Whacha think Will?
http://www.medpagetoday.com/tbindex.cfm?tbid=729
CME Teaching Brief
Steroid Medical Realities Outweigh Steroid Myths
By Colin Nelson, MedPage Today Staff Writer
Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University
of Pennsylvania School of Medicine.
March 17, 2005
Also covered by: CNN, MSNBC, LA Times
MedPage Today Action Points
Steroid use is not confined to professional athletes. School children
and amateur athletes are seeking a competitive edge with steroids as
well. Discuss the effects of steroids with patients and caution them
about potential dangers.
Review
WASHINGTON, March 17-To get a sense of the impact of Mark McGwire,
Sammy Sosa, and the other Major Leaguers scheduled to testify at
Congressional hearings today on steroid use, add to their number
another million. That's an estimate of the number of faceless,
nameless adolescent boys and girls mimicking their heroes by popping
and injecting steroids.
The numbers are disquieting. "We've got a million kids in this country
who have 'cycled' on these drugs," says Penn State's Charles E.
Yesalis, MPH, ScD, a pioneer in the research on anabolic steroids in
sports. "These sports stars are role models to these kids."
Among 9th- to 12-grade students in the U.S., nearly 7% of males and
more than 5% of females say they have used steroids at least once.
The use of anabolic steroids "has to be knocked out at the
professional level for it to be knocked out at the lower level," says
William O. Roberts, MD, president of the American College of Sports
Medicine.
"Physicians need to recognize the signs and symptoms of steroid
abuse," says Gary Wadler, MD, an associate professor of clinical
medicine at New York University, and a member of the World Anti-Doping
Agency. "It has to go into their differential diagnoses. I
particularly emphasize this for pediatricians."
Signs and symptoms of anabolic steroid use may include:
Behavioral and psychological changes - including aggression,
impulsiveness, and depression
Breast enlargement (men)
Breast shrinkage (women)
Body hair (women)
Deepening of voice (women)
Male-pattern baldness (men and women)
Acne
Striae in axilla
Testicle shrinkage
Menstrual abnormalities
Abnormal cholesterol distribution marked by very low levels of HDL
Dramatic changes in muscularity and athletic performance
And, finally, "The look," as Dr. Roberts calls it - "a little too
buff, a little too much muscle and a little too enhanced."
Evidence of steroids' effect on the heart and liver, and other health
problems, is conflicting. Some of the data are compelling, but many
are less so -- drawn from case studies or cohorts incapable of proving
causal links.
Most experts acknowledge this. "What scares me most is what we don't
know," says Dr. Yesalis. "We still have yet to do an epidemiologic
study of the long-term health effects of anabolic effects."
Nonetheless, say experts, the bottom line is that steroids appear to
increase the potential for serious, if rare, health problems.
Here's a rundown on what is known -- and what is not.
Cardiovascular. Experts list heart and stroke risks as among their
biggest worries. Steroids reduce HDL cholesterol, raise LDL, impair
glucose tolerance, and increase levels of triglycerides, clotting
factors, C-reactive protein, and insulin. Case reports and cohort
series have linked steroids to hypertrophic cardiomyopathy, myocardial
infarction, sudden cardiac death, and thrombotic events, but so far
it's difficult to prove a direct causal connection.
"The data are scant," says Dr. Wadler, "But from looking at case
reports I have been convinced that (anabolic steroid use) represents a
cardiovascular risk." Others agree.
Hepatic. "Oral anabolic agents are hepatotoxic," says Dr. Yesalis.
They lead to cholestatic jaundice, peliosis hepatis (a condition in
which microscopic pools of blood are present throughout the liver
parenchyma, which may lead to congestion and necrosis), and
hepatocellular hyperplasia and adenomas -- problems that are mostly
reversible when steroid use ends.
Although some allege a steroid connection to liver cancer, "that
hasn't been established," says Dr. Yesalis. But even benign tumors
pose a risk. "If a benign tumor ruptures, you hemorrhage to death,"
says Dr. Yesalis, as at least two case studies have documented.
Masculinization of females. A number of hormonal changes occur when
females use the primary male sex hormone. "Permanent masculinization
can take place," says Dr. Yesalis.
Male reproductive abnormalities. These include testicular shrinkage,
and a reduction in endogenous testosterone, sperm count, and sperm
motility.
Growth plates. Ironically, to become more muscular, some steroid users
may be giving up stature because androgens hasten epiphyseal closure.
"High doses can shut down their growth plates," says Dr. Yesalis.
Erythrocytosis. Erythrocytosis is a common side effect of
pharmacologic doses of all androgens, probably due largely to direct
androgen stimulation of erythropoiesis.
Musculoskeletal injuries. Case studies have attributed tendon injuries
and neuropathies to steroids. Researchers haven't yet established a
cause-effect link.
Prostatic cancer. Case reports, but evidence lacking.
Compromised immune function. Evidence lacking.
Anabolic steroids have the potential to wreak havoc on adolescents and
young adults. Some observers say their psychological effects -- mood
shifts, aggression, so-called "'roid rage," even suicide -- are as
profound and dangerous as the physiological ones.
However, there isn't yet sufficient scientific evidence to declare
steroids the root cause of all of these problems, says Dr. Yesalis.
It's even possible that increased aggression among users is a placebo
effect. In a surprising 1994 double-blinded study, men who received
placebo were judged to be more aggressive and impulsive than those who
received testosterone.
"Anticipation of the aggressiveness related to steroid use may lead to
actual violent acts and become, in effect, an excuse for aggression,"
write Dr. Yesalis and Michael S. Bahrke, PhD, in the current Research
Digest of the President's Council on Physical Fitness and Sports.
"We've established pretty well that kids become psychologically
dependent on these drugs," says Dr. Yesalis.
"But is there a causal relationship between 'roid rage' and steroids?
I don't believe so," he says. "Am I more suspicious [of the
connection] now than I was a decade ago? Yes."
Primary source:
Research Digest of the President's Council on Physical Fitness and
Sports
Source reference:
Yesalis CE, Bahrke MS. Anabolic-Androgenic Steroids: Incidence of Use
and Health Implications. Research Digest of the President's Council on
Physical Fitness and Sports, March 2005.
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http://www.cnn.com/2005/HEALTH/04/25/girls.steroids.ap/index.html
Girls are abusing steroids, too
Experts say some female users seek toned look
Tuesday, April 26, 2005 Posted: 12:13 PM EDT (1613 GMT)
TRENTON, New Jersey (AP) -- An alarming number of American girls, some
as young as 9, are using bodybuilding steroids -- not necessarily to
get an edge on the playing field, but to get the toned, sculpted look
of models and movie stars, experts say.
Girls are getting their hands on the same dangerous testosterone
pills, shots and creams that have created a scandal in Major League
Baseball and other sports. Often, these are the same girls who have
eating disorders, according to some research.
"There's been a substantial increase for girls during the 1990s, and
it's at an all-time high right now," said Charles Yesalis, a professor
of health and human development at Pennsylvania State University.
Lloyd Johnston, a University of Michigan professor who heads an annual
government-sponsored survey on risky behavior by young people, said:
"Other than pedophilia, this is the most secret behavior I've ever
encountered."
Overall, up to about 5 percent of high school girls and 7 percent of
middle-school girls admit trying anabolic steroids at least once, with
use of rising steadily since 1991, various government and university
studies have shown.
Researchers say that most girls are using steroids to get bigger and
stronger on the playing field, and they attribute some of the increase
in steroid use to girls' rising participation in sports. But plenty of
other girls are using steroids to give themselves a slightly muscular
look, they say.
"With young women, you see them using it more as a weight control and
body fat reduction" method, said Jeff Hoerger, who runs the staff
counseling program at Rutgers University in New Jersey.
In the past couple of years, he has helped two young women using
steroids -- one an 11th-grader with "an average figure" whose swimmer
friend suggested steroids would help with weight loss. "She was just
looking for quick results," Hoerger said.
The sports medicine division at the Oregon Health and Science
University found that two-thirds of Oregon high school girls who
admitted using steroids were not athletes and that girls who were
considering taking steroids had tried other, risky ways to get thin.
"They were more likely to have eating disorders and to abuse
diuretics, amphetamines and laxatives," said Dr. Linn Goldberg, head
of the division.
In teenage girls, the side effects from taking male sex hormones can
include severe acne, smaller breasts, deeper voice, irregular periods,
excess facial and body hair, depression, paranoia and the fits of
anger dubbed "roid rage." Steroids also carry higher risks of heart
attack, stroke and some forms of cancer.
Researchers say youngsters generally get illegal anabolic steroids on
the black market from relatives or friends, from the local gym and
over the Internet. At least one study indicates some parents and
coaches supply steroids to teen athletes.
Dr. Eric Small, chairman of the American Academy of Pediatrics'
committee on sports medicine, said adults should gently ask youngsters
about possible steroid use.
"Talking about supplements and steroids needs to start in the third
grade," Small said. "If you wait till ninth grade, it's too late."
Copyright 2005 The Associated Press