Riam Shammaa - A Doctors Journey through Steroids, Addiction and Online Fitness Culture

I am including a few brief extracts from the 2013 Swedish clinical guidelines for the benefit of my fellow healthcare providers, some of whom might be learning in this book for the first time about the likelihood of AED use by their patients. I have selected excerpts most pertinent to initial recognition of symptoms of AED abuse. To my knowledge, these are the only guidelines published anywhere for physicians and other healthcare workers. To see the full list of guidelines, please search the title below online, in case the URL (http://dopingjouren.se/Dopingjouren_EN_sept2013.pdf) changes in the future. The guidelines are published by the Anti-Doping Hotline, Karolinska University Hospital, and I am grateful to the publishers for their permission to include these excerpts.

SWEDISH CLINICAL GUIDELINES ON THE ABUSE OF ANABOLIC-ANDROGENIC STEROIDS (AAS) AND OTHER HORMONAL DRUGS

When to Suspect AAS Abuse

AAS abuse is quantitatively the greatest problem in doping. The typical patient is a male, between the ages of 17 and 30 years, engaged in weight-training, and using one or more AAS substances, who might, at some point, have tried growth hormone.

Table 2 shows a list of signs that should evoke suspicion of AAS abuse, as well as adverse effects that may require further investigation. Women abusing AAS experience the same adverse effects as men. Masculinization of features in women are common, and many of these adverse effects may be irreversible.

TABLE 2 Physical Signs and Adverse Effects of AAS Abuse

• Rapid and significant weight gain (approximately 10 kg in 2-3 months)

• Muscular physique

• Disproportionate muscle growth, mainly around the chest, neck and shoulders

• Edema

• Severe acne, mainly on back, shoulders and chest

• Striae (stretch marks) usually between the biceps and pectoral muscles, but may also occur on the back and thighs

• Excess body hair

• Gynecomastia (mammary enlargement)

• Altered sex drive, initially increased, then decreased, may cease after stopping cycle of abuse

• Potency problems

• Androgenic alopecia

• Cardiac problems (high blood pressure, lipid pattern abnormalities, palpitations, myocardial infarction)

• Liver abnormalities

• Local reactions at the injection site (swelling, redness, tenderness)

• Tendon and muscle tears

• Testicular atrophy (shrinking of the testicles)

• Fertility problems

Female-Specific Signs of AAS Abuse

• Abnormal menstruation

• Deepening of voice, irreversible

• Clitoral enlargement

• Increased growth of beard and body hair

TABLE 3 Common Adverse Psychiatric Effects of AAS Abuse

• Aggression

• Depressive symptoms (dysphoria, depression, suicidal thoughts, attempted suicide)

• Reduced impulse control

• Anxiety

• Panic disorder

• Affect instability

• Concern

• Psychosis

• Sleep disorders

• Megarexia

• Empathy disorder

• Reduced mentalizing capacity

• Jealousy

• Violence

It is the authors experience that patients are rarely questioned about doping, and that suspicion of an AAS abuse is seldom taken into account in the differential diagnosis. Since the effects and adverse effects are so multi-faceted, maintaining an index of suspicion to consider the diagnosis is needed.

In patients presenting with symptoms and clinical characteristics, history taking should include questions about AAS. The clinical suspicion must be verified by urine analysis for AAS substances.

Table 4 shows an example of recommended components of a medical history.

TABL E 4 Medical History for Suspected or Verified AAS Abuse

Characterization of AAS Abuse

In cases where it becomes evident that the patient has been abusing AAS, he or she should be questioned about what substances have been used, and to what extent.

Questions to Ask:

• Age for AAS abuse debut

• Duration of AAS abuse and duration of cycles

• Which substances have been abused, and in what combination

• Which pharmaceutical forms

• Cumulative dosage for each substance

Physical Examination

The physical examination includes performing a general examination of the patient, together with an extended/targeted status, regarding specific organ systems which may be affected by an AAS abuse, as well as possible observed adverse effects.

Table 5 gives an example of components of a physical examination.

TABLE 5 Physical Examination

• General appearance (height, weight, and body mass index [BMI])

• Heart (blood pressure, pulse, signs of heart failure, cardiac murmurs)

• Lungs

• Abdomen/rectal examination (hepatic enlargement, prostatic hypertrophy)

• Urogenital (testicular atrophy)

• Neurological examination

• Chest (gynecomastia)

• Skin/hair (acne, premature baldness, striae/stretch marks, especially axillary)

• Musculoskeletal (muscular)

• Specific to women: clitoral enlargement, deepening of voice, menstrual abnormalities, body hair

Measures Taken at Initial Patient Contact