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. Action Points
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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.
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.
