GP Guide to harm minimisation for patients using non-prescribed anabolic-androgenic steroids (AAS) and other performance and image enhancing drugs (PIEDs)

Practice point

Explain confidentiality

A common reason that patients do not disclose their use is because they are worried that the information will be passed on to a third party (e.g. police). It is therefore key to assure the patient of doctor-patient confidentiality.

·       Patients can be assured that information regarding the use of AAS and other PIEDs will be kept confidential unless that use is putting the patient’s or someone else’s life or health in immediate danger.

·       Although possession and use of non-prescribed AAS is a criminal offence there is no obligation to report this if a GP becomes aware of it. It is only mandatory to report serious offences (i.e. those that carry a sentence of 5 years or more (e.g. murder, rape, drug trafficking)). (Please check with local state legislation for any changes).

·       Insurers can request information in medical records to:

o   Gather/confirm information prior to providing insurance.

o   Assess a claim.

o   Ascertain any relevant non-disclosure of information on the part of the patient when purchasing insurance which may make a claim invalid. 

How to ask about AAS and other enhancement drug use?

·       Avoid asking patients directly if they are using non-prescribed AAS or other PIEDs, as there is the risk that patient will be offended. Instead ask about this as part of regular assessment/history taking.

Useful questions:

·       As part of a comprehensive assessment a GP could ask:

o   Do you use or take anything to help with your workouts or muscle gain?; or

o   Can you tell me about supplements you are using, including any use of pills, powders or injectables?

·       When asking, a GP could note:

o   I am asking this because am interested to see if we need to be checking for any other related health issues.

·       Age of initiation

·       Route of administration

·       Reason for commencement and specific goals;

o   It is important to examine why patients are using and what their relationship is with the substance. There may be underlying issues such as anxiety, depression or lack of body confidence.

·       How long has the patient been using AAS and other PIEDs, what regimen(s) have they used in the past and the duration of the cycles?

·       Current use including duration of cycle and amount.

·       What adverse effects or withdrawal symptoms has the patient experienced during or after a previous cycle of AAS? Particularly check for signs and symptoms that may indicate AAS-induced hypogonadism (see withdrawal section).[1]

·       Comorbidities – check for pre-existing conditions as well as conditions potentially caused by AAS use (list not exhaustive)

o   Cardiovascular disease including high blood pressure or high cholesterol;

o   Reduced kidney function or liver disease (particularly when patients are using oral AAS);

o   Sexual dysfunction: e.g. heightened or reduced libido

o   Psychiatric:

§  Depression or anxiety (particularly when patient stops using AAS). This is also important in contributing to poorer outcomes in relation to harm minimization.[2]

§  Body dysmorphic (particularly muscle dysmorphia) and eating disorders may also be present (not common).

§  Mental Health considerations can be very complex as different issues may arise depending on what stage of use a person is in (contemplating use, using or in recovery).

§  Psychosis (rare but may occur with prolonged use)

o   Sleeping disturbances (may be caused by disturbances on hypothalamic-pituitary-adrenal axis) – consider using the Sleep Disorders Questionnaire to screen for a sleep disorder

·       Current medications;

·       Current dietary supplement use; and

·       Alcohol and other substance use – people who use AAS may also use other illicit substances like cocaine, cannabis and amphetamines to further enhance training and for relaxation. The use of alcohol and other substances also increases the risk of behaviour and mood disturbances as well as end-organ damage (e.g., heart, liver).

In case of suspicion of a body dysmorphic disorder – checklist

·       A person may have a body dysmorphic disorder if they:

o   Have been very concerned about some aspect of their physical appearance;

o   Worry or think a lot about how they look;

o   Believe that they have a physical abnormality or defect that makes them ugly;

o   Frequently look in the mirror, body check or skin pick or avoid mirrors;

o   Engage in excessive grooming and frequent cosmetic procedures, with little to no increased satisfaction;

o   Wear excessive make-up or clothing to conceal perceived flaws;

o   Feel extremely insecure and self-conscious;

o   Avoid social situations and refuse to appear in photographs;

o   Belief that other people take special notice of their appearance in a negative way; and

o   Negatively compare their appearance to others.

·       The RACGP website provides useful information on body dysmorphic disorders, including  screening questions from dysmorphic concern questionnaire that GPs could use in their assessment:

o   Have you been very concerned about some aspect of your physical appearance?

o   Have you considered yourself misformed or misshapen in some way (e.g., nose, hair, skin, sexual organs, overall body build)?

o   Have you considered your body to be malfunctional in some way (e.g., excessive body odour, flatulence, sweating)?

o   Have you consulted or felt you needed to consult a plastic surgeon, dermatologist or physician about these concerns?

o   Have you been told by others or your doctor that you are normal in spite of you strongly believing that something is wrong with your appearance or bodily functioning?

o   Have you spent a lot of time worrying about a defect in your appearance or bodily functioning?

o   Have you spent a lot of time covering up defects in your appearance or bodily functioning?

·       Family history:

o   Medical history (particularly premature heart disease and prostate cancer[3]);

o   Psychiatric history (particularly check for depression, anxiety and major psychiatric conditions).  

·       Social history: e.g. profession, occupation, spare-time activities, relationship status, and checking if the patient wants a family.

Although the majority of adverse effects may be mild or may go unnoticed by the person using these substances, all people who use AAS experience some form of adverse effect (e.g., high cholesterol) and some of these may be long-term (even after stopping). The below adverse effects are commonly reported in the literature[4].

This Exchange Supply side effects and risks leaflet can be provided to patients.

 Note: The adverse effects in bold are well recognised in the literature and probably of serious concern.

Cardiovascular

·       Dyslipidaemia – atherosclerotic disease

·       Cardiomyopathy

·       Cardiac conduction abnormalities

·       Coagulation abnormalities

·       Polycythaemia

·       Hypertension

Hepatic:

·       Inflammatory and cholesteric effects

·       Peliosis hepatis (rare)

·       Neoplasm (rare)

Kidney:

·       Renal failure secondary to rhabdomyolysis  

·       Focal segmental glomerulosclerosis

·       Neoplasms (rare)

Neuroendocrine

Males

·       HPT suppression – hypogonadism from AAS withdrawal

·       Gynaecomastia

·       Prostatic hypertrophy

·       Virilising effects

·       Libido and other sexual function changes

Neuroendocrine

Females:

·       Amenorrhea

·       Changes in the reproductive system

·       Development of a more masculine physique; breast tissue atrophy, deepening of voice, coarse skin, and hirsutism (excessive hair growth)

Infectious

·       Soft tissue & muscular abscesses

·       HIV/Hepatitis risk

Musculoskeletal

·       Tendon rupture

·       Premature epiphyseal closure (in adolescents, rare)

Dermatologic

·       Acne (in some cases severe)

·       Striae

·       Premature balding

Neuropsychiatric

·       Mood disorders – mania, hypomania and depression

·       Aggression

·       AAS dependence

·       Neuronal apoptosis – cognitive deficits

Dependence is defined as the problematic pattern of non-prescribed AAS use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

·       Tolerance, as defined by either of the following:

o   A need for markedly increased amounts of the substance to achieve intoxication or desired effect.

o   Markedly diminished effect with continued use of the same amount of the substance.

·       Withdrawal, as manifested by either of the following:

o   A characteristic withdrawal syndrome, characterized for AAS by two or more of the following features: depressed mood, prominent fatigue, insomnia or hypersomnia, decreased appetite, and loss of libido.

o   AAS are used to relieve or avoid withdrawal symptoms.

·       Using larger amounts or over a longer period than intended.

·       There is a persistent desire or unsuccessful efforts to cut down or control substance use.

·       A great deal of time is spent obtaining the substance, using the substance, or recovering from its effects.

·       Important social, occupational, or recreational activities are given up or reduced.

·       Continued use despite persistent or recurrent physical or psychological problem caused or exacerbated by use.

Withdrawal symptoms

·       Withdrawal is characterised by psychiatric and neuroendocrine symptoms, with the patient ultimately re-initiating non-prescribed AAS to alleviate or avoid their onset.

·       Withdrawal symptoms typically appear upon discontinuation of AAS use due to AAS-induced hypogonadism (deficiency in testosterone), especially if they have used AAS for prolonged periods[6].

o   In some patients these symptoms can also be a result of underlying mental health disorders, such as depression, dependence and/or a body dysmorphic disorder.

·       Although hypogonadism may gradually resolve after AAS use is discontinued, in some cases patients will exhibit hypothalamic–pituitary–testicular (HPT) suppression that persists for many months after AAS are discontinued and in some there is the risk that it becomes permanent.

·       Common symptoms are:

o   Depressed mood

o   Prominent fatigue

o   Insomnia or hypersomnia

o   Decreased appetite

o   Loss of libido

Physical examination

Conduct a targeted examination based on any signs and symptoms, which may include:

·       General appearance.

·       Height, weight and BMI.

·       Chest (gynaecomastia). 

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

·       Abdomen/rectal examination (hepatic enlargement, prostatic hypertrophy).

·       Urogenital examination (testicular atrophy) and measuring of testes

·       Skin/hair (acne, premature baldness, striae/stretch marks).  

·       Musculoskeletal (musculoskeletal injuries).

Mental health assessment

Check for:

·       Depressed mood or other symptoms of depression.

·       Symptoms of anxiety.

·       Behavioural changes including aggression.

·       Sleep patterns.

·       Body dysmorphic disorders

Consider investigations on a case by case basis taking into account presenting signs and symptoms, and risk factors (e.g. co-morbidities, use of injectables):

Test

Laboratory abnormalities

Notes

Hormones, incl. a) Testosterone (serum), SHBG (serum), Oestradiol, LH (serum), FSH (serum), b) IGF-1 (serum), c) TSH, free T4; PSA (plasma) (men over age 45)

Decreased luteinizing hormone (LH) and follicle stimulating hormone (FSH), increased testosterone and estradiol (with use of testosterone esters), decreased testosterone (in individuals using other AAS but not testosterone).

Most useful when someone has stopped using, ideally for at least 3 months, to see how the patient is recovering. Hormone testing is less useful when someone is using as results are likely to be abnormal because of the effect of the AAS

Cholesterol profile (HDL, LDL, Triglycerides)

Non-prescribed AAS use may result in high levels of low-density lipoprotein cholesterol (LDL-C) and low levels of high-density lipoprotein cholesterol (HDL-C). Possible increase in total cholesterol. Elevated triglyceride levels.

Upon cessation of AAS use there will be gradual reduction in LDL-C, and an increase in HDL-C.

Haemoglobin (Hb) and haematocrit

Elevated Hb and erythrocyte volume fraction (EVF) levels

This can increase risk of thrombus formation.

Urea and electrolytes, and Cystatin-C

Elevated creatinine levels

Elevated creatinine levels may indicate kidney injury or reflect increased muscle mass as well as rapid breakdown of excess muscle tissue. It can also be a result of over-consuming protein-based supplements.

Cystatin C should be considered if the patient has abnormal renal function on initial testing. Not Medicare funded – costs around $50-60.

Liver function tests

Increased creatine kinase (CK), increased ALT, AST, alkaline phosphatase, lactate dehydrogenase (LDH), gamma-glutamyl transferase (GGT) and total bilirubin

Hepatic abnormalities may occur, especially with the use of oral forms of AAS.[7]

Note that increased ALT, AST, and LDH may also be muscular in origin as a result of extensive weightlifting and may not indicate liver disease.

Semen analysis Contact your laboratory for instructions on collecting the optimal semen sample.

Decreased sperm count and motility, and abnormal morphology.

Non-prescribed AAS use inherently results in suppression of spermatogenesis. Normalisation of sperm count lags behind normalisation of plasma testosterone concentrations. Therefore, a wait-and-see approach is justified as a first step, that is, semen analysis should not be done within the first 6 months after stopping AAS. If the sperm count is severely compromised 6 months after last use and the patient denies AAS use in the last months, check gonadotrophin and testosterone levels.

Thyroid function tests

Decreased serum levels of total thyroxine (T4)

Increase resin uptake of triiodothyronine (T3) and T4.

Non-prescribed AAS use may result in decreased levels of thyroxine-binding globulin causing decreased total serum T4 levels and increased resin uptake of T3 and T4.

Not routinely indicated but should be considered if signs or symptoms of thyroid dysfunction, if testes are smaller or if sudden weight changes.

Electrocardiogram (ECG) and/or Echocardiogram

Left ventricular hypertrophy (LVH)

AAS can cause left ventricular hypertrophy.

Sexually transmissible infection/ blood borne virus (STI/BBV) testing

Hepatitis B, Hepatitis C, and HIV. Patients who inject AAS, and particularly if they engage in risky injecting practices or risky sexual behaviours, should be tested for Hepatitis B, Hepatitis C, and HIV.

Consider if high risk behaviour (e.g. regular sexual activity with multiple partners, friend injecting patient) or to follow up vaccination status for Hep-B.

Prostate-Specific Antigen (PSA)

There is little evidence that AAS increases the risk of prostate cancer, but testosterone may stimulate prostate cancer growth.

Pregnancy test

AAS may impact the foetus. In case of positive test, it is recommended that the patient stops using immediately.