger muscle fibers. The increase in lean body mass and body weight continues for at least a short time after AAS use stops. However, AAS use is linked to a number of adverse side effects, which range from acne to life-threatening heart attacks and liver cancer. While most side effects, are reversible when the user stops taking the drug, some are permanent. Certain side effects occur due to some of the testosterone being chemically changed in the body to the female hormone estrogen. This leads to higher than normal estrogen levels—and potential side effects.

Harmful side effects

Hormonal effects. Steroid use alters the normal production of hormones, raising the blood levels to many times the amount naturally produced. This change in the body's hormonal balance can cause both reversible and irreversible effects in many parts of the body. Males can experience enlarged prostate glands, which makes urination difficult. A shrinking in testes (called testicular atrophy), lowered sperm production, and sterility has resulted from AAS use. In a 2001 study by J. Torres-Calleja published in Life Sciences, eight of 15 bodybuilders using AAS had below-normal sperm counts, and three had no sperm. The average sperm counts for the control group, 15 bodybuilders not on AAS, were within normal limits. Luckily, these changes are reversible, although one case of prostate cancer has been reported. Irreversible changes in males include breast enlargement, called gynecomastia, painful breast lumps, and baldness. In one study of male bodybuilders, more than half experienced testicular atrophy and gynecomastia. In fact, the number one visit to physicians for AAS users is gynecomastia. In severe cases, AAS users with enlarged breasts resort to surgical treatment that involves liposuction, a cosmetic surgery in which excess fatty tissue is removed. However, this is not without risks. A review of 20 patients surgically treated for AAS-induced gynecomastia showed six had complications or recurrence of the gynecomastia.

Children or adolescents taking AASs before or during puberty can seriously stunt their height. The artificially high sex hormone levels found in AASs can initiate the characteristics of male puberty. Normally, rising levels of testosterone trigger bone growth, but when hormones reach certain levels they signal a halt in bone growth. The high levels in AAS use can prematurely end the growth of the long bones, which results in shorter adult heights than would normally occur.

In women who take AASs, the surge in male hormones exerts a profound effect on a delicate hormonal balance. Due to the higher testosterone levels from AAS use, breast size and body fat decrease, skin becomes coarse, voice deepens, and the clitoris enlarges. Menstrual periods become irregular and sterility may result. Also, women may develop excessive hair growth on the chest and face but lose scalp hair. As steroid use continues, some of these effects may be permanent. For both sexes, increases and decreases in sex drive have both been reported.

Cardiovascular and liver effects. Steroid use has been linked to cardiovascular diseases (CVD), including heart attacks and strokes in athletes younger than 30. Although studies are required to determine how much of this is due to a genetic propensity for CVD, changes in cholesterol levels of AAS users have been noted. One study that analyzed the blood of AAS-using bodybuilders found high calcium and cholesterol levels in a significant number of them. Research has been published that shows AASs, particularly the oral or 17-alkylated compounds, decrease the level of high-density lipoprotein (HDL), which is referred to as the good cholesterol because it is thought to protect against heart disease. Some research has also shown increased levels of low-density lipoproteins (LDL) or bad cholesterol. Studies are mixed as to whether the lowered HDL level from AAS use leads to CVD.

Additionally, AAS users experience lower triglyceride levels than non-users. High triglyceride levels are also associated with heart disease. Low HDL levels and high LDL levels increase the risk of atherosclerosis, the condition where fatty substances are deposited on the inner walls of arteries. The disruption in blood flow can cause a stroke when blood is prevented from reaching the brain, or a heart attack when blood does not reach the heart muscle. Cholesterol levels return to normal when AAS use stops. The potential development of blood clots also increases with AAS use, which can disrupt blood flow. The changes in cholesterol levels appear to return to the person's baseline levels after AAS discontinuation.

Another possible adverse effect is an increase in blood pressure, which also returns to normal when AAS use stops. Some studies also show that those taking AASs can develop an enlarged heart. One 2001 study reported that 10 bodybuilders on AAS had larger left heart ventricles, the heart's primary pumping chamber, compared to 10 bodybuilders who were not taking AASs. It does appear that enlarged ventricles also routinely occur in AAS-free athletes who intensively resistance-train as part of the body's physiological response to weight lifting. Anabolic steroid use probably accelerates the process. As of early 2002, studies do not show evidence that this leads to heart problems.

As mentioned, the 17-alkylated AASs are more toxic to the liver than the other forms. With AAS use, the liver releases higher levels of some enzymes into the bloodstream. However, some researchers have found that all bodybuilders, both those taking and not taking AASs, experience higher enzyme levels due to the muscle damage that occurs in the sport. Bilirubin, the substance that causes the yellow skin and eyes, called jaundice, is also increased, and has been reported in users. A 2000 study by Yesalis showed that up to 17% of patients treated medically with 17-alkylated AASs developed jaundice. Jaundice usually disappears after anabolic steroids are discontinued. AAS use has been linked with a rare condition called peliosis hepatis, in which little sacs of blood form in the liver. Lastly, liver tumors may occur in 1–3% of patients or users who have taken high doses of 17-alkylat-ed AAS for more than two years. Other rare liver tumors have occurred with other types of AASs. Although more than half of the tumors disappeared with AAS stoppage, others were cancerous and/or resulted in death.

Other effects. The most common skin side effect with steroid use is acne, which is reversible, and occurred in 48% of AAS users in one study. Cysts, and oily hair and skin have also been reported. Other possible effects include small increases in the number of red blood cells, and a worsening of pre-existing conditions such as sleep apnea, a condition where people stop breathing during sleep; and muscle twitches called tics.

People who inject AASs are at higher risk for infections because of nonsterile injection techniques or sharing contaminated needles. In the United States, half of AAS users administer their compounds by needle and one-fourth of adolescent AAS users share needles, placing them at high risk. Products manufactured illegally may also have been prepared with nonsterile methods, which increase the potential of developing viral infections such as HIV, and hepatitis B or C. Bacterial infections can result at injection sites or in the body as infective endocarditis, a bacterial illness that causes a serious inflammation of the inner lining of the heart.

Long-term health effects

Overall, the incidence of life-threatening effects appears to be low, but this may be due to a failure to recognize and report negative effects. Most data on the long-term effects of AAS come from individual case studies rather than formal larger studies. Problems that may persist after usage stops in men are breast development (gyneocomastia) and male-pattern baldness. The situation for women is more serious. The side effects of excessive body hair, skin coarsening, male pattern baldness, and voice deepening are often irreversible. As mentioned, the stunting of normal growth in young AAS users may be permanent.

Increased mortality among AAS users is another possibility. In 2000 a study was published that analyzed 62 male high-ranking competitive powerlifters in Finland who were strongly suspected to have used AASs for several years. Following them for 12 years, nearly 13% had died compared to 3.1% in a control population of powerlifters. Suicide and heart attacks were the most common reasons. The Finnish authors identified three significant issues as causing early disease or death: negative effects on the cardiovascular system, effects on mental health, and a possible increase in the incidence of tumors. Probable causes were AAS use and other concurrent drug use. In fact, another study named the use of AASs with other drugs as a probable cause of increased death rates. Animal studies also demonstrate higher mortality. One study exposed laboratory mice to steroid doses comparable to human AAS doses for one-fifth of their life span. The result was a higher death rate among those given the highest dose than those given a low dose or no steroids. The average life span of the mice receiving the low dose was also shorter than the AAS-free group.

REACTIONS WITH OTHER DRUGS OR SUBSTANCES

As previously discussed, users often combine different AASs, sometimes over a dozen drugs, to achieve what they perceive as a more optimal effect. It is common for AAS users to take other drugs for several reasons: to increase body-building effects, to avoid detection by urine testing, or to manage unpleasant side effects. For example, research by Dr. Harrison Pope and other Harvard Medical School colleagues found that 9% of 227 men admitted for opioid treatment reported AAS use. Most had started opioid drugs to counteract steroid-induced insomnia and irritability or depression. Many said they were introduced to opiods through their steroid dealers and through the bodybuilding subculture. Other examples of drugs taken concurrently with AASs include estrogen blockers such as tamoxifen or clomiphene to prevent breast development; water pills (diuretics) to eliminate water so muscles look more defined; and human chorionic gonadotropin (HCG) to prevent testes shrinkage. HCG is an injectable, nonsteroidal hormone that stimulates the testicles to produce more testosterone. Another nonsteroidal hormone, human growth hormone, is taken to increase muscle and

body size. Other illegal drugs include thyroid hormones, amphetamines, gamma-hydroxybutyrate, clenbuterol, and Nubain. All these carry potentially serious side effects.

TREATMENT AND REHABILITATION

Studies on AAS treatment are lacking, but most experts believe a standard substance abuse treatment model works with AAS treatment. Current knowledge is based on feedback from a few physicians who have worked with patients undergoing anabolic steroid withdrawal. Supportive therapy, in which patients are educated about what they will experience during withdrawal, is helpful in some cases. Medications or hospitalization may be necessary if symptoms are severe or prolonged. Medications used have included antidepressants for depression, analgesics for pain, and other medications that help restore the hormonal system after AAS use. Behavioral therapies are sometimes used.

PERSONAL AND SOCIAL CONSEQUENCES

While AASs typically do not have any immediate effect, users often experience both negative and positive effects. People on steroids can experience personality and mood changes. Wide mood swings can occur, and users can suddenly become angry and bad-tempered. Withdrawal from steroids can be difficult. Significant depression often begins when AAS use is stopped. Dr. Roberto Olivardia, a psychologist at McLean Hospital, finds men often experience very severe depression within months of AAS stoppage. They are often emotionally numb, and operate in a zombie-like state, which often leads to a continued steroid use. Backing this observation are studies indicating between 14% and 57% of nonmedical AAS users develop depression. The depression can become severe enough that suicidal thoughts occur, with the suicide risk highest during withdrawal. Other reported side effects during withdrawal include fatigue, loss of appetite, difficulty sleeping, decreased sex drive, headaches, and muscle aches.

Another difficulty of AAS use is the expense. Anabolic steroids are not cheap. One teen's combination of four steroids for one "stack," consisting of two injectables and two pills, cost $800.

As mentioned above, a serious consequence among children or teens who use AAS is a stunting of growth, and never reaching their intended height. Because small doses of steroids can stunt height, physicians seldom prescribe AASs for young people.

How the AAS user is perceived

Most people believe AAS users take them because they want to improve their physical appearance. In fact, teens surveyed named this for a primary reason, as opposed to improving sport performance. One study found AAS users tend to have more narcissistic personalities traits, defined as excessive admiration of oneself, and have less empathy. It is unclear whether these traits contribute to starting AASs or result from the use of steroids. Adolescents are less likely than they were a decade ago to disapprove of short-term steroid use or to view it as a great risk. In the 2001 Monitoring the Future survey, 60% saw it as a great risk compared to 70% in surveys in the 1990s. Likewise, the number of adolescents who disapproved of using AAS once or twice had decreased from 90% in the early 1990s to 85%.

Perhaps more than other drugs, AAS users often hide use from their peers. "For many anabolic steroid users it can be a very isolating experience because they don't want anyone to know," says Dr. Olivardia. "They want to project the illusion that their body was produced by diet and hard work alone." Others will only disclose usage with close friends because of the element of shame that accompanies AAS use.

LEGAL CONSEQUENCES

Legal history

Although AASs were first developed in the mid to late 1930s for medical use, it was not until 1991 that AASs were added by federal law to the list of Schedule III of the Controlled Substances Act (CSA). In the mid-1980s media reports of the increasing use of AASs in sports and a "silent epidemic " in high schools came to the attention of the U.S. government and Congress. Between 1988 and 1990, Congressional hearings were held, and consequently AASs were added to Schedule III, the same legal class as amphetamines, methamphetamines, opium, and morphine. Before that, federal regulation for AASs came under the jurisdiction of the Food and Drug Administration. In fact, trafficking of anabolic steroids was already illegal before they became classified as controlled substances. The CSA defines AASs as any drug or hormonal substance chemically and pharmacologically related to testosterone (other than estrogens, progestins, and corticosteroids) that promotes muscle growth. Schedule III controlled substances have recognized value as prescribed medications but carry the potential for abuse that may lead to either low or moderate physical dependence or high psychological dependence. In 1994, another act called the Dietary Supplement Health and Education Act was passed. This opened the door for dietary supplements with steroidal properties to be easily purchased over the counter.

Federal and state guidelines and penalties

Simple possession of AASs is a federal offense punishable by up to one year in prison and/or a minimum fine of $1,000. If the person has a previous conviction for certain offenses, the penalty is imprisonment of at least 15 days up to two years and a minimum fine of $2,500. Selling or possessing AASs with intent to sell is a federal felony. The first time someone is caught making or distributing steroids the penalty is up to five years in prison and/or a $250,000 fine. If caught a second time, prison time can be increased to 10 years. During 1989 and 1990, many states reclassified AASs to become controlled substances under state law. A 1991 survey of state legislation found that approximately 22 states had tightened their AAS laws. Because state laws differ, however, a wide range of penalties exist.

People who receive AASs by mail order can also be arrested. Federal law enforcement authorities monitor both international and domestic mail and can open suspicious packages. The Customs Mail Division inspects packages from outside the United States, and the Postal Inspector inspects domestic parcels. The huge volume of mail makes it difficult, but these agencies monitor and try to intercept parcels from addresses known to be connected with steroids.

In the United Kingdom, AASs and other performance-enhancing drugs were added to the Misuse of Drugs Act (MDA) in 1996.

See also Creatine

RESOURCES

Books

Carson, Judy. Steroid Drug Dangers. Berkeley Hieghts, NJ: Enslow Publishers, Inc., 1999.

Pope, H., et al. The Adonis Complex: The Secret Crisis of Male Body Obsession. New York: The Free Press, 2000.

U.S. National Institutes of Health. National Institute on Drug Abuse. Anabolic Steroid Abuse Research Report. Washington, DC: U.S. Department of Health and Human Services, April 2000.

Periodicals

" NIDA Initiative Targets Increasing Teen Use of Anabolic Steroids." NIDA Notes 15, no. 3 (July 2000).

Other

Collins, Rick. "Anabolic Steroids, Bodybuilding and the Law." <http://www.steoidlaw.com>.

"Steroids (Anabolic-Androgenic)." NIDA Infofax. February 2, 2001 (July 8, 2002). <www.drugabuse.gov/infofax/steroids.html>.

SteroidAbuse.org: A Service of the National Institute of Drug Abuse. <http://www.steroidabuse.org>.

Organizations

National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686, webmaster@health.org, <http://www.health.org>.

National Institute on Drug Abuse (NIDA), National Institutes of Health, 6001 Executive Boulevard, Room 5213, Bethesda, MD, USA, 20892-9561, (301) 443-1124, (888) 644-6432, information@lists.nida.hih.gov, <http://www.drugabuse.gov>.

U.S. Drug Enforcement Administration, 2401 Jefferson Davis Highway, Alexandria, VA, USA, 22301, (800) 882-9539, <http://www.dea.gov>.

Linda S. Richards, MS, RD, CHES

Steroids

What Kind of Drug Is It?

Steroids are drugs that mimic the actions of testosterone (tess-TOS-tuhr-own), a hormone found in greater quantities in males than in females. Testosterone is responsible for male traits and the male sex drive. Steroids are synthetic versions of the testosterone that is produced by the body. Steroids help build muscle mass and strength.

Steroids are referred to medically as anabolic-androgenic steroids. The term anabolic describes the characteristics of the drugs that build muscle. The term androgenic refers to the way the substances heighten masculine traits. Most doctors use the acronym "AAS" to describe these steroids. This abbreviation helps avoid confusion with a different class of steroids, the corticosteroids. These other steroids are used widely to treat a variety of medical conditions, including internal swelling and inflammation; asthma (AZ-muh), a lung and breathing disorder; bronchitis, an illness that affects the bronchial tubes in the lungs; and allergic reactions. Unless otherwise noted, use of the term "steroids" in this entry refers to anabolic-androgenic steroids.

Anabolic-Androgenic Steroids (AAS)

Such steroids have some limited medical use. More commonly, though, they are abused in high doses to increase lean muscle mass and strength. Chemists have created more than 100 varieties of anabolic-androgenic steroids that are available legally by prescription only. New designer steroids, which are just slightly altered versions of existing prescription steroids, hit the black market regularly. Designer steroids are made in a laboratory and designed to pass through urine tests undetected.

Official Drug Name: Anabolicandrogenic steroids (ann-uh-BAH-lik ann-drah-JENN-ik STEH-roydz), androstenedione (ann-druh-steen-DIE-own or ann-druh-STEEN-dee-own), Deca-Durabolin, dehydroepiandrosterone (dee-HIGH-droh-EPP-ee-ANN-droh-stehr-own or dee-HIGH-droh-EPP-ee-ann-DROSS-tuhr-own; DHEA), Depo-Testosterone (DEH-poe tess-TOS-tuhr-own), Dianabol, ergogenic (UHR-go-JENN-ik) drugs, tetrahydrogestrinone (TETT-ruh-HIGH-droh-JESS-trinn-own; THG)

Also Known As: Andro, D-ball, D-bol, Deca, Deca-D, Depo-T, gear, juice, junk, ragers, roids, stuff

Drug Classifications: Schedule III, hallucinogens

In 1991, health concerns brewed over the abuse of steroids. As a result, steroids were placed on the list of Schedule III drugs under the U.S. Controlled Substances Act. Since then it has been illegal to possess or sell prescription steroids in the United States. While some illegal drug makers work hard to create synthetic male hormone drugs that will not be detected in drug tests, medical researchers are busy devising more accurate tests to spot these "designer" substances.

Overview

It is true that high doses of anabolic-androgenic steroids increase muscle size and endurance in both men and women. But this does not come without dangerous costs to the health of the user. "Research has shown that the inappropriate use of anabolic steroids can have catastrophic medical, psychiatric and behavioral consequences," wrote Dr. Nora D. Volkow, director of the National Institute on Drug Abuse (NIDA), in "Consequences of the Abuse of Anabolic Steroids." Volkow added: "We are now facing a very damaging message that is becoming [widespread] in our society—that bigger is better, and being the best is more important than how you get there."

In fact, use of high doses of anabolic-androgenic steroids by men and women has been linked to heart problems, negative sexual side effects, aggressive behavior, depression, and suicide. The way steroids are misused to build muscle leads to chemical imbalances in the body that can affect the mind and the body's metabolism. "Steroids are toxic [harmful and poisonous] substances that have to be cleaned from your body by your liver and kidneys," noted Terry Goodland in Flex magazine. Goodland added, "without regular testing by a doctor, you will have no idea how your body is dealing with the drugs until it's too late."

Research on Testosterone

The history of experimentation with testosterone, the main hormone associated with male characteristics, began in 1889. That year, French-born scientist Charles Edouard Brown-Sequard (1817–1894) reported that he had injected himself with a compound taken from the testicles of dogs. He said the compound made him feel stronger and more energetic. In fact, he recommended it highly as a "fountain of youth."

In the early twentieth century, scientists experimented with natural testosterone. They thought it might decrease symptoms of age-related illnesses and syndromes such as senility (suh-NILL-ihtee), a condition associated with old age that decreases a person's ability to think clearly and make decisions.

Testosterone was first isolated in a European laboratory in 1935, and synthetic versions of the hormone quickly followed. These were the first anabolic-androgenic steroids. Doctors began using the synthetic steroids to treat men who suffered from hypogonadism (high-poh-GO-nad-izm), which is the inability of the body to produce enough natural testosterone. Steroids have been prescribed by doctors for this purpose ever since.

Olympic-Sized Abuse

At the end of World War II (1939–1945), when Allied troops liberated prisoners from the Nazi concentration camps, many of the survivors were at the brink of death from starvation. Doctors gave some of these former prisoners anabolic-androgenic steroids to help restore their muscle mass and gain their weight back quickly. Soon after, bodybuilders and athletes began taking steroids to further develop their already-fit bodies. Historians believe that the abuse of synthetic steroids began in the weight lifting and bodybuilding communities in the late 1940s and spread to some Olympic sports by the 1950s.

Effective drug tests for anabolic-androgenic steroids did not exist before the early 1970s. Steroid use was widespread during that time in Olympic sports, particularly among Eastern European

competitors. Both female and male athletes from various countries in Europe broke records—and roused suspicions—with their heavily muscled frames. When questioned later about their training methods, many of these young athletes said they just took the "vitamins" their trainers offered and never asked what might be in them. (Barry Bonds [1964– ], the 2004 National League Most Valuable Player and record-holder for single-season home runs as of 2005, would later make the same claim when accused of abusing steroids in 2005.)

In 1975 the International Olympic Committee banned use of all anabolic-androgenic steroids and began a testing policy to keep steroid users out of the Olympics. The tests were only effective when they were done randomly. If athletes knew the test date ahead of time, they could cease steroid use beforehand. This would give them enough time to clean their systems of the drug and avoid detection. Scandal erupted at the 1988 Summer Olympic Games in Seoul, South Korea, when Canadian sprinter Ben Johnson (1961– ) tested positive for banned substances after winning a gold medal in the 100–meter dash. Johnson had to forfeit his medal to the runner-up, American Carl Lewis (1961– ).

Abuse Floods Other Sports

When Johnson lost his medal, the situation helped call attention to the rampant use of steroids in almost every high-level competitive sport. According to retired professional football player Steve Courson (1955– ), author of False Glory: Steelers and Steroids—The Steve Courson Story, many football players of the 1980s bulked up with steroids. In fact, Courson barely survived a damaged heart after taking steroids during his playing career with the Pittsburgh Steelers.

Since then the National Football League (NFL) has set down a strict set of guidelines regarding the use of steroids and other banned substances. The league's official "Steroid Policy," posted on the NFL Players Association Web site, notes that the league specifically "prohibits the use by NFL players of anabolic/androgenic steroids." The policy further states that such "substances have no legitimate place in professional football" and that "steroids and related substances threaten to distort the results of games and League standings." Furthermore, "the League is concerned with the adverse health effects of steroid use," along with "the wrong message [that a player's use of prohibited substances sends] to young people who may be tempted to use them."

Professional wrestling was popular in the 1980s as well. Many of the stars of that sport were involved in steroid abuse, too. Anabolicandrogenic steroids were also the drugs of choice for weight lifters and bodybuilders.

Women and Steroids

Young women began using steroids not only to improve their athletic ability but also to slim down and reduce body fat quickly. According to an article titled "Girls Are Abusing Steroids Too, Experts Say," published on MSNBC.com in 2005, the rate of steroid use among teenage girls has been rising since 1991. The article notes that "overall, up to about 5 percent of high school girls and 7 percent of middle school girls admit trying anabolic steroids at least once."

Steroids are also sometimes used by women in the aftermath of traumatic, dangerous, or life-threatening attacks, such as rape or assault. The psychology behind this type of use involves the woman's desire to appear stronger, less vulnerable, and consequently less likely to be the target of a future attack.

Steroids Join List of Controlled Substances

Concerns about the long-term health issues surrounding steroids led the U.S. government in 1991 to place all prescription steroids on the Schedule III list of controlled substances. However, this did not end steroid abuse. A $500-million-year black market developed, with dealers offering "juice" or "gear" of unknown strength and purity to people of all ages. American dealers typically smuggle steroids across the border to the United States from Mexico.

Illegal underground laboratories began creating compounds such as tetrahydrogestrinone (THG) that could not be detected in urine. Interest in herbal dietary supplements, such as ephedra, creatine, and androstenedione ("andro"), skyrocketed as young athletes sought legal ways to bulk up. (Entries on creatine and ephedra are available in this encyclopedia.) Coaches and trainers contributed to the problem by urging young athletes to bulk up. However, they failed to monitor the safety of the methods used to attain that goal.

Baseball, Hot Dogs, Apple Pie, and Steroids

The twenty-first century has seen the level of anabolicandrogenic steroid abuse decrease. In September of 2003, investigators from the U.S. Drug Enforcement Administration (DEA) raided the Bay Area Laboratory Cooperative (BALCO) in San Francisco, California, and discovered that the lab had been creating steroids that could go undetected in drug tests. The agents also uncovered the names of professional athletes in several sports who had received products from BALCO through personal trainers or other suppliers.

Rob Garibaldi: A Deadly Outcome

On October 1, 2002, Rob Garibaldi, a former University of Southern California baseball player, shot himself with a stolen gun after failing to be chosen in the Major League draft. Garibaldi had been using illegal steroids purchased in Mexico for about four years in order to increase his size and strength.

Mark Fainaru-Wada, writing in the San Francisco Chronicle, quoted one of Garibaldi's high school friends as saying: "Every hope and dream he had was surrounded by baseball. And you do whatever it takes."

This raid followed two highly publicized suicide deaths of aspiring baseball players: Rob Garibaldi in California, who shot himself in the fall of 2002, and Taylor Hooten in Texas, who hanged himself in the summer of 2003. Both men had abused steroids thinking that the drugs would help them make it to the major leagues. The U.S. Food and Drug Administration (FDA) declared THG illegal in 2003 and also, in early 2005, placed "andro" on the Schedule III list of controlled substances.

Steroid use made the headlines again in March of 2005, when several Major League Baseball players, executives, and the commissioner testified before Congress. One of those who testified, Jose Canseco (1964– ), wrote a book earlier that year called Juiced: Wild Times, Rampant 'Roids, Smash Hits, and How Baseball Got Big. In it, he states that he used steroid swhile he was with the Oak land Athletics. Canseco named other players whom he alleged used steroids too, including Mark "Big Mac" McGwire (1963–). McGwire broke the single-season home run record in 1998 while with the St. Louis Cardinals. Making his own appearance before the Congressional Committee, McGwire refused to answer questions about his alleged past use of performance-enhancing products.

In the wake of the hearings, Major League Baseball's steroid policy was criticized by many as not being strict enough. Many fans, lawmakers, and sports commentators didn't believe that the fines were set high enough or the suspensions set long enough. Some even suggested that players be banned from the sport if they violated the policy more than once. The notion that "three strikes and you're out" was expressed by many who want steroids out of baseball.

Bad News for Palmeiro

In August of 2005, steroids in baseball again made the headlines when Baltimore Orioles star Rafael Palmeiro (1964– ) was suspended for 10 days for "violating baseball's anti-drug policy," according to Jorge Arangure Jr. of the Washington Post. Palmeiro was one of the players who had testified before Congress just a few months earlier and had strongly denied ever having used steroids. When news of his positive drug test broke, Palmeiro again denied taking steroids. As reported on ESPN.com, Palmeiro explained: "Today I am telling the truth again that I did not do this intentionally or knowingly." He added: "Why would I do this in a year when I went in front of Congress and I testified.… Why would I do this during a season where I was going to get to 3,000 hits? It just makes no sense."

Turning Tides?

Opinion has begun to turn against steroid users, an attitude that is reflected in the 2004 Monitoring the Future (MTF) survey. The MTF report is an annual survey of drug use among young people in the United States. The MTF survey is conducted by the University of Michigan with funding from NIDA. The 2004 MTF study noted a general decrease in steroid use among eighth and tenth graders. According to the survey, these younger teens expressed more concern about the health issues surrounding steroids than their peers of the 1980s and 1990s.

Steroid use among seniors in high school, however, "remained stable at peak levels," according to the MTF. Researchers suggest that steroid use may be even higher among high school students than the survey shows, since some young athletes would never report their steroid use—even on an anonymous survey.

What Is It Made Of?

Testosterone is a naturally occurring hormone in both men and women, but men produce more of it than women. At puberty—the stage of growth in which a person becomes capable of sexual reproduction—the hormone is responsible for changing a boy into a man. It causes deepening of the voice, growth of facial hair, and the maturity of the reproductive organs. It also plays an important role in the growth and development of muscles. When men are finished growing, they typically produce between 35 and 50 milligrams of natural testosterone each week throughout life. The hormone is created in the testes, the male reproductive glands.

All Steroids Are Not the Same

Anabolic-androgenic steroids should not be confused with corticosteroids. Anabolic-androgenic steroids are prescribed only for a few, very uncommon disorders, such as muscle wasting in patients with acquired immunodeficiency syndrome (AIDS) and men with abnormally low testosterone levels.

Corticosteroids are widely prescribed for conditions that cause inflammation, including asthma, bronchitis, pneumonia, certain serious allergies, and even severe poison ivy blisters. Jacqueline Adams reported in Science World that people who take prescription corticosteroids according to a doctor's directions will not experience any of the side effects that plague abusers of anabolic-androgenic steroids.

Women also produce natural testosterone but at far lower levels than men. Female maturity is influenced chiefly by estrogen, a hormone that regulates the female reproductive system.

Synthetic anabolic-androgenic steroids are very similar to natural testosterone, except for a slightly altered carbon structure. Pill forms of steroids contain an extra chain of carbon and hydrogen atoms called an alkyl group. These can be dangerous to the liver and to cholesterol levels when taken at high doses. Injectable steroids contain an acidic chain of carbon and hydrogen called an ester that is slightly less toxic to the liver.

Steroid Chronology

Steroids have an interesting history. How much do you know about the history of the drug?

1889      Charles Edouard Brown-Sequard (1817–1894) reports that he feels more energetic after injecting himself with a compound taken from animal testicles.

1935      The hormone testosterone is isolated in a European laboratory. Chemists quickly learn how to make synthetic versions.

1945      Survivors of Nazi concentration camps are given anabolic-androgenic steroids to help restore weight and muscle lost during periods of starvation.

1975      After years of steroid abuse by Olympic athletes, the International Olympic Committee adds anabolic-androgenic steroids to its list of banned substances and announces plans to test athletes randomly for steroid use.

1988      Olympic sprinter Ben Johnson forfeits his gold medal in the 100–meter dash after testing positive for a banned substance.

1991      Anabolic-androgenic steroids are named Schedule III drugs under the Controlled Substances Act of 1970. Former Pittsburgh Steeler Steve Courson (1955– ) writes False Glory: Steelers and Steroids.

2003      Federal narcotics agents raid the Bay Area Laboratory Cooperative (BALCO), an alleged source of "designer" steroids.

2005      Former baseball star Jose Canseco writes the book Juiced: Wild Times, Rampant 'Roids, Smash Hits, and How Baseball Got Big. Major League Baseball players and management are called to testify before the U.S. Congress about steroid use in professional baseball. "Andro" is added to the Schedule III list of controlled substances. The Olympics Committee announces its decision to drop baseball and softball from the 2012 games in London, in the United Kingdom, due in part to the controversy surrounding steroid use in the sport.

Creatine and DHEA are considered dietary supplements. As of 2005, they have not been regulated as drugs by the FDA. Creatine provides fuel to muscles during periods of high exertion. DHEA is sold as an anti-aging supplement. But because DHEA turns into androstenedione in the body, it is used as a steroid. Users of either of these supplements run health risks when they exceed the doses recommended on the labels.

How Is It Taken?

With steroids, the issue is not only how they are taken, but how much of the substance is needed to produce results. A healthy man will produce 35 to 50 milligrams of natural testosterone each week. Most steroid programs involve 300 to more than 1,000 milligrams per week in pills, creams, or injectable forms.

Steroid users have several strategies for taking the substances. Medical professionals consider all of them extremely dangerous to immediate and long-term health.

• Cycling involves taking high doses of steroids for several weeks to several months, then discontinuing use of the steroids for as many weeks or months.
• Stacking involves using two or more different steroids or combining oral and injectable steroids in the belief that the drugs will interact to produce better results.
• Pyramiding involves beginning a cycle with a lower dose of steroids, gradually increasing the dose over time to a peak level, then gradually decreasing the dose down to zero again.

Those who use injectable steroids usually administer shots into their large muscles in the buttocks. Sometimes people who inject steroids share needles or inject one another without sterilizing the needles or the injection sites. This can cause infectious diseases such as HIV (the human immunodeficiency virus), which leads to AIDS (acquired immunodeficiency syndrome), and hepatitis, which is a liver disease.

Are There Any Medical Reasons for Taking This Substance?

Anabolic-androgenic steroids are legally prescribed for men who have lower than normal levels of testosterone. They may also be used to treat patients who have developed muscle-wasting syndromes associated with cancer and AIDS. Very rarely they are used to help restore tissue in burn victims. Female patients sometimes receive these kinds of steroids for problems associated with menopause and other issues related to the female reproductive system. In all of these cases, the dosage prescribed by physicians is far lower than the levels of steroids typically seen among illegal users.

Usage Trends

From 2002 to 2004, the number of teenagers reporting steroid use in the MTF survey declined overall, but the statistics can be misleading. Eighth- and tenth-grade respondents reported being more concerned about the health risks surrounding steroid use than older students. Use among twelfth-graders remained steady. A breakdown of the survey results showed a dramatic decrease in use among male seniors, from about 6 percent in 2002 to 4.4 percent in 2004. At the same time, however, the reported use of steroids by female seniors was nearly six times higher in 2004 than it was in 1991. This spike in usage among twelfth-grade girls made up for the drop in usage among twelfth-grade boys.

However, evidence shows that female users are not necessarily athletes. According to the 2005 MSNBC.com article "Girls Are Abusing Steroids Too, Experts Say," the Oregon Health and Science University found that about two out of every three high school girls in the state who said they had used steroids weren't looking for an athletic advantage. Instead, they just wanted to get thin. Members of the medical and health community are continuing their efforts to identify steroid abuse and to educate those who are at high risk for potential abuse.

It's Not about Getting High

muscle dysmorphia is the scientific name for a disease that affects some teenagers and adults. The condition resembles anorexia nervosa (ah-nuh-REK-see-uh ner-VOE-sah), a severe eating disorder characterized by an intense fear of gaining weight. People who have muscle dysmorphia are never satisfied with how muscular they appear. No matter how hard they train, they never feel "big enough." These individuals run a higher risk for steroid abuse because steroids build muscle rapidly.

Steroid abusers are very different from those who abuse other illegal drugs. For instance, heroin, cocaine, and marijuana users take the substances for an immediate "high," or rush of pleasurable feelings. (Entries for these three drugs are included in this encyclopedia.) Steroid users do not experience a high after taking pills or injecting the drug. They have different goals and may not notice the behavioral changes and compulsive behavior brought on by the drugs until their health is affected. In the meantime, they may spend many hundreds or thousands of dollars on illegal substances that have not been tested for strength or purity or safety.

Effects on the Body

Anabolic-androgenic steroids increase strength and lean muscle mass. However, flooding the body with any hormone at ten to twenty times greater strength than normal is dangerous. Anabolic-androgenic

steroids produce a long list of potential side effects. Some of these effects can be deadly. Others are just plain unpleasant.

Steroids Do More Than Just Build Muscles

Side effects for men abusing anabolic steroids include:

• acne and oily hair
• gynecomastia (GY-nuh-koh-MASS-tee-uh), the formation of female-type breasts on a male body, which is a permanent condition that can only be reversed with surgery
• testicular atrophy (tess-TIK-yoo-lar AH-truh-fee), the shrinking of the male testicles, which sometimes results from overdoses of testosterone or anabolic-androgenic steroids; this condition may not be reversible
• low sperm count
• disruption of the natural "growth spurt" in young users, which leads to abnormal shortness throughout life
• male-pattern baldness
• insomnia, which is difficulty falling asleep or an inability to sleep
• ruptured tendons
• increased chance of heart attack
• increased chance of liver cancer or bleeding in the liver, especially with pill forms of steroids
• bursts of aggressive behavior (called "roid rage")
• mania (a mental disorder characterized by intense anxiety, aggression, and delusions), loss of touch with reality, and delusions or false beliefs. (Note: anabolic-androgenic steroids are classified as hallucinogens, which are substances that bring on hallucinations that alter the user's perception of reality.)
• boils or infections at injection sites, as well as infections elsewhere from dirty needles
• human immunodeficiency virus (HIV) or hepatitis infections from sharing needles
• depression, sometimes leading to suicide, when steroid use is stopped
• loss of enthusiasm and sex drive when steroid use is stopped.

Side effects for women abusing steroids include:

• growth of coarse hair on the face and body
• enlargement of the clitoris (a part of the female genitals)
• deepening of voice
• male-pattern baldness
• mood swings and aggression
• insomnia
• loss of menstrual period (also referred to as a "menstrual cycle")
• infertility or the inability to have children.

Bulk v. Height

One of the most devastating side effects of steroid abuse occurs in the youngest users. If teens begin using steroids before they have stopped growing, the flood of hormones will alter the normal growth process. Under normal circumstances, height increases as the soft ends of the bones grow longer. However, high levels of testosterone shut down the production of new bone. The body is fooled into thinking that the user has already reached maturity. As a result, growth stops prematurely.

Reactions with Other Drugs or Substances

Any combination of anabolic-androgenic steroids and other mind-altering substances increases the risk of mental side effects and dangerously aggressive behavior. When users end a cycle of steroid use, they often find themselves sinking into depression. They may seek help from a doctor for depression without admitting to steroid use. Antidepressant medications should not be mixed with steroids. Doctors can only provide effective treatment when they have a complete medical history, including knowledge of any illegal substances—or even any dietary supplements—that the patient is taking or may have taken.

Users sometimes take other drugs to counteract some of the side effects associated with steroid use. diuretics may be used to rid the body of excess water. Human growth hormone may be taken to compensate for the effects steroids have on height. Estrogen blockers may be used to reduce breast enlargement in men. The practice of adding more and more drugs to the system can increase the risk of adverse reactions, or negative side effects, in the user.

Covering Up Steroid Use

Diuretics also have another impact on steroid use—one that some athletes use to their advantage. Some sports figures use diuretics to "mask" the use of steroids. They use diuretics to speed the elimination of banned performance-enhancing substances from their bodies in an effort to increase their chances of passing mandatory drug tests. Various sporting organizations have added diuretics and other masking agents to their list of banned substances. Athletes testing positive for banned diuretics will also be suspended or disqualified from competition just like those using steroids.

Treatment for Habitual Users

Even though steroids are not classified as addictive substances, steroid users do exhibit patterns of habitual behavior. Help for steroid abusers—and education for those considering trying steroids—is available through several national programs in the United States. The National Center for Drug Free Sport offers online and telephone support, newsletters, and other resources. (The Drug Free Sport Web site is located at http://www.drugfreesport.com.)

In addition, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) has pioneered two model programs: ATLAS (Athletes Training and Learning to Avoid Steroids) for boys and ATHENA (Athletes Targeting Healthy Exercise and Nutritional Alternatives) for girls. (SAMHSA's Web site is located at http://www.oas.samhsa.gov.) These programs are designed for school coaches and health teachers to use with sports teams. Even some bodybuilding magazines, including Flex, take pride in spotlighting drug-free athletes and their successful training regimens.

Some people who use steroids for a short period of time stop on their own without help. Many more will need counseling, prescription medications, and serious lifestyle alterations to stay clear of steroid use.

Consequences

Severe depression and an increased chance of suicide have been linked to steroid abuse. Other consequences may take years to develop. Steve Courson, the former Pittsburgh Steeler player who admitted to steroid use, almost lost his life to heart disease brought on by his drug abuse. He has since recovered, and he dedicates a great deal of his time to lecturing about the dangers of steroid use. Even short-term use of steroids can damage the heart, liver, kidneys, and sexual function in otherwise healthy people.

Ruined Reputations

Athletes who use performance-enhancing drugs are often seen as cheaters because they have used chemicals to achieve their goals. "Real men work for what they earn," wrote Terry Goodland in Flex. "They don't look for quick fixes or magic bullets. Lasting results don't come overnight. You need patience to grow, despite what some people would like you to think. Your progress will be unpredictable and temporary as long as you lean on the crutch of drug abuse."

On March 17, 2005, former Oakland Athletics and St. Louis Cardinals star Mark McGwire testified before Congress about the

use of performance-enhancing drugs in Major League Baseball. McGwire's seventy home runs in 1998 set a new single-season record in the sport (since broken by Barry Bonds). Although he had always previously denied steroid use, he refused to "talk about the past" when asked under oath if he had used steroids. McGwire told Congress, as reported in the Philadelphia Daily News, "I cannot answer these questions without jeopardizing my family, my friends, and myself."

The press reacted sharply, challenging McGwire's records and suggesting that he should not be eligible for the Baseball Hall of Fame. On the day of the testimony, according to Howard Bryant in the Boston Herald, "the entire nation witnessed the end of Mark McGwire as an American icon."

The Law

It is against the law to possess a Schedule III controlled substance without a valid prescription. It is also against the law to sell Schedule III controlled substances or their analogs. Penalties vary from state to state but can include high fines, probation, mandatory rehabilitation, a criminal record, and—especially with second and third offenses—jail time.

Chemists try to get around the law by creating steroids that cannot be detected in drug tests, or substances that can be called "dietary supplements." One anonymous "doctor" boasted to Sports Illustrated in2005:"Aguy on my stuff coul dwalk into the test with a needle in his [buttocks] and not worry." The same source said he knew of ten substances that could not be detected by urine tests.

The illegal creation of synthetic drugs that are not covered by law creates another challenge—that of detecting and revealing the substances and prosecuting their creators. The bust at the Bay Area Laboratory Cooperative in 2003 led to the scheduling of THG, a substance once thought to be undetectable by tests.

As of 2005, creatine and DHEA were still legal over-the-counter dietary supplements. However, the FDA was studying the effects of DHEA overdose and considering adding it to the list of controlled substances.

For More Information

Books

Canseco, Jose. Juiced: Wild Times, Rampant 'Roids, Smash Hits, and How Baseball Got Big. New York: Regan Books, 2005.

Carson, Judy. The Adonis Complex: The Secret Crisis of Male Body Obsession. New York: The Free Press, 2000.

Clayman, Charles B., ed. The American Medical Association Encyclopedia of Medicine. New York: Random House, 1989.

Courson, Steve. False Glory: Steelers and Steroids—The Steve Courson Story. Stamford, CT: Longmeadow Press, 1991.

Hoberman, John. Testosterone Dreams: Rejuvenation, Aphrodisia, Doping. Los Angeles: University of California Press, 2005.

Kuhn, Cynthia, Scott Swartzwelder, and Wilkie Wilson. Buzzed: The Straight Facts about the Most Used and Abused Drugs from Alcohol to Ecstasy, 2nd ed. New York: W.W. Norton, 2003.

Nelson, Rebecca, and Marie J. MacNee, eds. The Olympic Factbook: A Spectator's Guide to the Summer Games. Detroit, MI: Visible Ink Press, 1996.

Periodicals

Adams, Jacqueline. "The Incredible Bulk: Major League Baseball Struggles to Beat Performance-Enhancing Drugs." Science World (March 28, 2005): p. 18.

Adler, Jerry. "Toxic Strength." Newsweek (December 20, 2004): p. 44.

"Anabolic Steroid Control Act Passed." Nutraceuticals World (November, 2004): p. 8.

Bryant, Howard. "Ex-Slugger Whiffs with His Silence." Boston Herald (March 18, 2005): p. 4.

Burch, Nina. "Taylor Hooten's Parents Campaign to End Steroid Abuse." Plano Star Courier (March 6, 2004).

Carroll, Will. "The Creator." Sports Illustrated (April 25, 2005): p. 18.

Clark, Nancy. "Mirror, Mirror on the Wall … Are Muscular Men the Best of All? The Hidden Turmoil of Muscle Dysmorphia." American Fitness (January-February, 2004): p. 52.

Donnellon, Sam. "Swearing Thin." Philadelphia Daily News (March 18, 2005).

Evans, Nick A. "Anabolic Steroids: Answers to the Bigger Questions." Journal of Musculoskeletal Medicine (March, 2004): p. 166.

Fainaru-Wada, Mark. "Dreams, Steroids, Death—A Ballplayer's Downfall." San Francisco Chronicle (December 19, 2004): p. A1.

Goodland, Terry. "Dancing with the Dark Side: So, You Think You're Ready for Your First Steroid Cycle?" Flex (April, 2004): p. 190.

Jarvi, Jeffrey F. "Stay Alert for Performance-Enhancing Substance Use." JAAPA: Journal of the American Academy of Physician Assistants (December, 2004): p. 36.

Kluger, Jeffrey. "The Steroid Detective." Time (March 1, 2004): p. 60.

McGrath, Ben. "Dr. Juice." New Yorker (March 7, 2005): p. 28.

Mirkin, Gabe. "Anabolic Steroids Come at Big Cost." Washington Times (February 27, 2005): p. C12.

Starr, Mark. "Steroid Moments: Bash Thy Brother." Newsweek (February 28, 2005): p. 57.

Verducci, Tom. "Juice and Truth: Jose Canseco's Book Bashes Mark McGwire but Raises More Questions Than It Answers." Sports Illustrated (February 21, 2005): p. 40.

Wallace, Phil. "Bush Signs Legislation Banning Andro, Other Anabolic Steroids." Food Chemical News (November 1, 2004): p. 20.

Web Sites

"Anabolic Steroid Abuse: NIDA Research Report Series" (April 2000). National Institutes of Health, National Institute on Drug Abuse.http://www.nida.nih.gov/ResearchReports/Steroids/AnabolicSteroids.html (accessed August 19, 2005).

Arangure, Jorge, Jr. "Palmeiro Suspended for Steroid Violation: Orioles Star Denied Use Before Congress." Washington Post, August 2, 2005. http://www.washingtonpost.com/wp-dyn/content/article/2005/08/01/AR2005080100739.html (accessed August 18, 2005).

"Girls Are Abusing Steroids Too, Experts Say." MSNBC.com, April 25, 2005. http://www.msnbc.msn.com/id/7633384/ (accessed August 19, 2005).

"Growing Numbers of Girls Using Steroids." MSNBC.com, June 15, 2005. http://www.msnbc.msn.com/id/8233873/ (accessed August 19, 2005).

Monitoring the Future.http://www.monitoringthefuture.org and http://www.nida.nih.gov/Newsroom/04/2004MTFDrug.pdf (both accessed August 18, 2005).

"NIDA Community Drug Alert Bulletin—Anabolic Steroids" (April, 2000). National Institute on Drug Abuse (NIDA).http://www.nida.nih.gov/SteroidAlert/SteroidAlert.html (accessed August 19, 2005).

"Palmeiro Docked 10 Days for Steroids." ESPN.com, August 2, 2005. http://sports.espn.go.com/mlb/news/story?id=2121659 (accessed August 18, 2005).

"Steroid Policy" (2005). National Football League Players Association.http://www.nflpa.org/members/main.asp?subpage=Steroid+Policy+%2D+Full (accessed August 19, 2005).

"Steroids (Anabolic-Androgenic)." National Institute on Drug Abuse (NIDA), NIDA InfoFacts, March 2005. http://www.nida.nih.gov/infofacts/steroids.html (accessed August 19, 2005).

"Teen Drug Use Declines 2003-2004—But Concerns Remain about Inhalants and Painkillers" (December 21, 2004). National Institutes of Health, National Institute on Drug Abuse (NIDA), Monitoring the Future Survey on Teen Drug Abuse.http://www.nida.nih.gov/ (accessed August 19, 2005).

Volkow, Nora D. "Message from the Director: Consequences of the Abuse of Anabolic Steroids" (April 6, 2005). National Institute on Drug Abuse (NIDA).http://www.nida.nih.gov/about/welcome/MessageSteroids305.html (accessed August 19, 2005).

See also: Creatine; Ephedra

Steroids

Steroids are a family of lipid molecules that includes cholesterol, steroid hormones, and bile salts. These amphipathic molecules (containing both hydrophobic and hydrophilic regions) are derived from two-carbon acetyl-CoA units, whose combination leads to the formation of isoprenoids (five-carbon isoprene molecular units), and finally to the formation of a seventeen-carbon tetracyclic hydrocarbon, the steroid skeleton. Figure 1 shows the basic steroid skeleton structure, made up of three six-membered rings and one five-membered ring. The fused six-membered cyclohexane rings each have the chair conformation . Each member of the steroid family has a structure that differs from this basic skeleton in the degrees of unsaturation within the ring system and the identities of the hydrocarbon side chain substituents attached to the rings. These substituents are in most cases oxidized to alcohol, aldehyde , ketone , or carboxylic acid functional groups .

The general term sterol refers to a subgroup of steroids that contain an alcohol functional group, which is signified by the -ol ending. Steroids are found predominantly in eukaryotic cells , with cholesterol being the most abundant steroid molecule. It contains twenty-seven carbons, has an alcohol functional group at C-3, a methyl group at C-13, and a branched aliphatic hydrocarbon (eight carbons) unit at the C-17 carbon atom. It is the basic building block for all the other steroid molecules. The biosynthesis of other steroids from cholesterol yields molecules that have fewer carbons, are more polar and more oxidized, and have smaller and more oxidized hydrocarbon units at C-17. It should be emphasized that cholesterol and most steroids contain predominantly single (C–C) bonds and take on non-planar structures. Intracellular cholesterol is predominately found as part of (embedded in) the plasma cell membranes. Because of cholesterol's bulky structure, it does not embed well into the lipid bilayer structure of a membrane and as a result disrupts the order or regularity of the membrane. Increasing levels of embedded cholesterol, which can be as high as 25 percent of membrane volume, correlates with increasing the fluidity (as opposed to rigidity) of the membrane.

The level of extracellular cholesterol in blood serum correlates with the degree of advancement of atherosclerosis and the development of coronary heart disease. The serum cholesterol is obtained from diet and from biosynthesis, which occurs primarily in the liver of mammals. The usual metabolic pathway for cholesterol biosynthesis involves a sequence of more than twenty reactions, each catalyzed by a specific enzyme. The committed and the rate-limiting step in the sequence is the synthesis of a six-carbon molecule, mevalonate, catalyzed by the enzyme 3-hydroxy-3-methylglutaryl CoA reductase (HMG CoA reductase). The development of drugs that inhibit the activity of HMG CoA reductase (and that reduce levels of serum cholesterol), has led to a decline in coronary heart disease. These drugs have structures similar to that of mevalonate and serve as competitive inhibitors of HMG CoA reductase. The binding of a competitive inhibitor to the enzyme and of the substrate mevalonate to the same enzyme are mutually exclusive events. One of the most potent inhibitors of HMG CoA reductase is the drug lovastatin, which binds very strongly at the active site of the enzyme, and, as a result, serum cholesterol levels in humans are decreased by as much as 20 percent.

The hydrophobic, water-insoluble cholesterol is transported in blood to cells predominantly as part of high density and low density lipoprotein particles (HDLs and LDLs, respectively). LDLs transport cholesterol to extrahepatic tissues. The LDL particles bind to LDL receptors on the cell membranes, facilitating cholesterol deposition at the cells, for use primarily as a component of the membrane. HDLs carry out a similar transport function but also return cholesterol to the liver, where it can be metabolized. In this way HDLs decrease the levels of the cholesterol that contributes to the deposition of plaque in arteries and is implicated in heart disease. In a number of cases, patients have been found to have defective genes that code for the LDL receptors. In these cases the LDL particles cannot deposit the cholesterol at cell sites. The LDLs remain in the blood, and eventually their lipid molecules accumulate on the arterial walls, which can lead to blockage of arteries and a heart attack.

Cholesterol is the precursor of other important steroid metabolites , which include bile salts and steroid hormones. Bile salts, which are the major breakdown product of cholesterol, resemble detergents, which are amphipathic molecules (having both polar and nonpolar regions). Their primary function is to emulsify dietary lipids. This interaction between bile salt and lipid increases the surface area of exposed lipid, which greatly enhances the ability of lipase enzymes to get access to and hydrolyze lipid molecules, thereby promoting their absorption and digestion. Bile salts are synthesized and secreted by the liver, stored in the gall bladder, and pass through the bile duct and into the small intestine. Bile salts are the major metabolic product of cholesterol, their manufacture accounting for the consumption of approximately 800 mg/day of cholesterol in a normal human adult. (On the other hand, less than one-tenth that amount of cholesterol is utilized for steroid hormone synthesis.) A major bile salt is glycocholate.

Cholesterol is also the precursor of all the steroid hormones, which can be subdivided into five major classes. The first and second classes of hormones, the mineralocorticoids and the glucocorticoids , are synthesized in the adrenal cortex. The mineralocorticoids (e.g., aldosterone) regulate the body's ion balance by promoting the reabsorption of inorganic ions, such as Na⁺, Cl⁻, and HCO3⁻, in the kidney. As a result, they are involved in the regulation of blood pressure. The glucocorticoids (e.g., cortisol) regulate gluconeogenesis and, in pharmacological doses, inhibit the inflammatory response. The third class includes progesterone , associated with the female reproductive cycle and synthesized in the cells of the corpus luteum; it prepares the lining of the uterus for implantation of the ovum and is essential for the maintenance of pregnancy. The sex hormones are synthesized in the male and female gonads and in the placenta. These hormones, the fourth and fifth classes, are androgens (primarily testosterone) and the estrogens (primarily estradiol). These two classes of hormones are associated with the development of the secondary sexual characteristics of males and females, respectively. They exert powerful physiological effects in humans because of their importance in the regulation of a variety of vital metabolic processes.

Steroid hormones, like all hormones, are chemical messengers. They are synthesized in the cells of an endocrine gland, secreted by the cells into the bloodstream, and travel to target organs in which they direct cell-to-cell communication and the "global regulation" of metabolism in a multicellular organism such as humans. The levels of the steroid hormones are also highly regulated, with levels in the blood or in cells being very small, typically less than micromolar amounts. Because of their hydrophobic

character, they must associate with carrier molecules for their transport in the blood.

In contrast to polypeptide hormones that bind to hormone receptor proteins embedded in the plasma membranes of cells, the hydrophobic steroid hormones pass from the bloodstream into cells readily via passive diffusion across the membrane. Although the steroid hormones can in principle enter all cells, the only cells that are responsive to steroid hormones are those cells that contain proteins called steroid hormone receptors. These receptors reside in an inactive state either in the cytoplasm or in the cell nucleus. There are specific hormone receptors for each of the hormone types: estrogen , androgen, progesterone, glucocorticoid, and mineralcorticoid. As a result of the hormone binding to the recognition site of its hormone receptor, an inactive receptor is transformed into a functionally active one. These active hormone-receptor complexes are ligand -activated transcription factors, which are then able to migrate to the DNA in the nucleus and bind to the promoter regions of a specific subset of genes. This stimulates the transcription of genes that are sensitive to the presence of the hormone. These genes are only expressed or transcribed when the hormone is present. The messenger RNA that is produced is then translated into a new set of proteins. As a result of this stimulation of gene expression, the metabolic character of the cell is dramatically changed.

Anabolic steroids are synthetic substances related to male sex hormones (androgens). Although it is illegal in the United States to possess or distribute anabolic steroids for nonmedical use, a "black market" for them exists, and many amateur and professional athletes take them to enhance performance. In many cases, the athletes take doses that are extremely high—perhaps 100 times the doses that might be prescribed for medical use. As a result, they put themselves in real danger of short-term and long-term health problems. Blood testing, as has been used in the Olympic Games, can detect, identify, and quantify the presence of anabolic steroids in the blood of athletes, which can lead to the disqualification of an athlete.

see also Cholesterol; Cortisone; Estrogen; Lipids; Testosterone.

William M. Scovell

Bibliography

Alberts, Bruce; Johnson, Alexander; Lewis, Julian; Raff, Martin; Roberts, Keith; and Walter, Peter (2002). Molecular Biology of the Cell, 4th edition. New York: Garland Science.

Garrett, Reginald H., and Grisham, Charles M. (1999). Biochemistry, 2nd edition. Fort Worth, TX: Saunders College Publishers.

steroids comprise a large group of substances that mediate a very varied set of biological responses. The most widespread in the body is cholesterol, an essential component of cell membranes, and the starting point for the synthesis of other steroids — the sex hormones, adrenal cortical hormones, and the bile salts.

The steroids are grouped together because their chemical structures are all very similar. The steroid chemical nucleus consists of four carbon rings, three 6-sided and one 5-sided, joined together by their edges. The specificity of their different biological actions is due to the various groups attached to a common nucleus. When alcohol groups (OH) are attached, steroids should properly be called sterols (such as cortisol), whereas ketone groups (C=O) make them sterones (such as aldosterone).

Different steroids react with different membrane receptors in cells, and a precise fit between the steroid and the receptor is required. Therefore a single steroid can be expected to have a specific effect.

Steroids have major responsibilities as hormones, controlling metabolism, salt balance, and the development and function of the sexual organs as well as other bodily differences between the sexes. Steroids in the form of bile salts assist in digestive processes, while another steroid is a vitamin that takes part in calcium control.

Steroid hormones

Steroid hormones are made and secreted into the circulating blood by the cortex of the adrenal glands and the gonads (testes or ovaries). Mostly, their secretion is regulated by hormones from the pituitary gland, and those in turn by chemical messages from the hypothalamus.

Two types of steroids are released from the adrenal cortex, the glucocorticoids, mainly cortisol (hydrocortisone) and the mineralocorticoids, mainly aldosterone. Both types of hormone are important in stress situations such as disease or injury.

Glucocorticoids mobilize glucose, which is particularly important in fasting conditions. They do so by promoting glucose formation from non carbohydrate sources in the liver, increasing glycogen levels, and raising the blood glucose concentration. Liberation of glucocorticoids from the adrenal cortex is caused by adrenocorticotrophic hormone (ACTH), released from the pituitary gland. When the glucocorticoid level in the blood is low, ACTH is released, but when it is high the release of ACTH is suppressed. This is a good example, one of many that occur in the body, of a feedback system. Large doses of glucocorticoids are anti-inflammatory and at one time it was thought they would provide suitable treatment for inflammatory conditions such as rheumatoid arthritis. However, the excessive breakdown of proteins, mobilized to form glucose in the liver, leads to muscle weakness and osteoporosis and there is also ‘moon face’ and obesity. This describes exactly the features of Cushing's syndrome, a condition caused by excess secretion of corticosteroids. Furthermore, if therapy with glucocorticoids is withdrawn rapidly the pituitary system is so suppressed that the body's own system takes a while to trip in, leading to an ‘Addisonian crisis’, mimicking Addison's disease in which there is a deficiency in glucocorticoid production. With due precautions, however, corticosteroids remain a useful treatment in some severe allergic and inflammatory conditions.

The mineralocorticoid aldosterone is released at an increased rate from the adrenal glands if the body is salt depleted; this is stimulated by a complex detecting system in the kidneys, resulting in an increase in circulating angiotensin, which acts in turn on the adrenal glands. Aldosterone promotes sodium reabsorption by the kidneys, so that there is less salt in the urine, thus correcting the deficiency. It acts on sweat glands similarly, diminishing salt loss in sweat.

Male steroid sex hormones, androgens, are produced in the testes. Testosterone is the most important of the androgens and is responsible for controlling the production and maturation of sperm, as well as male characteristics, such as the distribution of body hair. Anabolic steroids are derivatives of testosterone and act on androgenic receptors. They build up muscle mass and cause virilization — features of masculinity. They are useful in the treatment of debilitated patients to help restore their physique. Unfortunately these substances have been taken illicitly by athletes for body-building. Their use carries considerable risk, as sudden withdrawal will leave the body's natural processes suppressed, by interference with the feedback system as described above. Detection of the use of anabolic steroids has become difficult as it appears that one that is commonly used, namely nandrolone, can be synthesized by the body itself in small quantities, especially when under physical stress. Female steroid sex hormones are of two types, oestrogens and progestins, both from the ovaries. Again under pituitary hormone regulation, their relative secretion varies within the menstrual cycle. Oestrogens promote the growth of the lining of the uterus in preparation for implantation of a fertilized egg. Once the egg has been shed from the ovary, the corpus luteum (yellow body), which develops in the cavity left behind, secretes progesterone; this promotes further development of the uterine lining and, if implantation of an embryo occurs, maintains changes here and elsewhere for the duration of pregnancy.

The understanding of these processes is the basis of the contraceptive pill. Synthetic steroids were devised for this purpose, as natural steroids are metabolized by the liver if taken by mouth. As with the other steroid hormones, there are feedback systems involving the pituitary gland. Taking oestrogens inhibits the release from the pituitary of the follicular stimulating hormone that would normally cause maturation of eggs in the ovary: so, no ovulation, no conception. Contraceptive pills usually contain both oestrogens and progestins, which are taken concurrently or sequentially during the 4 week course, menstruation following when the course ceases. A large dose of both an oestrogen and progestin promotes uterine bleeding within a few hours and is the basis of the ‘morning after’ pill.

Steroids and bile

Cholesterol, taken up from the blood into the liver or synthesized there, can be oxidized in the liver to cholic acid. Conjugation of this with taurine or glycine gives the bile salts, taurocholate and glycocholate. These bile salts pass into the small intestine and have important actions in aiding the digestion and absorption of fats. Cholesterol itself is excreted in the bile.

The steroid vitamin

Exposure to ultraviolet light converts a steroid, dehydrocholesterol, in the skin to vitamin D. This is what happens when you sunbathe, but in climes where exposure to the sun is limited it is necessary to supplement the diet with the vitamin. Fish oils are rich in vitamin D and the Eskimo diet ensures that they get a sufficient supply. The vitamin primarily promotes calcium absorption from the gut. Calcium is essential for bone growth and maintenance, muscle contraction, and many signalling processes in the body.

While steroids have many different actions on the body, their mechanism of action is similar in all instances. The receptors for steroids are inside cells (unlike those for many other substances, which are on the cell membrane). The complex formed by combination of the steroid with its specific receptor enters the nucleus and switches on or off the appropriate genes, which then gives rise to the characteristic effect. Their actions are not therefore immediate as with, for example, neurotransmitters, nor are they as rapid as those of the peptide hormones; several hours elapse before the effect appears. To give one example, the receptors for aldosterone are located in the end part of the kidney tubules. Here genes are switched on which lead to the synthesis of the molecules that actually handle the reabsorption of sodium ions from the urine back into the blood. The process becomes more efficient because there are a larger number of molecular entities dedicated to the task.

Alan W. Cuthbert

Steroids

Definition

Description and doses

Demographics

Health consequences

Prevention

Diagnosis and treatment

Resources

Definition

Steroids are drugs chemically related to hormones in the body, including cortisol, estrogen, and testosterone. Steroids, characterized by a “steroid nucleus,” are fat-soluble organic compounds derived from plants and animals. Hormones are chemical messengers produced by the endocrine glands. The glands secrete hormones directly into the bloodstream where they are transported to a distant part or parts of the body where they play specific roles to benefit the body as a whole. Steroid hormones, distinct entities, are crucial for the proper functioning of the body. They mediate various vital physiologic functions ranging from anti-inflammatory agents to regulating events during pregnancy. They are synthesized and secreted into the bloodstream by endocrine glands such as the adrenal cortex and the gonads (ovary and testis). Cholesterol is the precursor for steroid hormones, as well as bile acids and provitamin D. Steroid hormones can be divided into five classes: androgens, estrogens, progestins, min-eralocorticoids, and glucocorticoids. Many steroids are approved for medical use, anti-inflammatory drugs, contraceptives, and growth inducers. Steroids are also taken to build muscle and enhance athletic performance, which is misuse or abuse in that its purpose is not medical in nature.

Misuse of steroids occurs with the so-called anabolic and androgenic steroids—those compounds that are human-made versions of the male sex hormone testosterone. They promote muscle growth (anabolic effect) and development of male sexual characteristics in both men and women (androgenic effect). Steroid abuse can lead to serious health problems, including early heart attacks, abnormal lipid profiles, strokes, kidney failure, serious psychiatric disturbances and depression , and severe liver problems including liver tumors, cancer, and jaundice. Additionally, they are often injected, and individuals who share needles are at risk for HIV/AIDS and hepatitis B and C.

Description and doses

Anabolic steroids are prescription drugs used clinically for low testosterone levels or to prevent muscle wasting in AIDS patients or patients who are bedridden. Any other source of anabolic steroids is illegal, whether synthesized, smuggled, or stolen. Steroidal supplements such as androstenedione (“Andro”) used to be commercially available but were made illegal in 2004 in an amendment to the Controlled Substances Act. The only remaining legal steroidal supplement is dehydroepiandrosterone (DHEA), which may or may not be converted to testosterone in the body.

Anabolic steroids are taken orally as tablets or capsules, by injection into muscles, or by ointment preparations rubbed into the skin. Doses taken by abusers are often 50 to 100 times more than the doses used for treating medical conditions.

The methods of misuse go beyond high dosing. Frequently, steroids abusers take two or more anabolic steroids together, or take them by more than one route of administration, or mix them with other drugs such as stimulants or painkillers. This practice is known as “stacking.” Other practices are cycling, where periods of steroid use are alternated with periods of abstinence, or “pyramiding,” in which cycles of dose escalation over several weeks are following by a phase of decreasing the steroid dose. Both these dosing schedules are believed by the user to maximize the desirable effects of steroids, while reducing the untoward effects, although there is no scientific evidence that these goals can be achieved.

Common oral steroids include:

• oxymetholone (Anadrol)
• oxandrolone (Oxandrin)
• methandrostenolone (Dianabol)
• stanozolol (Winstrol)

Common injectable steroids include:

• nandrolone decanoate (Deca-Durabolin)
• nandrolone phenpropionate (Durabolin)
• testosterone cypionate (Depo-Testosterone)
• boldenone undecylenate (Equipoise)
• tetrahydrogestrinone (THG)

Demographics

Most anabolic steroid users are adult males, but misuse is increasing in women and adolescents in conjunction with athletics. Six to 11% of high school boys have admitted using steroids, with 2.5% of boys reporting use within the last year. For high school girls, 2.5% have used steroids. Part of a 2002 National Institute on Drug Abuse (NIDA)-funded study, teens were asked if they ever tried steroids—even once. Only 2.5% of eighth graders ever tried steroids; only 3.5% of tenth graders; and 4% of twelfth graders.

Health consequences

With high doses of anabolic steroids, muscles increase rapidly in size and strength and this effect is enhanced in conjunction with strength training. There is some evidence of increased energy and libido, as well. This is in contrast to the slow and even unnotice-able growth effects at medically prescribed doses.

Similarly, side effects are few with medical use of anabolic steroids. However, misuse of steroids for body image or athletic performance usually entails much higher doses.

As anabolic steroids are related to male reproductive hormones, misuse interferes with normal hormonal function. Men can experience reduced sperm count and shrinkage of the testicles. They also may show baldness and development of breast tissue; these changes may persist even if steroids are discontinued. Changes in women can be described as masculization: The size of their breasts decreases and their clitoris enlarges; they may grow more body and facial hair, yet show male-pattern baldness; they stop menstruating and their voice deepens. With continued use of steroids, some of these effects may be irreversible. In adolescents, anabolic hormones mimic the onset of puberty. This may both cause a growth spurt, but it also sends signals to the bones to stop growing. If the skeleton matures too soon, growth may be halted and shorter than normal stature results.

Anabolic steroids can also have behavioral effects beginning with mood swings ranging from mania to depression. Users may also experience aggression (’roid rage), paranoia , irritability, and delusions . Further, users may become psychologically or physically dependent on anabolic steroids to the point of addiction .

KEY TERMS

Addiction —A chronic condition characterized by compulsive drug-seeking and drug-using behavior.

Anabolic —Causing muscle and bone growth and a shift from fat to muscle in the body.

Androgenic —Causing testosterone-like effects in the body, specifically on the male reproductive organs and the secondary sexual characteristics of men.

Cortisol —Hormone involved in stress response.

Estrogen —The primary female sex hormone.

Hormone —A chemical signal produced in glands and carried by the blood to influence the functioning of bodily organs.

Sex hormones —Those hormones that are responsible for sex effects and reproductive function.

Steroids —A chemical class of drugs and hormones that include sex hormones, stress hormones, and medicines for inflammation, contraception, and promoting growth.

Testosterone —The primary male sex hormone.

Prevention

Three major reasons have been identified as contributors to steroid use: to improve athletic performance, to change one’s body to be more muscular and less fat or flabby, and to engage in high-risk behavior. Educating those who might be tempted to use anabolic steroids is the first step, and it has been recommended that such education be started in middle school to help adolescents obtain a balanced picture of the benefits and risks of taking steroids.

Many programs target school- or community-sponsored athletic teams, where coaches and team leaders are trained to educate young athletes about anabolic steroids in the context of training.

Drug testing may also be effective for discouraging steroid use and are used for amateur and professional athletes. However, the technology for detecting steroids in blood or urine has often been one step behind the drug designers making compounds that go undetected.

Diagnosis and treatment

Anabolic steroid use can be determined through urine screening. Metabolites of known drugs can be detected for as long as six months after last use.

Treatment of steroid abuse is in its infancy and few methods have been tested for effectiveness. Treatment approaches may include a counseling component to address the reasons for steroid use. A withdrawal syndrome has been characterized and thus some physicians use medications to alleviate the discomfort associated with withdrawal. Hormones may be used to restore normal hormonal functioning in the body and antidepressants may be used to alleviate depression that can occur when steroids are terminated.

Resources

BOOKS

“Anabolic Steroids.” The Merck Manual of Diagnosis and Therapy, Professional Edition. 18th ed. Ed. Mark H. Beers. Whitehouse Station, NJ: Merck & Co., 2005.

“Testosterone, Testosterone Cypionate, Testosterone Enanthate, Testosterone Propionate.” AHFS Drug Information. Ed. Gerald K. McEvoy, PharmD. Bethesda, MD: American Society of Health-System Pharmacists, 2006.

GOVERNMENT REPORTS

“Anabolic Steroid Abuse.” The National Institute on Drug Abuse Research Report Series. NIH Publication Number 06-3721, 2006.

Jill U. Adams