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Anabolic Steroid Use: A Looming Public Health

Problem?

Harrison G. Pope, Jr., M.D.

November 14, 2017

McLean Hospital /

Harvard Medical School

Belmont, MA, USA

Anabolic-Androgenic Steroids

(AAS):

Testosterone: The natural male hormone

Synthetic hormones similar to

testosterone:

• Nandrolone (Deca-Durabolin)

• Methenolone (Anadrol)

• Methandienone (Dianabol)

• Stanozolol (Winstrol)

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History of AAS:

1935: Testosterone first isolated by David et al.

1940’s: Many synthetic AAS developed

1950-1980: AAS spreads through elite athletics

1980’s: AAS use spreads to non-athletes

1990-2010: AAS use becomes widespread

among young men in Western countries

Thus, most illicit AAS users are young, rank-

and-file gym clients who are NOT competitive

athletes.

AAS Use Among American Men

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Myths About AAS Use

Most AAS users are competitive athletes.

AAS use is common in adolescents.

Girls and women often use AAS.

Why do People Use AAS?:

I. Highly Effective Drugs

II. Supportive Social Climate

III. Individuals with Body-Image

Concerns

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I. Highly Effective Drugs

1947

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Today

Today

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1939

1956

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Today

Today

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II. Supportive Social Climate

19751964 1992

GI Joe

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199719911982

GI Joe : Small Version

Star Wars : Luke Skywalker

1977 1997

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Star Wars : Han Solo

1977 1997

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Western Mythological

Tradition:

Bernadino Genga’s drawing

of the Farnese statue of

Herakles (1691)

Scandinavian

Mythological

Tradition:

Johann Heinrich Füssli’s

Der Kampf des Thor mit

der Schlange des Midgard

(1788)

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Japanese

Mythological

Tradition:

Eitaku Kobayashi’s

Izanagi and Izanami

(1885)

Japanese

Mythological

Tradition:

Unknown sculptor:

Seated Male Deity

(c. 800)

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III. Individuals With Body-Image Concerns

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Time to onset of AAS use for men with

high vs. low adolescent body-image

concerns

Pope et al., Biological Psychiatry, 2011

Highly Effective Drugs

+

Steroid Use

+

Supportive Social Climate

Individuals With

Body-Image Concerns

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Who is at risk for possible

adverse AAS effects?

Initial AAS

Use

“Casual” Use

AAS Dependence

What Should We Be Worrying

About?

Cardiovascular effects

Persistent hypogonadism

Psychiatric disorders

Neurotoxicity

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Dilated Cardiomyopathy

Echocardiography

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A' A'

A' A'

E' E'

E' E'

Le

ft V

en

tric

ula

r E

jectio

n F

ractio

n

(%)

AAS Users

Lower Limit of Normal

All-Users On-Drug Off-Drug Non-Users10

20

30

40

50

60

70

80

All-Users On-Drug Off-Drug Non-Users2

4

6

8

10

12

14

16

Lower Limit of Normal

Ea

rly D

iasto

lic L

eft

Ve

ntr

icu

lar

Tis

su

e V

elo

city

(cm

/s)

AAS Users

A.

B.

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Coronary CT Angiography

CT Angiography: Non-calcified plaque in right proximal coronary artery

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Cumulative Years of AAS Use

Coro

nary

Art

ery

Pla

que V

olu

me (

mm

3)

2 5 10 15 20 30

0100

500

1000

2000

Persistent Hypogonadism

In males, exogenous AAS

suppress the hypothalamic-

pituitary-testicular axis.

If a man stops AAS after a

prolonged “cycle,” he will likely

be hypogonadal.

Hypogonadism may resolve

within weeks, but can persist

more than a year.

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Psychiatric Disorders

Hypomanic or manic episodes during

AAS exposure

Major depression during AAS

withdrawal

Manic or Hypomanic Episodes in

Steroid Users

0

5

10

15

20

25

30

Low Dose Medium Dose High Dose

%

Pope et al., Arch Gen Psychiatry, 1994

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USA, 1992

NORWAY, 2011

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Major Depressive Episodes

Usually associated with hypogonadism

during AAS withdrawal

Affects only a minority of users

In rare cases may lead to suicide

AAS-Induced Apoptosis:

Programmed Cell Death

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Study Participants

• Long-term AAS users (at least two

years of total lifetime AAS use), N = 22

• Short-term AAS users (less than two

years of total lifetime AAS use), N = 9

• Experienced weightlifters reporting no

AAS use, N = 13

Pattern Recognition Memory

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Pattern Recognition Memory, Errors

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

AAS Users AAS Non-Users

Long-Term AAS Users vs. Non-AAS Lifters : p < .05

Nu

mb

er

of

Err

ors

Paired Associates Learning, Errors

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Paired Associates Learning, Errors

0

0.5

1

1.5

2

2.5

3

3.5

AAS Users AAS Non-Users

Current AAS Users vs. Non-AAS Lifters : p < .05

Nu

mb

er

of

Err

ors

Pattern Recognition Memory, Errors

PRM Errors vs. Lifetime AAS Dose: r = 0.54; p = 0.002

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Paired Associates Learning, Errors

PAL Errors vs. Lifetime AAS Dose: r = 030; p = 0.10

Kaufman et al., Drug Alcohol Depend, 2015

Magnetic Resonance Spectroscopy

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A Looming Public Health

Problem?

Widespread illicit AAS use did not

begin until about 1980.

Therefore the leading edge of the

population of illicit AAS users – those

who first tried steroids as youths in

the 1980’s – is only now reaching

middle age.

A Looming Public Health

Problem?

Imagine that widespread cigarette

smoking did not arise until 1980, and that

the great majority of cigarette smokers

were still under age 50 today…

An analogous situation might presently

exist for AAS.