July 13, 2004

The Abuse of Anabolic Steroids and Their Precursors by Adolescent and Amateur Athletes

Don H. Catlin, MD
Professor of Molecular and Medical Pharmacology
UCLA Olympic Analytical Laboratory

Good morning Senator Grassley, members of the Drug Caucus, ladies and gentlemen:

It is a pleasure and honor to speak to you today. Twenty years ago I was pursuing a classical career as an academic physician at UCLA. My world abruptly changed when a member of the International Olympic Committee (IOC) came to visit and asked if I would develop a laboratory that could test urine of athletes competing in the 1984 Olympic Games. He showed me a list of the drugs that were forbidden, and although I was a practicing physician, I barely recognized many of the drugs. Besides I was a physician not a chemist - so I turned him down. I was so naive that I could not understand why a young athlete, at the pinnacle of their sport career, would take a drug. Athletes are young and healthy. It made no sense. But he came back a few weeks later and by then I had learned a few things.

I went to the medical library and looked for articles about drugs and sport, but I could not find much. I did find one article by an influential editor of a Sportsmedicine Journal. He explained that anabolic steroids do not work: ‘all you have to do is educate' the athletes and the problem will go away. This was strange - why was I asked to develop a lab to test Olympic athletes for steroids if they don't work.

My next stop was a local gym where I very quickly learned what anabolic steroids can do for you: They are extremely potent hormones that can profoundly alter your athletic performance - and cause many nasty side effects. They can make you run faster, jump higher, and lift more - things that matter if you are an Olympic athlete. If your high school football coach says ‘put on twenty pounds over the summer and you will start in the fall' there is only one way to do it - anabolic steroids!

Steroids can also make you look ‘buff' - have better defined muscles - a look that is considered desirable - particularly in the adolescent. Interestingly the buff look is sought after by both boys and girls. The girls do not want the huge muscles, they are more desirous of better ‘definition' of their muscles, less body fat, and better muscle tone.

Once I realized that anabolic steroids were so powerful, it was immediately clear that they should be forbidden in sport. Essentially there are two sports: one with and one without steroids. In many sports there is no hope for the ‘level playing field' if steroids are around. The issue was and still is how to control or curtail the problem. For the last twenty of so years I have sought to better define the issue and perhaps to make it better - in short I devoted my professional life to the problem of drugs and sport. Now the issue is well beyond sport, the abuse of anabolic steroids has become a serious and growing concern for all.

I brought along a few slides to illustrate some of my points. In the first [Ben Johnson before, 1988 Olympics] you see an athlete walking. In the second slide [pineapple] taken a few years later the same athlete is seen leaving the starting line at the 1988 Olympic Games in Seoul. It was Ben Johnson leaving the starting blocks on his way to defeat Carl Lewis in the 100 meter dash. Later that day his urine was found to contain stanozolol, an anabolic steroid. The Olympics literally stood still for a day while the world came to grips with the its first major sport drug scandal. Before that, we sort of knew that weightlifters used anabolic steroids, but the public ws not so interested in weightlifting and it is not a particularly telegenic sport. But this was Track and Field, the 100 meter dash, Carl Lewis versus Ben Johnson - a truly premier. The enormous pineapple (slide 2) sitting on his shoulder - that is his deltoid muscle. This photo removes doubts about whether or not steroids work. Of course they do! They work in men and still more in women.

But there is a cost - - - -.

The next slide [schematic of a person with arrows pointing to body organs] shows that anabolic steroids produce changes in virtually all organ systems: liver, heart, skin, brain, and more. Many of the effects are internal metabolic changes that cannot be directly observed. But if you study the blood there are changes in blood cholesterol and many other hormones that circulate [point] The level of HDL-cholesterol level (the good cholesterol) in blood goes down and the LDL - cholesterol goes up, and the ratio of bad to good cholesterol goes way up. This ratio is a marker for cardiovascular events such as myocardial infarctions, blood clotting, and strokes. We know these serious adverse effects are associated with AAS, but they occur relatively infrequently and we have no way to predict who will get them. The elevated bad to good cholesterol ratio makes us concerned that there will be more cardiovascular side effects months and years after the steroids are discontinued.

The next slide [gynecomastia] is one of the most common side effects of AAS in males. Somehow the balance of male and female hormones is changed by AAS such that men develop female-like breasts. This effect will reverse if the steroids are discontinued but often it takes months or years of being steroid free. Sometime the males resort to surgery to ‘get back to normal'. The next slide [microscope view of subaceous glands] shows a microscopic view of acne (zits) which are very common among AAS users. The drugs make the sebaceous glands, shown here on the right, very big and juicy. The gland on the left is normal. If the sebum clogs the channel from the subcutaneous tissue to the skin, inflammation breaks out and one gets ugly inflammatory acne.

Strange as it may seem, AAS in some ways make men more like women and women more like men. For women their breasts shrink, their menstrual periods become irregular, and their clitoris enlarges. For the men their breast enlarge, their testicles shrink, sperm production declines the stops altogether and they are sterile.

Inside their body there are profound changes in many hormones that are made in the pituitary gland. In effect the pituitary-testicular axis, the glands that normally control virility and manhood in the male, wither and stop producing. The body ‘lives off' the supply of foreign steroids. When the AAS are finally discontinued it takes a long time, months and years, for the effect to reverse. Some of the effect may be permanent.

In order to learn more about the adverse effects in women, a ‘closet' topic about which virtually nothing is published, I started a clinic for women steroid users. At first nobody came. Finally a few from the body building culture came to see me. They had two main complaints: what can I do about my low voice and when will my periods come back. The low voice is due to the effect of AAS on the larynx. It is a disaster for female. The ladies have trouble explaining to their moms that the low voice is due to a cold - when it never goes away. The main issue with the amenorrhea is the fear that they will not be able to have children. As far as we know the AAS will not effect pregnancy but there are no studies on this. None of them wanted to discontinue steroids as they were critical to their work as bodybuilders, but all wanted their voice back and reassurance that they will be able to have children when they do quit. Several had high blood pressure and I used this finding as a way to keep them coming back to the clinic. Eventually I was able to show them their abnormal blood finding and this interested them. A few actually did quit AAS. Although it is written that steroids produce drug dependence like heroin and cocaine, I did not observe any evidence of dependence.

Of course the most common and feared effect in women is virilization - they become more masculinized. A little bit is ok because it tones up the muscle, but when the hair growth on the face gets out of control as shown in the next slide [female with hair growth on face] virilization has been established and is definitely not wanted. Other findings that go along with virilization are more hair on the back, chest, and under the arms; less hair on the head (temporal balding); oily skin, and acne. These side effects also happen to men but they are less apparent and somewhat moot. Adolescents certainly do not want acne (pimples and zits). By explaining that this is a common side effect of AAS I have had some success in persuading some adolescents not to take AAS.

The next slide shows a former East German well-known swimmer. In the inset [slide of East German female] of the slide is the before photo showing a markedly virilized woman with massive arms and shoulders and lots of underarm hair. A few years later in the right side of the photo, she is shown off all steroids and with her Olympic Gold medals around her next. During the seventies and early eighties the East German teams were invincible largely due to steroids. The athletes had no choice, there were little blue pills at the breakfast table and you took them or you were off the team. The accounts of the effects on the women, the terrible side effects, and how the athletes were coerced are quite horrifying.

A rare but distinctly unattractive effect in males or females is linear keloids [slide with keloids] Keloids are areas of the skin that are thin thus allowing the blood vessels that are normally not visible to show through. These lesions will gradually regress if the steroids are discontinued.

Psychiatric or behavioral changes do not lend themselves to photos, so I will tell a story: Some years ago a man on his way to work stopped at a convenience store on a country road, bought a soda, and asked for change to use the phone. He thought the clerk was a bit surly. That night he obsessed about the incident, dug out his old hunting knife and sharpened it. The next day he went back to the store with the knife and abducted the clerk. He had to slow for construction, she jumped out of the car and was severely injured. He went home and waited for the police. When they arrived he said " I don't know what happened, it must have been the steroids'. Now, I cannot prove beyond a shadow of a doubt, according to placebo-controlled, accepted medical research protocols, that anabolic steroids altered this mans psyche such that he could do this. But I am convinced that the anabolic steroids were instrumental. Before the event he was a law abiding productive citizen. One cannot do research to see if such things happen - it is not ethical and would not be approved by Ethics committees. But I have read and studied other dramatic cases that convince me that AAS severely alter the mental status and behavior of some people. I know of no way to predict who will have such remarkable behavioral effects, they are not very common, but they do happen.

On the other hand ‘roid range' seems to be quite common. This term is used to describe men that become hyperaggressive, combative, and argumentative on steroids. There are many grades of roid range. Whether or not the bizarre event that I just described is an advanced form of roid range or something entirely different remains to be elucidated.

Medical patients who take anabolic steroids in conventional doses for an illness generally do not experience much behavioral change, although a few cases of profound psychopathy are described. Some behavioral effects are much more common but it is difficult to know just how common they are. Solid statistics are just not available in this field. Some of the most commonly described behavioral effect of AAS are mania, hypomania, and depression - such as you heard described by Mr. X. Sadly, suicide has been described as a side effect of AAS.

Athletes and adolescents are not stupid. They will not take a drug if the risk of a serious adverse side effect is high, however they do greatly underestimate the risks. They simply do not have the background or training to evaluate the risks. They tend to believe, as many young people do, that they are invincible and indestructible, or it ‘won't happen to me'. They are not good at assessing the risks and benefits, largely because their information comes from dubious sources. Indeed the most serious adverse side effects are rare, the problem is that if you get one of them it is generally too late. They are invincible - and so they start.

Tumors, neoplasia, benign and malignant cancers have all been associated with AAS. The ugly mass filling the left side of this patients liver [slide of liver tumor] is one example of a tumor associated with AAS. And the next tumor [very ugly tumor] is even more dramatic and frightening. These lesions do occur, they are not common, but they are dramatic - particularly to affected person.

The next slide is peliosis hepatitis (slide of peliosis), a rare and dangerous tumor of the liver that is associated with AAS. It is not dangerous because it is malignant, it is dangerous because the tumor is very vascular and tends to bleed. The liver is gradually replaced by these lake-like lesions. If they start to bleed, they are vary difficult to control. The patient bleeds into their abdomen. This complication, while fortunately rare, is highly dangerous: patients can bleed to death internally.

Can you figure out what this remarkable slide is showing. It is a surgical scene. The surgeon has opened up the knee joint. It is a frontal view, what you would see if your neighbors knee were being operated on.. That little strap-like thing coming out of the wound is a tendon. [slide of tendon] The tendon belongs to a very strong athlete. So strong that he snapped the tendon when he was doing a squat. The steroids are so powerful that they can lead to ruptures like this if the muscles become too strong for the rest of the body. Also the steroids may weaken tendons.

This person is well known and not with us any more [slide of Lyle] This is Lyle Alzedo on the cover of Sports Illustrated many years ago. He died of an unusual type of cancer. In his mind the tumor was due to AAS. Whether or not it was, we will never know, and some experts doubt, but it was important that Lyle believed his tumor was due to AAS. He was a huge powerful man, the terror of the NFL, with a profound influence on professional football players. His passing I believe did more to curtain AAS use among athletes than any other single event.

Why do adolescents take steroids? Ten and more years ago the surveys showed that adolescents only used anabolic steroids to improve their sport performance. Further they were virtually all males. Now there is a distinct trend toward using anabolic steroids to more buff, to tone-up. The athletes still wish to get bigger and stronger but now so do the non-athletes and the females. They want muscles that are distinct and ‘cut' - like rabbits running under a rug. All surveys and epidemiology studies are showing a substantial increase in usage among adolescents.

Typically they begin with oral doses of an OTC steroid. How can there be anything dangerous about an OTC drug, they ask? Stacking describes adding another steroid. The more determined users move on to injectable steroids or take multiple types of steroids (stacking). If they are competing athletes that are subject to testing, such as the NCAA athlete, they learn various ways to avoid getting caught. Generally the AAS user is not very selective about where they will get their steroids. They will take steroids from a variety of sources: friends, contacts, webb-sites, doctors and pharmacies that deal in steroids, and other clandestine sources. Veterinarian steroids are particularly popular these days.

Switching gears a little bit as I approach the conclusion please focus for a moment on OTC steroids.

Is supply limiting? I do not believe that supply is a problem. AAS are readily available around most gyms, on the webb, and across the boder. The local health food stores carry an incredible array of over-the-counter steroids - steroids that are presently legal and in fact enabled by the DSHEA Act. This 1994 act was a boon to the supplement industry because it legitimized many OTC steroids. As long as the manufacturer could show that the steroid occurred naturally, it was possible to package it and sell it as a OTC supplement. Further, the health risks of anabolic steroids are the same for the OTC steroids as they are for the prescriptions ones.

Here is a short list (slide of OTC steroid names) of steroids that are available OTC. (Dhc reads them out.) And here is the chemical structure of testosterone on the left and andro or androstenedione on the right. (Slide showing chemical structure of andro and T) Can you see the difference? Well, it is not easy for the lay person, but if you look carefully right here (dhc points) you can see a subtle difference in the structures, one is a prohibited AAS that can lead to jail time and the other is Andro or androstenedione. Testosterone is a prescription drug and Andro is sold OTC. Ladies and gentlemen, Andro and other steroids should not be sold over-the-counter.

One cannot reasonably expect to get them out of sport if they are available for the asking in the shops, ‘health' food stores, and supermarkets.

Show andro text slide, read and emphasize.

Last, this presentation would not be complete without mentioning designer steroids (show slide on THG). On one hand it shows just how desperate some people are to win an Olympic medal. On the other hand it also shows just how far we have come in detecting them. Ladies and gentlemen the problem will not go away without serious attention and commitment. Designer steroids will soon affect your local schools and teams. It is time to act now while the nations attention is focused on the problem. It will take human and instrumental resources and a dedication to return pee-wee baseball and Olympic sports to their rightful and original condition: drug free.

Ladies and gentlemen, thank you for your careful attention to this critical issue that may affect your children and certainly plays havoc with sport.