Adverse effects of anabolic-androgenic steroids

AAS use has several kinds of short and long term adverse effects. Many of them are caused by that the steroid abuse suppresses the normal production of hormones, which may cause reversible or irreversible changes. In fact, the use of AAS very rarely causes death, but the potential side effects may reduce the life expectancy.

1.7.5.4.1 Physical side effects of anabolic-androgenic steroids

Gynecomastia is a common side effect of AAS use, which means the growth of the breast tissue under the nipples, caused by the imbalance of testosterone-estrogen hormones during the period of AAS use. Once it has developed, the condition is irreversible and the enlarged breast can be removed only surgically. According to the results of a survey, 10-34% of the AAS users experience gynecomastia (Evans, 2004).

Another long-term physical side effect of AAS use is the increased level of LDL-cholesterol and the decreased level of HDL-LDL-cholesterol, which increases the risk of artherosclerosis (Hurley et al., 1984). Artherosclerosis is the thickening and hardening of the walls of medium- and large sized arteries and responsible for coronary artery disease and stroke.

Many men also report the shrinking of their testicles (testicle atrophy) while they are on steroids. This is caused by the suppression of natural testosterone level, which inhibits production of sperm. However, this side effect is only temporary, since the size of the testicles usually returns to their normal size after a few weeks of discontinuing AAS use as normal production of sperm resumes. Reduced sexual function and temporary infertility can also occur in males. According to the results of a survey, 40-51% of the AAS users experience testicle atrophy (Evans, 2004).

Long-term AAS use is also a great concern, since it may cause prostate enlargement.

Some study also pointed out the relationship between AAS use and prostate cancer (Creagh, Rubin, & Evans, 1988). The high doses of oral AAS are highly hepatotoxic, as the steroids are metabolized and can cause liver toxicity. In more serious cases there is also a higher risk for fatal liver cysts, liver changes, and cancer (Stimac, Milic, Dintinjana, Kovac, & Ristic, 2002).

Steroids also can cause myocardial hypertrophy, which can increase the risk for cardiac arrhythmias, hypertension, heart attacks, and sudden cardiac death (Karila et al., 2003;

Sullivan, Martinez, & Gallagher, 1999). Anabolic steroids have been linked with cardiovascular issues, e.g., high blood pressure, or headaches, and kidney failure.

Another common side effect of AAS use is the development of acne, since steroids enlarge the sebaceous glands in the skin. These enlarged glands produce an increased amount of oil. Research data show that 40-54% of the AAS users reported the presence of acnes (Evans, 2004). AAS use can also accelerate the rate of premature baldness for those males who are genetically predisposed.

Anabolic steroid use in adolescence can possibly stunt the growth potential. This is because of the premature closure of the epiphysial cartilage, caused by aromatizable steroids, which finally leads to a possible growth inhibiting effect, and could results in a shorter adult height. This side effect is irreversible. The use of AAS has been also linked with ligament and joint injury. Steroids increase muscle mass and muscle strength, but the joints and ligaments can not adapt. Putting too much strain on

ligaments that cannot properly anchor the new muscle strength, can result in severe injury.

1.7.5.4.2 Psychiatric side effects of anabolic-androgenic steroids

Even though the use of AAS rarely cause immediate acute medical side effects, the use of these substances can be dangerous because of their psychiatric side effects. Steroids may induce changes in the personality and behaviour, which can have an adverse effect on the social, occupational, and other important areas in life.

Many studies suggested that AAS use can cause hypomania or mania, sometimes co-occurring with increased aggressiveness and mild irritation (e.g., Choi and Pope, 1994;

Kouri, Pope, & Oliva, 1996; Pope and Katz, 1990). The degree of these effects is mostly based on the dosage level of the AAS. The manic symptoms were described by irritability, aggression, grandiose beliefs, euphoria, hyperactivity, violence, and dangerous behaviour. These manic symptoms are occasionally accompanied by psychotic symptoms, such as beliefs about having a special power (Pope et al., 2000;

Pope & Katz, 1988). Studies which examined the mood disorders and aggression among those AAS users who used high dose steroids (> 1000 mg/week) found that 23% of the AAS abusers developed mania, hypomania, or major depression, and 3-12% had psychotic symptoms (Pope & Katz, 1994; Pope, Kouri, & Hudson, 2000).

Studies also documented depressive symptoms associated with AAS use (Brower, 2002;

Malone & Dimeff, 1992; Malone, Dimeff, Lombardo, & Sample, 1995; Pope & Katz, 1994). Depressive symptoms are more likely to present in the withdrawal phase of AAS use. Relevant to these studies, some research also reported suicides related to AAS use (Brower, Blow, Beresford, & Fuelling, 1989; Papazisis, Kouvelas, Mastrogianni, &

Karastergiou, 2007; Thiblin, Runeson, & Rajs, 1999). Most of the mood changes are only temporarily and experienced for short-term during or after the AAS use. However, suicidal cases are of great concern. One study examined older powerlifters and documented that 3 of the 8 death were caused by suicide (Parssinen, Kujala, Vartiainen, Sarna, & Seppala, 2000). Recent study findings also indicated that suicide was a more common cause of death among AAS users than among other substance users (Petersson

et al., 2006). Another study found that 6.5% of the AAS user bodybuilders attempted suicide after discontinuing steroids (Malon et al., 1995). However, there are some studies that have not documented such mood changes during AAS use (Basaria Wahlstrom, & Dobs 2001; Bhasin et al., 1996; Tricker et al., 1996).

Sexual dysfunctions are also associated with AAS use (Pope, Phillips, et al., 2000). The dysfunction can be experienced in extremities. One extremity is the increased libido and the increased sexual drive, which usually occur during the active phase of AAS. The other extremity is the decrease of libido and sexual drive, sometimes accompanied by impotence, which can be experienced during withdrawal from AAS when the natural testosterone level is still suppressed (Pope, Phillips, et al., 2000).

The long term use of AAS may also lead to dependence. One study pointed out that AAS may cause withdrawal symptoms, and those men who discontinued AAS use reported depression, decreased libido, energy level, and self-esteem (Bahrke, Yesalis, &

Wrigh, 1990). Although the AAS do not have strong euphorigenic effects, the dysphoric effects of the withdrawal may contribute to the development of their dependence (Pope

& Katz, 1988). Brower (2002) proposed a two-stage model for AAS dependence. In the first stage, subjects use AAS for their anabolic (muscle gaining) effects. During this stage, the AAS users also experience the psychological effects of AAS, since the achievement of their goals (i.e., muscle gain) reinforces their use. In the second stage, the psychoactive effects of the AAS use develops and through the high doses of steroids affect the brain mediated reward systems. Some AAS users are at risk for dependence because of the withdrawal symptoms (e.g., fatigue, depression, low energy levels) and also because discontinuity of AAS is usually accompanied by some decrease of muscle mass and strength. Brower, Eliopulos, Blow, Catlin, and Beresford (1990) documented that 57% of the AAS user male weightlifters fulfilled the DSM-III criteria for dependence. Another study examined the symptoms of AAS dependence and withdrawal among 49 male weightlifters (Brower, Blow, Young, & Hill, 1991). Eighty-four percent of the sample reported different symptoms of withdrawal: 52% reported steroid craving, 43% fatigue, 41% depressed mood, 24% loss of appetite, 20%

insomnia, 20% reduced sex drive, 20% headache, and 29% restlessness.

Another great concern relating to AAS use is that in most cases the use of AAS is associated with other substance use as well. For instance, a study found that 79% of the AAS users also used some kind of psychotropic substances (Petersson et al., 2006).

1.7.5.5 Characteristics of anabolic-androgenic steroid users and risk factors for