This is a 17 year old male who has come to see you for his annual well-teen sports health evaluation. As with all your patients, you meet with him alone and discuss his physical and psychosocial health and development over the past year. He acknowledges no significant physical illness and feels he is developing appropriately. He reports getting along well with his parents and he is generally a "B" student at school. He is involved in his school's track team and also belongs to a paddling club. He denies any substance use. He is sexually active with his 16 year old girlfriend and reports using condoms consistently. He denies any major mood changes or suicidal ideation. His physical exam was completely normal.
Although he is unaware, you recently received a call from his father who had found pills in his son's room. He believes they may be steroids since he had overhead his son talking with other teammates about someone dealing in steroids at school. He asks you to bring this up with his son. When you specifically address steroid use, he admits that he and several of his friends on the track team have been using steroids regularly for the past 4 months. He believes it has increased his muscle mass and improved his appearance but admits he knows little about the potential side effects of steroid use.
Anabolic steroids, which are synthetic derivatives of testosterone, have legitimate uses in the treatment of male hypogonadism, chronic illness and other starvation or catabolic states. However, they also belong to a group of drugs known as "performance enhancers" (1). Their first use among athletes was in the early 1950s, most notably among male and female Soviet athletes competing internationally. The anabolic (tissue-building) effects of these steroids come from their binding to specific cellular receptors resulting in increased protein synthesis. In addition, they have an anti-catabolic effect by competitively binding to glucocorticoid receptors. The result is increased lean body mass (muscle) as well as increased muscle strength, especially if accompanied by a rigorous exercise regimen and adequate diet. These, in turn, can result in enhanced athletic performance. Their use is most common in football, wrestling, basketball, track and field, swimming, weight training and bodybuilding. Performance also may be enhanced through increased aggressiveness and endurance resulting from steroid use. Anabolic steroids do not improve and may actually limit aerobic capacity, agility and athletic skill. Other "performance enhancers" include human growth hormone (hGH), stimulants, diuretics and a variety of protein, vitamin and mineral supplements. Blood-doping (intravenous infusion of blood) is another technique used by athletes to improve performance. Some male adolescents take anabolic steroids not to enhance athletic performance but to improve their physical appearance through increased muscle mass and definition.
Studies of anabolic steroid use among high school students show a prevalence rate of 5-11 percent for males and 1.4-2.5 percent for females (2). A 1998 survey of junior high school students revealed that nearly four percent had used anabolic steroids (3). During the decade of the 1990s, anabolic steroid use among both males and females has increased (4).
Anabolic steroids can be taken orally or injected intramuscularly. Often both routes are employed simultaneously, a process known as stacking. Another pattern of use is megadosing, with doses up to forty times greater than therapeutic doses. Pyramiding is a third technique in which doses are increased then decreased on a cyclic basis.
Anabolic steroids are not difficult to obtain, even for high school students. Sources of the drug include friends, coaches, veterinarians and physicians. Anabolic steroids can be purchased over-the-counter in many foreign countries and brought back into the U.S. for distribution.
The use of anabolic steroids can result in increased muscle mass and strength. These attributes are highly desired by the adolescent user. However, many negative effects of chronic anabolic steroid use have been documented (Table 1 below). These primarily relate to its effects on growth and the hepatic, cardiovascular, and reproductive systems. Anabolic steroids can also have serious effects on a patient's psychological state, typified by violent mood swings ("roid rage"). Oral preparations are more hepatotoxic than injected forms, but with injection comes the risk of Hepatitis B and HIV (if contaminated or shared needles are used). Studies have shown that as many as 25 percent of users who inject steroids have shared needles (5). Anabolic steroid users are also more likely to use other drugs and experience their attendant risks. Most side effects of steroid use disappear on discontinuation of use. However, premature epiphyseal closure is irreversible and peliosis (purpura), hepatoma, baldness, clitoromegaly and voice changes will likely persist.
Because anabolic steroid use can have multisystemic effects as described above, the differential diagnosis would at first appear to be a lengthy one. However, a history of athletic involvement in sports where muscle mass is important coupled with an unusual degree of muscle development should place anabolic steroid use at the top of the differential diagnosis list. Testosterone-producing tumors may have masculinizing effects on both males and females, but usually result in muscle-wasting and other signs of chronic illness.
Once an adolescent who is using anabolic steroids has been identified, the pediatrician assumes the role of educator and counselor. Traditional drug treatment programs do not treat youths using anabolic steroids unless this use is part of a broader spectrum of substance use. Guidelines for the approach to the adolescent using anabolic steroids have been established by the American Academy of Pediatrics (2). In general, counseling should be provided in a confidential and non-judgmental manner. It is appropriate to acknowledge to the patient that anabolic steroids may, in fact, lead to increased muscle mass and strength. It is also appropriate to express an understanding of why athletes and others might want to increase muscle mass, strength and definition. This honest discussion of the "benefits" of steroid use must then be balanced with an honest review of the risks of use. Simply citing the negative effects is both dishonest and diminishes the physician's credibility in the adolescent's eyes. There is no evidence that scare tactics work in diminishing steroid use since the drive to excel athletically is so strong.
Pediatricians also have a role in prevention. At the individual patient level, screening questions and anticipatory guidance regarding anabolic steroid use should be a part of each well-teen visit. Adolescents who present with signs or symptoms suggestive of steroid use, even if not related to the presenting complaint, should be asked specifically about the possibility of anabolic steroid use at acute care visits. Adolescents can be counseled about alternatives for improving their strength and appearance through healthier diets and appropriate physical training. Discussions about the concept of "fair play" and the satisfaction coming from relying on one's natural abilities and hard work are reasonable, but will be counterproductive if they sound like lecturing.
At a community level, pediatricians can educate parents, schools and coaches about the prevalence and risks of anabolic steroid use among students. Drug screening programs at a school or team level are impractical and expensive.
Table 1. Negative effects of anabolic steroid use (2).
. . . . . Musculoskeletal: premature epiphyseal closure, short stature, ligament and tendon injuries.
. . . . . Hepatic: benign and malignant tumors, toxic hepatitis, peliosis hepatis, decreased HDL, increased LDL and cholesterol.
. . . . . Cardiovascular: hypertension, stroke, thrombosis.
. . . . . Male reproductive: decreased testosterone production, decreased testicular size, impotence, enlarged prostate.
. . . . . Female reproductive: breast atrophy, clitoromegaly, menstrual changes, teratogenicity.
. . . . . Other: deepened voice, acne, alopecia.
. . . . . Psychological: severe anger outbursts, hallucinations, paranoia, anxiety, addiction.
1. True/False: Anabolic steroid use is usually effective in enhancing athletic performance.
2. Name the two most common routes of anabolic steroid administration. Which is the more hepatotoxic route?
3. In an adolescent using anabolic steroids who is at Sexual Maturity Rating (Tanner Stage) II, what is a major danger involving the musculoskeletal system?
4. In which patients should pediatricians consider the possibility of anabolic steroid use?
5. What is the role of the pediatrician in addressing anabolic steroid use?
1. Metzl JD. Performance-enhancing drug use in the young athlete. Pediatr Ann 2002;31(1):27-32.
2. American Academy of Pediatrics, Committee on Sports Medicine and Fitness. Adolescents and anabolic steroids: A subject review. Pediatrics 1997;99(6):904-908.
3. Faigenbaum AD, Zaichowsky D, Gardner DE, Micheli LJ. Anabolic steroid use by male and female middle school students. Pediatrics 1998;101:E6.
4. Irving LM, Wall M, Neumark-Sztainer D, Story M. Steroid use among adolescents: Findings from Project EAT. J Adolesc Health 2002;30(4):243-252.
5. DuRant RH, Rickert VI, Seymore Ashworth C, et al. Use of multiple drugs among adolescents who use anabolic steroids. New Engl J Med 1993;328(13):922-926.
Answers to questions
1. True. One of the reasons it is difficult to dissuade competitive athletes from using anabolic steroids is that it can, in fact, result in increased lean body mass, muscle strength, and aggressiveness. These may, in fact, contribute to enhanced athletic performance.
2. Anabolic steroids may be taken orally or injected intramuscularly. Oral steroids are more hepatotoxic.
3. An adolescent in early puberty who uses steroids risks premature epiphyseal closure with resultant shorter stature than otherwise would be predicted.
4. Anabolic steroid use should be considered and addressed with all adolescent patients, male or female, athlete or non-athlete. Particular attention should be paid to those adolescents who have greater than expected muscle-mass development or in females with signs of masculinization.
5. On an individual level, pediatricians should, without lecturing, initiate an honest discussion of the risks and benefits of steroid use. They should ask all adolescents, and especially those with signs and symptoms of steroid use, about the possibility of using steroids. They also have a role in educating parents, teachers and coaches about the prevalence and dangers of anabolic steroid use.