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INTRODUCTION

Clinicians of all types are likely to encounter male patients who have used various types of body-appearance and performance-enhancing supplements or drugs. Particularly important among these substances are anabolic-androgenic steroids (AAS), which are illegal without a prescription in the United States, but are easily obtained illicitly through the Internet or from underground dealers. Some men use AAS and other substances to improve athletic performance, but a substantially larger percentage have no athletic aspirations when using these substances and instead are attempting to improve their personal appearance by gaining muscle and losing body fat.1

Mounting evidence shows that AAS and many other appearance- and performance-enhancing substances exert both short-term and long-term adverse medical and psychiatric effects. Most clinicians are not nearly as familiar with these effects as they are when dealing with conventional drugs such as tobacco, alcohol, and classic drugs of abuse. Moreover, patients often fail to mention their use of these substances to clinicians and may be reluctant to disclose this information even when asked directly. Accordingly, it is critical for clinicians to become familiar with the effects and side effects of commonly used appearance- and performance-enhancing substances.

SUBSTANCES USED

Over-the-Counter Supplements

The substances most commonly used for both athletic performance and personal appearance are various types of over-the-counter supplements, purchased in local nutrition stores or similar establishments. Many of these supplements, such as protein powders and amino acids, are simply food substances. Creatine, an amino acid that occurs naturally in humans and in meats consumed by humans, is a particularly popular food supplement claimed to increase muscle mass and improve athletic performance. Although of questionable efficacy for genuine long-term muscle gain, there is little evidence of serious long-term effects from its use.2

Many other supplements are widely sold over-the-counter with claims that they work as “testosterone boosters,” “growth hormone stimulators,” “fat burners,” etc. A substantial percentage of such supplements do not produce their advertised effects. Although some of these products are fairly harmless, a substantial minority of supplements—especially those sold over the Internet—may contain AAS or other potent pharmaceuticals with unknown and possibly substantial toxicity.3,4 This issue is discussed in more detail in the section “Over-the-Counter Supplements.”

Anabolic-Androgenic Steroids

AAS are the illicit drugs most widely used by men seeking appearance or performance enhancement. Virtually all men who are using AAS are also engaging in some type of weightlifting program. The family of AAS comprises testosterone and hundreds of synthetic derivatives of testosterone that have been synthesized over the last 80 years since testosterone was originally isolated in the 1930s (Table 22-1).1 Soon after the initial discovery of AAS, elite athletes discovered that these drugs could greatly enhance their performance, especially in sports requiring muscle strength. As a result, AAS spread rapidly throughout the elite athletic world in the 1950s ...

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