Adolescent, Anabolic Steroids
The adolescent girl described in the vignette probably is using anabolic steroids. Many athletes use performance-enhancing drugs to supplement their training, although there may not be a noticeable increase in muscle size and strength. Anabolic steroids are synthetic derivatives of testosterone and can be injected or taken orally, frequently at 10 times the recommended therapeutic drug dose. Combinations of oral and injectable agents often are used concurrently in 6- to 12-week cycles, which is known as "stacking."
Growth hormone (GH) also is used to enhance athletic performance, although not as commonly as anabolic steroids. It is claimed that its use increases protein anabolism, enhances tissue repair, and increases fat metabolism. GH is particularly attractive among athletes because it is not commonly detected in current drug testing procedures.
Anabolic steroid and GH use can be diagnosed by careful history and physical examination. All athletes, whether in organized sports or individual bodybuilding, should be asked about the use of performance-enhancing drugs. Other high-risk behaviors should be reviewed at the same time because there is an increased use of other illicit drugs with anabolic steroid use. Obvious signs of virilization in females on physical examination should not be relied upon to distinguish the user from the nonuser, but the presence of acne, deepening of the voice, and hirsutism in a female or gynecomastia and a high voice in a male should make the examiner suspicious. Hypogonadism or a decrease in testicular size also can be seen in the male user. Other side effects associated with steroid use include hypertension, hyperaggressiveness, mood swings, psychosis, and mania. Depression can occur during drug withdrawal.
The laboratory evaluation of anabolic steroid use involves both specific and nonspecific data. Orally administered steroids may be present in the urine for days to weeks; injected steroids can be present for 6 months or longer. Nonspecific evidence of anabolic steroid use may include elevated liver enzyme concentrations, decreased high-density and increased low-density lipoprotein cholesterol levels, oligospermia, and azoospermia. In addition, prepubertal athletes may have premature epiphyseal closure.
Arrhythmias, seizures, and weight loss are not associated with anabolic steroid use. Although psychosis may be seen, hallucinations are not a common side effect.
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