Steroid pathway for DHEA and androstenedione showing conversion to testosterone or estrone. Adapted with permission from DPC Company Web site. Available at: www.dpcweb.com/documents/news%26views/ fall_2003/images/androsteine.html. 

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... Manual of Mental Disorders, Fourth Edition , the American Psychiatric Association’s standard for de- fining mental illnesses, it has been reported that nearly 50% of steroid users in a series met criteria for being dependent on or abusing steroids (Table 3). 39 Apart from medical adverse effects, several investigators have documented social risks to steroid use. Middleman et al 40 documented an association with other high-risk activities such as driving under the influence, carrying weapons, and engaging in unsafe sexual practices by young users. Durant et al 41 also elaborated on the increased use of other illicit substances by youths who take steroids, including marijuana and alcohol. The Anti-Drug Abuse Act in 1988 first prohibited the distribution of steroids for any purpose other than treatment of a disease. This was followed by the Anabolic Steroid Control Act of 1990, which placed steroids under Schedule III of controlled substances. The illegal possession of anabolic steroids is punishable by 1 year in prison and/or a minimum $1000 fine, with selling or intent to sell incurring a 5-year prison sentence and/or a $250 000 fine. Steroids are banned from use by all major sporting leagues, although each governing body has in- dividualized testing and penalization policies. Estimates of high school steroid use range from 4% to 11% in boys and up to 3.3% of girls. 1,25 The landmark study in this area was performed by Buckley et al. 2 This nationwide survey of Ͼ 3000 boys found that 6.6% of male high school seniors had tried steroids, with 67% beginning use by 16 years of age and 40% using multiple cycles. This was later confirmed in a survey of Indiana high school football players documenting a 6% use rate (mean age at first use: 14 years) and a 2003 nationwide Centers for Disease Control and Prevention data finding a 6.4% use of steroids by 12th-grade boys. 1,42 Subse- quent publications have continued to document child- hood steroid use with consistent findings of 2% to 3% of students using steroids in ages from 9 years to young teens, with numbers reaching 9% among middle school children who reported being gymnasts or weightlifters. 38,43,44 Unfortunately, even when examining only ninth-graders, one investigator found percentages that quickly reflected previous estimates for use over the entire high school population with 5.3% of boys and 1.5% of girls using steroids in a survey of nearly 2000 Georgia students. 45 The ongoing Monitoring the Future study, which has the largest nationwide cohort of nearly 50 000 students, showed a 1.3%, 2.3%, and 3.3% an- nual prevalence of male steroid users in the 8th, 10th, and 12th grades, respectively, in 2004. Girls in the 12th grade had a 1.7% use rate of steroids in the past year, whereas the Centers for Disease Control and Prevention found a 3.3% lifetime prevalence of steroid use in 12th- grade girls. 1,46 Although the numbers from the Monitoring the Future survey are more modest than other reports, it is important to remember that these numbers reflect the entire student population, not just athletes, and that a concerning trend was found with 12th-grad- ers showing a steadily decreasing perceived risk of steroid use yearly since 1993, with now only 55% of seniors viewing occasional steroid use as a great risk. 46 Even in Buckley’s initial work, it remains noteworthy to realize that nearly one third of young steroid users do not participate in formal school sports. 2 In the 1980s, estimates of steroid use reached 20% for division I college athletes. 47 Subsequently, the National Collegiate Athletic Association (NCAA) began surveying its athletes to better define the demographics of substance use in this population. The latest NCAA survey in 2001 polled Ͼ 21 000 student athletes in all champion- ship sports and all divisions. 48 They reported that 1.4% of these individuals used steroids in the past 12 months. Recent independent studies of college athletes, however, raise the possibility of underreporting to the NCAA as results show up to 9% of athletes using steroids on 1 campus. 49 Worrisome trends discovered by the NCAA included a change in utilization, with most athletes in 1997 using steroids to recover from injury, whereas current athletes mainly reported use to improve performance or appearance. Also, steroids were the only ergogenic drug class to increase in all collegiate divisions. Furthermore, steroid use was beginning earlier than in the past, with 42% of users reporting first use in high school and 15% beginning steroids in junior high or before. 48 Androstenedione and closely related dehydroepiandrosterone (DHEA) are 2 popular steroid precursors, or prohormones. DHEA is a weak androgen that is produced in the adrenal cortex, whereas androstenedione, a more potent anabolic-androgenic steroid, is made in the adrenal glands and gonads. DHEA is converted in the body to androstenedione, which then can be transformed into either testosterone or estrone (Fig 1). 50 Athletes use these substances with the belief that they will boost testosterone levels, thereby having ergogenic effects similar to anabolic steroids. DHEA’s recommended dosing is in a range of 50 to 100 mg/day for up to 1 year. The number of adverse effects increases at doses that exceed this amount, although athletes may well take more than the recommended amounts. 51,52 Although now off the supplement market, androstenedione’s upper limit for dosing was 100 to 300 mg/day. In 1962, Mahesh and Greenblatt 53 published that androstenedione given to 2 female individuals resulted in increased testosterone levels. Since that time, there has been little support for these precursors having any ergogenic effects, although their popularity soared after Mark McGwire admitted to using androstenedione during his 1998 quest to break Roger Maris’s single-season home run record. Leder et al 54 in 2000 reported that men who were given androstenedione showed increased testosterone levels, although this effect was seen only in the first few hours after initial use. Furthermore, the early boost in testosterone levels reached only the upper limit of normal for physiologic male individuals. Later, after several weeks of use, the only hormone change was increased estrogen. 54 Most studies have found no change in testosterone levels but have confirmed increasing estrogen levels in male individuals. 4 Specific to athletes, King et al 55 in 1999 published a series of 20 healthy male individuals with 8 weeks of standardized resistance training, whereby androstenedione was given in a double-blinded manner versus placebo. At the conclusion of the testing period, those who received the drug showed no change in any athletic measure or testosterone levels but were found to have significantly increased estrone and estradiol levels. In the literature to date, there is no convincing evidence that these prohormones have any true benefit for the athletes, and as Tokish et al 20 reported in 2004, “The marketing of this supplement’s effectiveness far exceeds its science.” Although androstenedione and DHEA are without proven benefit, they are not without risk. As they share a metabolic pathway with anabolic steroids, they share several common adverse effects. These include adverse changes in lipid profiles as well as potential male gynecomastia and virilization of female individuals. Use of these substances may also downregulate endogenous testosterone over time. 56 In addition, priapism has been reported and animal studies have found resultant hyperplastic prostatic changes with use. 57,58 Finally, although DHEA is a legal supplement, impurities during production can place athletes at risk for testing positive for a banned substance. In 2004, a new Steroid Control Act that placed androstenedione under Schedule III of controlled substances effective January 2005 was signed. DHEA was not included in this act and remains an over-the-counter nutritional supplement. Androstenedione now is banned by all major sporting leagues, including Olympic and collegiate sports. Sparse literature is available for evaluating use of androstenedione and DHEA. In 2002, Reeder et al 59 surveyed 475 high school students and found that 4% of this population of athletes and nonathletes used steroid precursors within the past year. Meanwhile, the NCAA’s 2001 study found that 5.3% of their athletes admitted to use of androstenedione or DHEA in the past year. 48 The high number of adolescent users in Reeder’s student body cohort suggests that these drugs are being used by adolescents and again raise concern that collegiate student athletes may be reluctant to report use to the NCAA. Growth hormone is a polypeptide secreted by the soma- totrope cells in the anterior pituitary. Secretion is pulsa- tile and gradually decreases after peaking during early adolescence. Growth hormone is converted in the liver into insulin-like growth factor 1, which has several effects throughout the body. Insulin-like growth factor 1 serves to increase protein synthesis, lipid catabolism, and bone growth. 60 Growth hormone first was used in children who were growth hormone deficient. This was initially derived from cadavers and proved dangerous with the transmission of prion disease. Now, there is a biosynthetic growth hormone available. Growth hormone is produced only in injectable form. It may be used several times per month, and the cost of a 1-month supply can approach $5000. 61 Athletes who take growth hormone often com- bine use with anabolic steroids. 5 Although growth hormone has many benefits for those who are congenitally deficient, it does not seem to hold similar promise for healthy young athletes. No conclu- sive evidence exists that growth hormone enhances athletic performance. 62–64 In fact, patients who have acromegaly with an excess of growth hormone may be the most accurate model for the athlete who is supplement- ing an already normal hormone level. ...