A body-builder and his surreptitious steroid use Learning Objectives Initial Studies Differential Diagnosis

A body-builder and his surreptitious steroid use
Sonica Bhatia, M.D.; Anne Kastor, M.D.
Department of Medicine, New York Presbyterian Hospital/Weill Cornell Medical College; New York, NY
Learning Objectives
1. To recognize signs and symptoms of anabolic-androgenic steroid (AAS) use.
2. To recognize AAS dependence, and barriers to AAS cessation in the primary
care setting.
Initial Studies
Hemoglobin : 17.6 g/dL
(Borderline high)
LDL: 262 mg/dL
HDL: 19 mg/dL
Basic metabolic panel & TSH: normal
EKG: Normal sinus rhythm, with borderline left
ventricular hypertrophy
3 months later
Chief Complaint: Palpitations, flushing, chest discomfort, loose bowel
movements, and shortness of breath over the last month.
HPI: 31 year-old male presents at a primary care doctor’s office for follow-up of
multiple episodes of the above symptoms over the last month.
- associates symptoms with eating a variety of foods and taking a caffeine pill
prior to exercising.
- notes increased anxiety when going to the gym, but does not feel chest
discomfort or shortness of breath while exercising.
- denies sexual dysfunction.
- Reports that he last took human growth hormone about 3 months prior to this
Past Medical & Surgical History: asthma, obstructive sleep apnea
Allergies: NKDA
Family History: Father with myocardial infarction at age 50
Social History: Works as concierge at a gym. Former body-builder. No tobacco,
alcohol, or cocaine.
Physical Exam:
134/90 69 BMI 30
Young man with very muscular build
Mild b/l gynecomastia
Normal cardiac and pulmonary exam
Normal testicular size
References available upon request.
Differential Diagnosis
Differential diagnosis of constellation of presenting symptoms:
• carcinoid
• hyperthyroidism
• pheochromocytoma
• myocardial infarction
• panic disorder
• cocaine abuse
• adverse effect of supplement
Subsequent Studies
5-HIAA urine: normal
TTE: borderline low ejection fraction
24-hour EKG monitoring: no arrhythmia
LH: <0.2mIU/mL
FSH: <0.2mIU/mL
8 months later
Additional History Obtained
- methenolone acetate (primabolan) for 16 years
- human growth hormone in past year
- clomiphene in past year
- tapering testosterone from daily to weekly injections.
Started on SSRI
4 months after initiation of SSRI:
- Improvement in symptoms
- Improvement in lipid panel
- Improvement in blood pressure
AAS use became more prevalent among non-elite athletes
beginning in the 1980s.
Adverse effects linked to AAS use include:
• AAS-induced cardiomyopathy
• hypertension
• dyslipidemia
• polycythemia
• atherosclerotic disease
• sexual dysfunction
• symptoms of mood disorders
Underground steroid guides advise AAS users to inject in “cycles”
and to use clomiphene, both of which allow the HPG axis to recover.
AAS withdrawal may induce major depression and uncover bodyimage disorders:
• Loss of muscularity can induce anxiety.
• SSRIs and cognitive behavioral therapy can help patients with signs
of AAS dependence.
This case demonstrates some of the signs and symptoms of AAS
use, and that mood disorders and body-image disorders may be
revealed in the setting of discontinuation of AAS, making AAS
cessation challenging for patients and providers.