Teens and Performance-Enhancing Drugs: A Bigger Problem Than We Think

Laurie E. Scudder, DNP, NP

Disclosures

August 15, 2016

Editorial Collaboration

Medscape &

Editor's Note:
Performance-enhancing drugs (PEDs) are again in the news, with widespread coverage of the controversy swirling around PED use by athletes on the Russian Olympic team. However, PED use is not limited to elite athletes, and in fact, most users are nonathletes. With crowds of teenagers presenting to primary care practices for preparticipation in sports exams before the school year begins, this seems to be a good time to review the epidemiology, recognition, and management of adolescent and young adult PED use.

Medscape spoke with Alan Rogol, MD, PhD, a pediatric endocrinologist at University of Virginia School of Medicine, about this issue. Dr Rogol was a member of the expert panel convened by the Endocrine Society in 2013 to develop a scientific statement on PEDs.[1]

Alan Rogol, MD, PhD: Who takes these drugs? People who will progress to use of long-term, hard-core steroids usually begin at age 22-24 years. On the other hand, teenagers who use PEDs typically only do so intermittently and transiently. Use is much higher in boys than girls.

According to data in the Endocrine Society scientific statement, approximately 2% of US high school students report using androgenic anabolic steroids just in the previous 12 months, usually as high school seniors. About one half of these young people take PEDs for athletic purposes, and the rest just because they want to "look good." So PED use is not limited to athletes, and most adolescent users probably do not know a lot about what they are taking.

Girls do take PEDs, but in numbers that are significantly lower. Girls take PEDs for some of the same reasons as boys, but the side effects are much more prominent in girls and include acne, hirsutism, and disordered menstrual function. How long girls take PEDs isn't known.

Of the boys who have used PEDs, most take them intermittently, and those who do take them consecutively usually do not do so for a long period. Data on who takes PEDs, and for how long, are very scarce and difficult to come by. Most of the data come from surveys that are done every other year in high schools.

Medscape: Most PED use in teenagers is reported to be androgenic anabolic steroids. Is that correct?

Dr Rogol: We need to careful about the word "steroids." Far and away, the most common steroids that people take are glucocorticoids for asthma and other conditions. Therein lies part of the problem with surveys, because it's not always clear what type of steroid use we are asking about. Many teenagers using glucocorticoids may report on a survey that they are using steroids when the steroids we are asking about are anabolic steroids, not glucocorticoids.

Very few people take anabolic steroids by mouth. They are available, but most PED users take testosterone by injection, creating a risk for infectious diseases, such as hepatitis and HIV, owing to needle contamination. Kids don't typically understand these risks.

Medscape: The most obvious signs of PED use include hirsutism, muscle mass increase, and gynecomastia, but are these effects apparent with intermittent, short-term use? When should a primary care clinician suspect PED use?

Dr Rogol: Many of the adverse effects associated with PED use are extraordinarily difficult to separate from typical teenage characteristics and conditions. Teenage boys produce their own testosterone. If a teen has acne, it is difficult to tell whether it is natural puberty or related to PED use. The same is true of aggressive behavior. Is it this teen's natural temperament, or is it a consequence of PED use? As you go down the line, it is quite difficult to disentangle the signs and behaviors of normal male puberty from those caused by exogenous PED use.

As you go down the line, it is quite difficult to disentangle the signs and behaviors of normal male puberty from those caused by exogenous PED use.

Unfortunately, we just don't know enough about what to look for in teens with reported or suspected PED use. Where would we find a group of kids who are most likely to be taking PEDs? That would be teens presenting for sport preparticipation exams, both boys and girls. Girls have to have preparticipation exams as well.

The pediatrician best knows the patient, but because of normal physiology, it's often difficult to separate normal puberty from the effects of PED use. If the teen is still growing, are increases in muscle mass or development of facial hair or acne part of a normal pubertal growth spurt, or due to androgenic steroids? The signs (rather than symptoms) of import include a rather marked rise in blood pressure and new-onset edema, but these can also be caused by a lot of other things. Has the teen's acne become much more severe? Is the teen exhibiting more severe aggression? These are all well-known side effects of exogenous androgens, but PED use isn't the only possible explanation for these changes.

In an adult, it is bit easier, because if a 25- to 30-year-old patient suddenly has a steep rise in blood pressure, acne, or edema coming from nowhere, PED use should be considered. The vast majority of adults (90%-95%) who take anabolic steroids are not athletes. They are bodybuilders, weight lifters, firemen, police, bouncers at bars—all sorts of people. Unlike athletes, these people may be continuously taking these drugs. They are addicted to them, and have been using them for many years. The kinds of heart disease, strokes, and myocardial infarctions that would be seen at age 60-65 years may now be seen at age 45-50 years.

Medscape: Can you walk us through your approach to an adolescent or young adult with suspected PED use, particularly in the case of a teenager whose parents may not be aware of such use? How do you walk that fine line between maintenance of trust and confidence with your teenage patient and the need to potentially involve parents?

Dr Rogol: First, I consider whether the teen with significant muscle growth, worsening acne, or hirsutism is experiencing natural puberty. Then I look for other signs, such as edema or increased blood pressure. If a child I know appears very different from previous visits—gained more weight, became more muscular, developed worsening acne or edema—it is more likely I would consider PED use. With an adult, it is possible to get a urinary screen for the 300-400 steroids (and their metabolites) that are commercially available.

If I suspect PED use, I try to talk to the teen absolutely in private. Then, at a very easy pace, I do pituitary and testicular tests—testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels—after which I have a pretty good idea whether the patient is using PEDs.

In the primary care pediatric setting, doping may be the farthest thing from one's thoughts when evaluating an adolescent boy. And although the pediatrician may have an opportunity to talk to that kid confidentially-- without a parent present-- an evaluation for PED use will not remain confidential. The only way I could talk to the parents of a teenager if I suspected PED use would be if and when that teen lets me. And I would ask for that permission. But, even without permission to speak with them, the parents are going to get a bill for any work-up I perform. And they will rightly ask, why did he do that? Therein lies to me the biggest difficulty.

Medscape: Should the pediatric primary care provider conduct that evaluation, or should the patient be referred to an endocrinologist?

Dr Rogol: Patients aged 17-18 years or older probably should be referred to an adult endocrinologist. Younger children, or those in whom it is difficult to separate signs of possible PED use from normal puberty, should be sent to pediatric endocrinologists, who understand a lot more about pubertal maturation.

Medscape: While waiting for an endocrinology consult and evaluation, what should the pediatrician do in terms of intervention? Should the teen be counseled to discontinue PED use immediately?

Dr Rogol: Of course there will be situations where an endocrinologist is not available in a timely manner. One possibility if for the primary care clinician to order LH, FSH, and testosterone levels and have them sent to a consulting endocrinologist to review—and to assist with making a determination about how quickly that kid needs to be seen. If the serum testosterone level is sky-high, LH and FSH levels are zero, and his testes are 15-20 mL, then I know he's taking something. And that should prioritize that kid's visit to the endocrinologist.

As for recommending discontinuation of whatever the teen is using—with intermittent PED use, stopping "cold turkey" is not an issue. It can be very different with adult PED users, who have been taking the drugs in large doses for many years. When a real addiction is present, the drugs used to manage opioid dependence and other addictions might be useful. And discontinuation should be managed very closely by a team that includes an endocrinologist and a psychiatrist.

In association with the Endocrine Society

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